Party popper Before you break out the noisemakers, be sure to RSVP for our special December 15 webinar on the new PT and OT evaluation CPT codes for 2017. Register now.


Tom AmburyToday's post comes from Tom Ambury, PT and compliance officer at PT Compliance Group. Thanks, Tom!

“Tom, how can you make a statement that the Medicare 8-minute rule is simple yet diabolically complicated?” I can make that statement because even though this rule has been in effect for years—and thus, people should have the hang of it—mistakes still happen. And when I talk to therapists about it, a lot of confusion still exists.

The 8-minute rule is how we determine what to bill to Medicare. To correctly calculate the charge, you must divide charges into two categories: time based (or “constant attendance”) modalities and procedures as well as supervised modalities and procedures. Constant attendance modalities and procedures include therapeutic exercise, manual therapy, neuromuscular reeducation, therapeutic activities, gait training, ultrasound, iontophoresis, and electrical stimulation attended. Supervised procedures and modalities would include physical therapy evaluation, physical therapy reevaluation, electrical stimulation unattended, and whirlpool.

What the 8-minute rule says—and how it got its name—is if you are performing only one constant attendance modality or procedure, you have to perform that modality or procedure for at least eight (8) minutes in order to bill that charge.

For example, I see a patient for the initial visit, and I perform my initial evaluation for 35 minutes with seven (7) minutes of therapeutic exercise. My charges are one unit of physical therapy evaluation. I cannot bill for therapeutic exercise because I performed that procedure for seven (7) minutes. So, by rule, I would need to perform therapeutic exercise for eight (8) minutes in order to bill it. Most therapists understand this, and your documentation system should prevent this type of error.

Where the diabolically complicated part comes in is when the therapist performs multiple constant attendance procedures or modalities and then must correctly calculate the charge. Complications arise because there’s a cumulative and distribution part of the rule.

When calculating the correct charges for multiple procedures and modalities, you must add the total constant attendance modalities and procedures together to get the “Direct Timed Minutes.” This number determines how many constant attendance units you can charge. At this point, you would determine how many supervised units to charge and determine the “Total Treatment Time.” To add to the diabolically complicatedness, there is also a rule to determine the correct distribution of charges. Let’s go through some examples:

Example #1

On a date of service, you perform 30 minutes of therapeutic exercise (EX), 15 minutes manual therapy (MT), 8 minutes ultrasound (US), and 15 minutes of electrical stimulation unattended (ESUN). To correctly calculate the charge, add the constant attendance procedures and modalities:

30 min + 15 min + 8 min = 53 min of Direct Minutes, which supports four units of charge. The 15 minutes of ESUN supports an additional supervised unit charge for a total of five units billed.

Now the distribution: How many full 15-minute units did the therapist perform? In this example, there are two full 15-minute units of MT and one full 15-minute unit of EX. So, that‘s three units out of four. The ultrasound performed for 8 minutes is the remaining charge, so the correct bill would be two units of EX, one unit of MT, one unit of US, and one unit of ESUN.

Ok, that example was pretty straight forward; now let’s get more diabolical.

Example #2

In this example, there are 30 minutes of EX, 25 minutes of neuromuscular (NM), 17 minutes of MT, 13 min of therapeutic activity (TA), eight (8) minutes of US, and 15 minutes of ESUN. Let’s calculate the charge:

30 min + 25 min + 17 min + 13 min = 93 min of Direct Minutes, which supports 6 units of charge. The 15 minutes of ESUN supports an additional supervised unit charge for a total of seven units billed.

Now the distribution: How many full 15-minute units did the therapist perform? There are two units of EX, one unit of NM with ten minutes left over, and one unit of MT with two minutes left over, all of which support four units of charge. The next step is to compare the minutes left over of the procedures performed: 13 minutes of TA, ten (10) minutes of NM, eight (8) minutes of US, and two (2) minutes of MT.

We have justified four units of charge, and because of the time, we are justified in charging two more units, but which two? To make this decision, we compare the time left over from the incomplete units and then bill the two larger of the units left over. So, in this example, we would add a unit of TA (13 minutes) and NM (ten minutes). We are not justified in billing US or an additional unit of MT.

So the correct billing in this example is two units of EX, two units of NM, one unit of MT, one unit of TA, and one unit of ESUN.

The key to the 8-minute rule is to do the math. Calculate the total units justified by time. Calculate the full 15-minute units. If time justifies additional units, compare the minutes of the partial units remaining and bill the larger of the minutes remaining.

Even though your documentation system will provide lots of assistance with the 8-minute rule, it’s a good idea to check your work; make sure your system is correctly calculating the charges using the Medicare 8-minute rule. After all, the 8-minute rule is ultimately your responsibility as the therapist.

Thank you for the opportunity to present this topic to you. If you have any questions, please post them in the comments section below or shoot me an email (questions@ptcompliancegroup.com). 

New Year, New Codes: How to Bill for PT and OT Evaluations in 2017 - Regular BannerNew Year, New Codes: How to Bill for PT and OT Evaluations in 2017 - Small Banner
  • The 8-Minute Rule Showdown: Medicare vs. AMA Image

    articleNov 25, 2015 | 5 min. read

    The 8-Minute Rule Showdown: Medicare vs. AMA

    The guidelines for using the 8-Minute Rule are kind of like the instructions for building a piece of furniture from IKEA: they appear simple at first, but before you know it, you’ve been struggling for hours, you’ve got a lopsided futon, and there are seven leftover screws of various shapes and sizes scattered around your living room floor (maybe they’re just extras, right?). To make matters even more confusing, not all payers adhere to the same set …

  • Everything You Need to Know About the Medicare 8-Minute Rule Image

    articleNov 11, 2013 | 5 min. read

    Everything You Need to Know About the Medicare 8-Minute Rule

    In honor of this month’s compliance theme, here’s everything you need to know about how therapists determine what to bill to Medicare for outpatient therapy services (a.k.a. the 8-Minute Rule): CPT Codes  There are two types of CPT codes you’ll need to understand in order to bill properly: service- and time-based. Service-based (or untimed ) codes are those that you’d use for things like conducting a physical therapy evaluation or re-evaluation, applying hot/cold packs, or performing electrical …

  • Can You Ace Our 8-Minute Rule Quiz? [Quiz] Image

    articleJul 21, 2015 | 1 min. read

    Can You Ace Our 8-Minute Rule Quiz? [Quiz]

    Maybe you thought your days of grinding through word problems ended when you sold that college algebra textbook back to the university bookstore (for less than half of its original price). But if you’re a rehab therapist who treats Medicare patients, you probably have to call upon your math skills—and maybe even the ol’ TI-83 Plus—fairly often, because sometimes Medicare’s 8-minute rule seems more like a complex trigonometric function than a seemingly straightforward billing formula. Think you’ve …

  • The Complete PT Billing FAQ Image

    articleMay 24, 2016 | 25 min. read

    The Complete PT Billing FAQ

    Over the years, WebPT has a hosted a slew of billing webinars and published dozens of billing-related blog posts. And in that time, we’ve received our fair share of tricky questions. Now, in an effort to satisfy your curiosity, we’ve compiled all of our most common brain-busters into one epic FAQ. Don’t see your question? Ask it in the comments below. Questions related to: • WebPT • Modifier 59 • Other Modifiers • Coding • ICD-10 • …

  • Compliance Considerations with Holiday Gift Giving Image

    articleDec 11, 2014 | 4 min. read

    Compliance Considerations with Holiday Gift Giving

    The holidays are here; I love this time of year—it’s a time for reflection, for feeling grateful, and for giving gifts. As you create your gift-giving list, you may find yourself adding friends who also are your peers. Unfortunately, a problem can arise when you give a gift to someone who has the ability to refer patients to you, because you could inadvertently violate the Anti-Kickback Statute (AKS). This is a good place for me to insert …

  • One-on-One Services vs. Group Services Image

    articleDec 7, 2015 | 4 min. read

    One-on-One Services vs. Group Services

    Billing for one-on-one therapy and group therapy services can be tricky (so tricky you may need a bit of therapy yourself). You should never use one-on-one CPT codes if you’ve provided group therapy services, as doing so increases your risk of a Medicare audit. But what, exactly, are you allowed to bill? How do you even know if you’ve provided one-on-one or group therapy? Why is Medicare so complicated? While I don’t have the answer to that …

  • articleMay 21, 2013 | 4 min. read

    4 Key Things You Should Know About the MPPR Changes

    Today’s blog post comes from Chuck Felder, PT, DPT, SCS, MBA. For follow-up questions, please email Chuck at  CFelder@HCSconsulting.com . 1.)    What? In 2012, CMS began a process of reducing payment for therapy services based on multiple procedures performed during the same visit. This is termed the Multiple Procedure Payment Reduction (MPPR).  Despite APTA’s and others best efforts to get this removed, CMS began a 20% reduction policy on the second and subsequent procedure each day. This …

  • articleFeb 20, 2013 | 4 min. read

    Medicare Issues Facing Cash-Based PTs

    Today’s blog post comes from  Ann Wendel ,  PT.  Ann is the owner of  PranaPT , a member of WebPT, and an active social media participant (@PranaPT). Thanks, Ann! Grab a cup of coffee (or a stiff drink) because we’re going to talk about Medicare. Currently, there are two issues that we as physical therapists need to be aware of because they affect how we treat patients on a daily basis. First, it is vital for all …

  • Founder Letter: My Evaluation of the New PT and OT Eval Codes Image

    articleNov 3, 2016 | 5 min. read

    Founder Letter: My Evaluation of the New PT and OT Eval Codes

    Over the last several years, healthcare providers in general—and rehab therapists, specifically—have been hit with a seemingly constant barrage of regulatory requirements. And the vast majority of these initiatives—PQRS, functional limitation reporting, MPPR, ICD-10, and the like—have either: Had a direct negative impact on our payments, or Forced us to devote extra time to satisfying the criteria of the requirements—with zero compensation for that time. So, it should come as no surprise that the rehab therapy community …

Achieve greatness in practice with the ultimate EMR for PTs, OTs, and SLPs.