cumentation is a thorn in the side of many a rehab therapist. It can be convoluted, confusing, and insanely time-consuming—and it definitely doesn’t help that the rules change every year. (Thanks a lot, CMS.) But, even though writing SOAP documentation can feel like an unforgiving and tedious task, it still deserves your full and undivided attention—because distractions can trigger mistakes, which can trigger denials, which can trigger attention from CMS, which can trigger an audit.
Earlier this week, Heidi Jannenga, PT, DPT, ATC—WebPT’s Co-Founder and Chief Clinical Officer—and John Wallace, WebPT’s Chief Business Development Officer of Revenue Cycle Management, paired up to answer rehab therapists’ most burning billing questions during a live Q&A-style webinar.
With most buyer-seller transactions, calculating the cost of a product or service is fairly simple. There are no complicated formulas for determining the monetary value of a pizza or a movie ticket; you simply pay the business’s advertised price. When it comes to Medicare’s payment for rehab therapy services, however, things aren’t always so simple. Yes, I’m talking about the dreaded 8-Minute Rule (a.k.a. the Rule of Eights). So, here’s a rundown of the rule as well as how it works in WebPT—followed by a comprehensive FAQ.
The 8-Minute Rule governs the process by which rehab therapists determine how many units they should bill to Medicare for the outpatient therapy services they provide on a particular date of service (extra emphasis on the word “Medicare” as this rule does not apply to other insurances unless they have specified that they follow Medicare billing guidelines). Basically, a therapist must provide direct, one-on-one therapy for at least eight minutes to receive reimbursement for a time-based treatment code. It might sound simple enough, but things get a little hairy when you bill both time-based and service-based codes for a single patient visit—and therein lies the key to correctly applying this rule.
Time-Based vs. Service-Based
So first, let’s talk about the difference between time-based and service-based CPT codes. You would use a service-based (or untimed) code to denote services such as conducting a physical therapy examination or re-examination, applying hot or cold packs, or providing electrical stimulation (unattended). For services like these, you can’t bill more than one unit—regardless of the amount of time you spend delivering treatment.
Time-based (or direct time) codes, on the other hand, allow you to bill multiple units in 15-minute increments (i.e., one unit = 15 minutes of direct therapy). These are the codes you use for one-on-one, constant attendance procedures and modalities such as therapeutic exercise or activities, manual therapy, neuromuscular re-education, gait training, ultrasound, iontophoresis, or electrical stimulation (attended).
Minutes and Units
According to CPT guidelines, each timed code represents 15 minutes of treatment. But your treatment time for these codes won’t always divide into perfect 15-minute blocks. What if you only provide ultrasound for 11 minutes? Or manual therapy for 6 minutes? That’s where the 8-Minute Rule comes in: Per Medicare rules, in order to bill one unit of a timed CPT code, you must perform the associated modality for at least 8 minutes. In other words, Medicare adds up the total minutes of skilled, one-on-one therapy (direct time) and divides the resulting sum by 15. If eight or more minutes are left over, you can bill for an additional unit. But if seven or fewer minutes remain, Medicare will not reimburse you for another full unit, and you must essentially drop the remainder. To give a simple example, if you performed manual therapy for 15 minutes and ultrasound for 8 minutes, you could bill two direct time units.
However, when untimed codes come into play, things get a little more confusing. So, to figure out how many total units you should bill, you should always start by calculating your total time (i.e., direct time + unattended time). Then, check your total against the chart below to see the maximum total number of codes you can bill:
8 – 22 minutes
23 – 37 minutes
38 – 52 minutes
53 – 67 minutes
68 – 82 minutes
The key word here is “maximum.” There are times when you cannot bill the full number of units given in the chart. For example, let’s say that on a single date of service, you provide a patient with 30 minutes of therapeutic exercise, 15 minutes of manual therapy, 8 minutes of ultrasound, and 30 minutes of electrical stimulation (unattended). Per the 8-Minute Rule, you would first calculate the total treatment time: 30 min + 15 min + 8 min + 30 min = 83 total minutes
According to the chart, you could bill a maximum of 6 units. However, in this case, when adding up your direct time (time-based) codes, it equals 53 minutes. If you divide 53 by 15, you get 3 with a remainder of 8, which means you can bill 4 units of time-based codes. But because the untimed code accounts for the remaining 30 minutes of your total time—and you can only bill 1 unit for that an unattended modality regardless of how many minutes the patient spent receiving the service—you could not bill the full 6 units indicated in the chart above. Instead, you would bill 2 units of therapeutic exercise, 1 unit of manual therapy, 1 unit of ultrasound, and 1 unit of electrical stimulation (unattended), for a grand total of 5 units.
Last week, WebPT’s trio of billing experts—Dr. Heidi Jannenga, PT, DPT, ATC/L, WebPT President and Co-founder; John Wallace, PT, MS, WebPT Chief Business Development Officer of Revenue Cycle Management; and Dianne Jewell, PT, DPT, PhD, WebPT Director of Clinical Practice, Outcomes, and Education—hosted a live open forum on physical therapy billing.
There’s nothing scarier than a Medicare audit. But if you avoid these compliance mishaps, you can keep yourself—and your practice—out of the line of fire.
During our denial management webinar, we discussed the difference between rejections and denials, explained how to handle both, and provided a five-step plan for stopping them in their tracks. The webinar concluded with an exhaustive Q&A, and we’ve amassed the most common questions here.
Knowing when to bill for individual services in a group setting can be tricky. Here’s what to keep in mind.
Here are answers to every question you’ve ever had about Medicare Part B for outpatient rehabilitation services.
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. (And be sure to check out this separate PT billing FAQ we recently put together.)
Questions related to:
• Modifier 59
• Other Modifiers
• Advance Beneficiary Notice (ABN) of Noncoverage
• Contracts and Fee Schedules
• 8-Minute Rule
• Functional Limitation Reporting
• Cash-Pay Patients
How does WebPT help me bill better?
WebPT prompts users to apply modifier 59.
When WebPT detects that you have billed two codes that form a CCI edit pair, the system will alert you and ask whether you performed these services separately and distinctly of one another—and, therefore, should receive payment for both. If you attest that this is the case, WebPT will automatically apply modifier 59 to the appropriate code.
For WebPT Members
To activate this feature, please follow the steps below. Note that you’ll need to complete these steps for each insurance plan. We recommend applying this to commercial and government plans only (i.e. no workman’s compensation, legal/lien, and auto liability policies).
- Select “Display Insurance,” located on the left side of the WebPT Dashboard.
- Click “Edit” on the individual insurance for which you want to activate the feature.
- Once the insurance editing screen opens, check “Apply CCI edits”; then, select “Save.”
For Non-WebPT Members
If you’re not yet a WebPT Member, you can see this functionality and an array of other awesome features in a free, live online demonstration. Request one here.
WebPT tracks the therapy cap.
WebPT offers the Medicare Cap Report, which enables you to view Medicare beneficiaries’ progress toward the therapy cap and see whether therapists have affixed the KX modifier for those patients who have, in fact, exceeded the cap. In addition to tracking the therapy cap, WebPT alerts providers when a patient is:
- approaching the cap
- exceeding the cap (time to attach the KX modifier!)
- approaching the manual medical review threshold ($3,700)
- exceeding the manual medical review threshold
To learn more about the Medicare Cap Report and WebPT’s other compliance reporting and tracking capabilities, check out this blog post.
WebPT calculates the 8-minute rule.
As this blog post explains, “WebPT automatically double-checks your work for you and alerts you if something doesn’t add up correctly. All you have to do is record the time you spend on each modality as you go through your normal documentation process, along with the number of units you wish to bill. If those two totals don’t jibe, WebPT will not only let you know something’s off, but we’ll also tell you whether you overbilled or underbilled. That way, you can quickly identify and fix the problem—and thus, ensure accurate payment. Plus, you’ll have a detailed record of the services you provided on each date of service—something many local MAC auditors request to substantiate billing claims and processes.”
WebPT handles PQRS reporting.
WebPT is a certified PQRS registry. This means we collect PQRS claims data and submit it to Medicare on your behalf. We also have all the PQRS reporting requirements in our system, so depending on the Medicare beneficiary and visit, we’ll prompt you to complete the appropriate measure. Learn more about PQRS with WebPT.
What diagnosis code flows over from WebPT into my billing?
When you use WebPT, your treatment diagnosis is the one that is billed—not the medical diagnosis.
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?
Not every minute a patient spends in your office is billable. Here’s how to figure out which time warrants payment.