Medicare 8 Min Rule Physical and Occupational Therapy

[JDuhaime]

Looking to get some information on the 8 min rule. I code for ortho (New to Physical Therapy) and our PT department bills everything by the 8 min rule. After lots of research- I know the cpt codes are 15 min time based- I know Medicare allows the 8 min. However not all insurances do, Does anybody have any insight on how to go forward with billing PT/OT codes?

 

[thomas7331]

I don't think the '8 minute rule' is specifically a Medicare rule - it's part of the CPT guidelines for code selection. You'll find it documented in the introduction to the CPT book under 'Instructions for Use of the CPT Codebook' in the section on 'Time': "A unit of time is attained when the mid-point is passed. For example, an hour is attained when 31 minutes have elapsed (more than midway between zero and sixty minutes)." Since most PT codes include 'each 15 minutes' in their descriptions, 8 minutes is the minimum time necessary to pass the midpoint for use of the code.

Any payer that accepts these CPT codes would by default recognize those guidelines unless they have a published policy or contract clause that instructs you to bill differently. Typically, if a payer disagrees with CPT guidelines, in order to avoid confusion, they will simply not accept those codes at all and require you instead to use substitute codes (as Medicare does with the 'G' HCPCS codes) which have different descriptions attached.

 

[leagle]

It is insurance specific, and not all insurances follow that rule - with the exception of federal payers as they all do (Medicare, Medicaid, VA, Tricare, DOL,etc). For example, BCBS of MI's Provider Manual for PT/OT/ST specifically says that they do not. So, you would have to check each insurance if you didn't want to bill using the 8 min rule across the board. We have recently implemented not using it for our local Blue patients.