What is The 8-Minute Rule for Medicare?

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Contributor, Benzinga
November 16, 2021

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The 8-minute rule for Medicare stipulates that outpatient services like physical therapy must perform at least 1 billable unit to charge Medicare. A billable unit is at least 8 minutes but no more than 22. The rule went into effect on April 1, 2000.

Billable units are divided into 15 minute chunks known as Current Procedural Terminology (CPT) codes. However, all treatments don’t last exactly 15 minutes. That’s where the 8-minute rule comes in. If the next chunk is at least 8 minutes long, then this overage is counted as a unit.

The 8-minute rule goes into effect only when the provider has direct contact with the patient, like physical therapy. When there is more than 1 service, Medicare is billed for each individual service. If any 1 individual procedure does not last at least 8 minutes, Medicare is not billed an additional billable unit.

What Is the 8-Minute Rule?

Medicare charges are based on billable units. Types of physical therapy can include:

  • Pain therapy
  • Nerve injuries
  • Sports injuries
  • Congenital conditions
  • Brain disorders

Nurses at a skilled nursing or rehabilitation facility who have direct contact with patients also fall under the 8-minute rule. Emergency rooms and home health care are included as billable units as well.

Outpatient providers who follow the Medicare 8-minute rule include:

  • Skilled nursing facilities
  • Rehabilitation facilities
  • In-home health care treatments (under Part B)
  • Emergency rooms

The Medicare 8-minute rule applies CPT codes as required by the Centers for Medicare and Medicaid Services. The rule applies to all Medicare providers, but not necessarily private insurance. If a private provider wishes to employ the 8-minute rule, it must stipulate it in the policy. In private insurance, under the Substantial Portion Methodology, there is no billing for leftover minutes.

Because treatments cannot be divided into perfect 15-minute allotments, the 8-minute rule provides that if there are 8 minutes or more, Medicare will pay for an additional unit. At 7 minutes or less, there is no reimbursement. Billable units break down as such:

8-22   minutes1 unit
23-37 minutes2 units
38-52 minutes3 units
53-67 minutes4 units
68-82 minutes5 units
83-97 minutes6 units

Care must be performed by the attending physician or other skilled provider. Diagnostics, like time spent determining the patient’s condition for that day, is counted as skilled and therefore is billable. Services provided by an aide are deemed unskilled and thus not billable. This kind of work does not conform to the one-on-one definition of the 8-minute rule. As well, any time spent waiting, changing or resting does not count either. 

Medicare, Physical Therapy and the 8-Minute Rule

The 8-minute rule applies to any direct contact between physician and patient, affecting mainly physical therapy. Medicare pays for physical therapy only when it’s deemed medically necessary, and the determination, after being made by the doctor, must be approved by Medicare.

Physical therapy is deemed necessary when it:

  • Improves your current physical condition
  • Maintains your current physical condition
  • Slows down any deterioration of your physical condition

If your physical therapy is administered on an inpatient basis, such as in a hospital, then it’s covered by Medicare Part A. Coverage under Part A can be extended to as much as 3 days when you’re discharged to a skilled nursing facility or your home.

For outpatient services, Part B pays for physical therapy procedures:

  • At a doctor’s office or a therapist
  • At outpatient facilities in a hospital
  • At outpatient rehabilitation facilities
  • At skilled nursing facilities if you qualify for outpatient services
  • At your home if not covered by Part A

You’re responsible for 20% of Part B services if you don’t have a Medicare supplement or advantage plan. Deductibles may apply.

Medicare does not cover massage therapy. Massage therapy is considered alternative therapy and thus is not covered by Medicare.

Who Is Required to Bill by the 8-minute Rule?

  • Medicare
  • Medicaid
  • Medicare Advantage Programs
  • Tricare (Armed Services)
  • Blue Cross for Federal employees
  • Champus for veterans
  • Office of Workers’ Compensation Programs
  • Medicare Plus Blue

How Does the 8-Minute Rule Impact Your Care?

When it comes to billing Medicare, the 8-minute rule can mean the difference between you getting the minimum amount of care you need or just the right amount. Let’s say, for example, a therapist bills 2 units for 37 minutes. While this does qualify for 2 units, still it’s just 1 minute away from the next charge unit. Would you, the patient, have benefitted from more time? Was the decision based on billing or by what you really needed medically?

If you had private insurance, or were paying for the session yourself, limits like these would likely not be placed on your care. In the case of private insurance, the decision on how much therapy time you get is based on your medical needs in conjunction with specifications of your healthcare insurance policy. 

Coordinate With Your Provider

Outpatient services are covered by Medicare Part B. Part B pays for 80% of your medical costs after your $203 deductible. There is no limit to how much it will pay in 1 calendar year.

Although there used to be a limit of $2,080 on what Medicare would pay in a calendar year for physical therapy services, Congress eliminated this cap in 2018.

If your physical therapy is inpatient care, then Medicare Part A picks up the tab. If your physical therapy is prolonged, you could pay a Part A deductible of as much as $1,364 for the 1st 60 days. For days 61 to 90, your coinsurance could go as high as $341 per day. After day 91, as much as $682 per day.

These high costs are why you should consider buying a Medicare supplement plan. Medicare supplement plans help pay your deductibles and coinsurance. 

In the case of physical therapy needs, coordinate with your provider and see what kind of and how much treatment you’re going to need. Ask your physical therapist:

  • How many physical therapy sessions will your treatments require?
  • What is the cost per treatment?
  • Where will the treatment take place?

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Frequently Asked Questions

Q

What is the 8-minute rule?

A

The 8-minute rule stipulates that outpatient services like physician therapy must perform at least 1 billable unit to bill Medicare for the service. Billable units get divided up into chunks of 15 minutes. A billable unit is defined as at least 8 minutes but no more than 22. 

 

Q

Does the 8-minute rule apply only to Medicare?

A

While the 8-minute rule applies to all Medicare and Medicare-related providers like Medicaid, Tricare and Medicare advantage plans, it does not apply only to Medicare. Private insurers may  go by the 8-minute rule if they choose. Check your policy to see if your provider adheres to the 8-minute rule.