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Medicare and the 8-Minute Rule

Summary: The Medicare 8-minute rule is typically used by physical therapists and other service-based providers for billing and claims. It’s important to understand the 8-minute Medicare rule so that you know how your Medicare coverage gets charged for any services you may receive from healthcare providers under this rule. Estimated Read Time: 5 mins

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Table of Contents:

  1. What is the Medicare 8-Minute Rule?
  2. How Does Medicare’s 8-Minute Rule Work?
  3. Who Follows the 8-Minute Medicare Rule?
  4. Other Types of Health Insurance that Use the 8-Minute Rule
  5. Exceptions to the 8-Minute Rule for Medicare Services
  6. Examples of How the 8-Minute Rule Works for Medicare Beneficiaries
  7. Impact of the 8-Minute Rule on Patients
  8. Possible Costs for Patients Under the Medicare 8-Minute Rule

As a Medicare beneficiary, it’s helpful to be acquainted with terms such as Medicare’s “8-minute rule” to understand how Medicare gets charged for the services you receive. Due to the limited understanding of some practitioners regarding this rule, errors occasionally happen. These errors can result in delayed reimbursement or underbilling.

The Medicare 8-minute rule is most commonly used for physical therapy services. Physical therapists and other service-based providers bill Medicare for the services beneficiaries receive. Billing and claims procedures involve the use of CPT (Current Procedural Terminology) codes and rules. The 8-minute rule, which is followed by Medicare, is one of these rules. We’ll discuss why it is important for beneficiaries to understand what the 8-minute rule is and how it works.

What is the Medicare 8-Minute Rule?

Medicare’s 8-minute rule is determined by the Centers for Medicare and Medicaid Services (CMS). It is a stipulation that applies to time-based CPT codes for outpatient services, such as physical therapy. Introduced in December 1999, the 8-minute rule became effective on April 1, 2000.

The rule allows practitioners to bill Medicare for one unit of service if its length is at least eight minutes but less than 22 minutes. A billable “unit” of service refers to the time interval for the service. Under the 8-minute rule, units of service consist of 15 minutes each.

Medicare 8-Minute Rule

How Does Medicare’s 8-Minute Rule Work?

The 8-minute rule applies only to services where the practitioner has direct contact with the patient. Therefore, the service must be in-person for the 8-minute rule to apply.

If you’ve received more than one service, Medicare will be billed based on total timed minutes per discipline. If an individual service takes less than eight minutes, Medicare won’t be billed for it.

The services are then billed in 15-minute units. Therefore, if a service or services take(s) 20 minutes, Medicare will be billed for one unit because the number of minutes falls between eight and 22.

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If 23 to 37 minutes is spent on the service(s), Medicare can be billed for two units. If the service(s) take(s) 38 to 52 minutes, the practitioner can charge for three units, and this pattern continues (in 15-minute intervals) beyond two-hour services (see chart).

The 8-minute rule applies only to services where the practitioner has direct contact with the patient. Therefore, the service must be in-person for the 8-minute rule to apply.

If you’ve received more than one service, Medicare will be billed based on total timed minutes per discipline. If an individual service takes less than eight minutes, Medicare won’t be billed for it.

The services are then billed in 15-minute units. Therefore, if a service or services take(s) 20 minutes, Medicare will be billed for one unit because the number of minutes falls between eight and 22.

If 23 to 37 minutes is spent on the service(s), Medicare can be billed for two units. If the service(s) take(s) 38 to 52 minutes, the practitioner can charge for three units, and this pattern continues (in 15-minute intervals) beyond two-hour services (see the above Medicare 8-minute rule chart).

Who Follows the 8-Minute Medicare Rule?

The 8-minute rule is not used in all healthcare settings. It’s mainly used in certain outpatient settings. The following outpatient providers follow the 8-minute rule when billing Medicare for their services:

  • Private practices
  • Skilled nursing facilities
  • Rehabilitation facilities
  • Home health agencies providing therapy covered under Medicare Part B in the home of the beneficiary
  • Hospital outpatient departments (including emergency)

The common thread among practitioners who follow the 8-minute rule is that the services they provide are outpatient and in-person.

Other Types of Health Insurance that Use the 8-Minute Rule

The 8-minute rule also does not only apply to Medicare. It applies to federally funded plans, including those listed below:

  • Medicaid
  • TRICARE
  • CHAMPUS (Civilian Health and Medical Program of the Uniformed Services)

Additionally, some commercial plans also follow the 8-minute rule. Since Medicare requires the 8-minute rule to be followed for these in-person, outpatient services, providers do not have the choice of using another billing method.

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Exceptions to the 8-Minute Rule for Medicare Services

The 8-minute rule only applies to one-on-one direct contact outpatient services. This means that services such as group therapy don’t apply. Some telehealth services may also be exempt from the 8-minute rule, but you would have to check with your health service provider.

There are also certain cases where a healthcare provider may be able to bill for extra time spent on a service if that service requires more time than the time assigned.

However, if you don’t use all of the minutes assigned to your outpatient service, your healthcare provider won’t bill Medicare extra for time not used.

Examples of How the 8-Minute Rule Works for Medicare Beneficiaries

Lynne visits the hospital where her physical therapist’s office is located. She receives 31 minutes of therapeutic exercise and 14 minutes of manual therapy. She then goes upstairs and receives an ultrasound, which takes nine minutes. The total number of minutes between services is 54, so Lynne’s Medicare plan will be billed for a total of four units of service.

As shown in the above example, the ultrasound is not billed separately. Since each service takes longer than eight minutes, the minutes are added together and billed to Medicare as the total number of units.

As another example, Gregory visits his physical therapist’s private practice. His physical therapist spends 16 minutes assessing his situation, 23 minutes on manual therapy, and seven minutes answering Gregory’s questions. This visit totals 46 minutes, so the office will charge Medicare for three units of service.

At times, providers are unaware of the full range of services for which they should bill, such as assessments. This results in underbilling. Therefore, patients should understand what Medicare can and should be charged for so they can be confident they are not being overbilled. It is also crucial for providers to keep this in mind so they do not underbill for services.

Impact of the 8-Minute Rule on Patients

The 8-minute rule may have a negative impact on Medicare beneficiaries as it can cause limited access to some outpatient services, especially therapy services. Due to these billing regulations, some providers may limit the length of therapy sessions or only provide services to those who need at least 8 minutes of continuous one-on-one care.

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Possible Costs for Patients Under the Medicare 8-Minute Rule

In addition to billing, If you have Original Medicare, you are responsible for up to 20% of coinsurance costs for any Part B outpatient services. However, if you have a Medicare Supplement (Medigap) plan, your out-of-pocket costs could be less, depending on the Medicare Supplement plan.

Medicare Advantage plans (Medicare Part C) have a different billing schedule. This means that even though the 8-minute rule still applies to services for MA beneficiaries, your costs may vary based on the plan and network.

How to Get Help Understanding the 8-Minute Rule

We hope the above information helps in clearing up any confusion you might have about the 8-minute rule. It’s advantageous for Medicare beneficiaries receiving physical therapy or another outpatient, direct-contact services to understand how Medicare is billed.

If you’re in search of a Medigap plan to cover what Original Medicare doesn’t, give us a call. Our team of licensed insurance agents is here to help you find a plan that fits your needs. You may also fill out an online rate form to see options available in your area.

Sources

MedicareFAQ is dedicated to providing you with authentic and trustworthy Medicare information. We have strict sourcing guidelines and work diligently to serve our readers with accurate and up-to-date content.

Jagger Esch

Jagger Esch

Medicare Educator
Jagger Esch is the Medicare Educator for MedicareFAQ and the founder, president, and CEO of Elite Insurance Partners and MedicareFAQ.com. Since the inception of his first company in 2012, he has been dedicated to helping those eligible for Medicare by providing them with resources to educate themselves on all their Medicare options. He is featured in many publications as well as writes regularly for other expert columns regarding Medicare.
Ashlee Zareczny

Ashlee Zareczny

Compliance Manager
Ashlee Zareczny is the Compliance Manager for MedicareFAQ. As a licensed Medicare agent in all 50 states, she is dedicated to educating those eligible for Medicare by providing the necessary resources and tools. Additionally, Ashlee trains new and tenured Medicare agents on CMS compliance guidelines. Ashlee is a Medicare expert who specializes in Medicare Supplement, Medicare Advantage, and Medicare Part D education.

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