When a person starts Medicare, it can be pretty confusing. Knowing what all of the terms mean will help during each beneficiary’s journey under Medicare insurance. The 8-Minute Rule is one to know and understand.

Some providers also have a limited understanding of these rules, leading to underbilling or delayed reimbursement errors.

Service-based healthcare providers, such as physical therapists, provide services to Medicare beneficiaries, and then they bill Medicare. The current procedural timed code dictates the billing and claims processes.

Medicare 8-Minute Rule Explained

The 8-Minute Rule has been in effect since April 1, 2000, and it applies to time-based current procedural terminology (CPT) codes for outpatient services.

This rule allows healthcare providers to bill for units of service and must be between 8 and 22 minutes.

A unit is a term used for the time interval of the service, and a unit of service is 15 minutes.

How Does The Medicare 8-Minute Rule Work?

The 8-Minute Rule applies to services where the beneficiary and the healthcare provider have direct contact. This means it must be an in-person visit.

Medicare-8-Minute-Rule

Medicare will be billed based on the total number of minutes timed per regulation but won’t be billed if the individual service is less than 8 minutes.

Services are billed in 15-minute increments. If the service lasts only 20 minutes, Medicare will be billed for one unit through CPT codes.

This is because the service was less than 22 minutes, and between 8 minutes and 22 minutes are deemed one unit.

Medicare beneficiary services that last between 23 and 37 minutes are billed for two units, 38 to 52-minute services are billed as three units, and so on.

Examples of How The 8-Minute Rule Works

Suppose there is an appointment for physical therapy at a physical therapist’s office. The person receives 28 minutes of physical therapy billing and a 9-minute consultation about the treatment plan at the appointment. That is a total of 37 minutes. So Medicare will be billed for 2 units.

Services are not billed separately, and they are combined based on the number of units for things such as therapeutic exercise or even applying cold packs. Timed procedures and modalities — even things like neuromuscular re-education or electrical stimulation are all billed this way for Medicare’s sake.

Another example would be if there was another appointment at a medical facility. In this scenario, an ultrasound takes 11 minutes, then is followed by a 21-minute consultation, and ends with a 15-minute physical therapy session. The total is 47 minutes, so Medicare will be charged for 3 billable units of total time.

Understanding how this works is essential, so the person in question is not over-billed.

Who Is Impacted By The 8-Minute Rule?

The 8-Minute Rule applies to these outpatient healthcare providers. Private practices, skilled nursing facilities, rehabilitation facilities, minutes of manual therapy services, therapeutic activity, and hospital outpatient departments.

This rule also applies to home health agencies that provide approved Part B therapy covered in the beneficiary’s home.

FAQs

Do Medicare Advantage plans follow the 8-Minute Rule?

No! Medicare Advantage plans do not have to follow the 8-Minute Rule.

Does the 8-Minute Rule only apply to Medicare?

No, in addition to Medicare, CHAMPUS and Tricare will also follow the 8-Minute Rule.

Does group therapy apply to the 8-Minute Rule?

No! The rule applies to 1-on-1 direct contact services.

Does the 8-Minute Rule apply to Medicare Part A?

No, this rule applies only to Medicare Part B, which is the payer for these services.

How are therapy minutes calculated?

Minutes of therapeutic exercise is calculated according to Medicare’s 8-Minute Rule, just like anything else.

How many minutes are 3 units for Medicare?

Anywhere between 38 and 52 minutes is billed as 3 units for Medicare’s 8-Minute Rule. An additional unit will be billed past 52 minutes for the appropriate amount of time.

Does Medicaid use the 8-Minute Rule?

Yes, Medicaid uses the same CPT codes, billing guidelines, and amount of time to calculate minutes from healthcare professionals.

What are leftover minutes?

These refer to minutes that aren’t fully used in the 8-Minute Rule. Still, since the 8-Minute Rule acts like tiers, Medicare won’t be charged extra if you don’t reach the next range.

Getting Supplemental Medicare To Cover for You

The 8-Minute Rule can be a bit confusing and strange for beneficiaries who haven’t dealt with it. But it benefits Medicare recipients to understand how their coverage is billed for direct contact services like physical therapy.

If you’d like a Supplemental Medicare plan to assist you in covering any portions of your care that you’d be financially responsible for, our licensed insurance agents are experts in the field. Our highly motivated agents will help pick the right plan for your unique needs.

Best of all, there is no obligation to talk to an agent, and the assistance is complimentary. Give us a call or fill out our online request form to find the best rates in your area.

Written By:
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Lindsay Malzone, Lindsay Malzone is the Medicare editor for Medigap.com. She's been contributing to many well-known publications since 2017. Her passion is educating Medicare beneficiaries on all their supplemental Medicare options so they can make an informed decision on their healthcare coverage.
Reviewed By:
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Rodolfo Marrero, Rodolfo Marrero is one of the co-founders at Medigap.com. He has been helping consumers find the right coverage since the site was founded in 2013. Rodolfo is a licensed insurance agent that works hand-in-hand with the team to ensure the accuracy of the content.