MDS Alert

Published on Mon Apr 16, 2012 PDF

The following Q&A has been provided by Rick Gawenda, PT, president of Gawenda Seminars & Consulting Inc.

Question: Does Medicare's "8-minute rule" apply to non-Medicare insurance companies such as commercial insurance companies and state workers compensation programs?

Answer: The "8-minute rule" was developed by CMS and is applied to Part B therapy services reimbursed under the Medicare Physician Fee Schedule. It does not apply to other insurance companies unless the insurance company tells you in a policy or some other written notice that they are following Medicare's "8-minute rule" for their members receiving outpatient therapy services. The CPT® codes are developed by the American Medical Association (AMA) and are owned and copyrighted by the AMA. It is AMA's intent that providers look at how much time each time based intervention was provided towards the "each 15-minutes" or "per hour" time based CPT® codes.

The AMA defines substantial as providing more than half the time of the time based CPT® code. For example, for a 15-minute time based CPT® code, more than half would be 8 minutes. For a 30-minute code, more than half would be 16 minutes and for a 1-hour code, more than half would be 31 minutes. While that is the intent of the AMA, the AMA realizes that some insurance carriers can be more or less restrictive. CMS choose to be more restrictive, hence, providers must then follow the "8-minute rule" for Medicare beneficiaries receiving outpatient therapy services.

There are two references for my answer that I would recommend you review. The first is either the 2011 or 2012 CPT® book. In the beginning of those books in the roman numeral pages, you will find written documentation from AMA defining that substantial is more than half the code. The second reference is CPT® Assistant December 2003. AMA provides a case scenario and documents page 6 of this publication as the AMA provides a case scenario and documents what their intent is for the billing with their rationale why. The publication costs $19.95 and can be purchased at https://catalog.ama-assn.org/Catalog/cpt/issue_search.jsp.