8 Minute Rule - AMA or CMS?
Unfortunately, very few therapists understand the core differences between billing for insurances that follow AMA guidelines and insurances that follow CMS guidelines. Within your EMR, you should be able to set up and customize the billing and payer settings to ensure you are billing accurately and getting reimbursed properly for the services you have rendered.
8-Minute Rule Cheat Sheet:
Please note: It is important for you or your billing team to verify with each insurance carrier to determine which guidelines they follow.
Before addressing the 8 minute rule, it is imperative to understand the difference between service-based CPT codes and time-based codes. Short and sweet, here’s a breakdown:
Service Based codes can only be billed once per treatment session, no matter how long the procedure takes.
Examples:
physical therapy evaluation (97161, 97162, or 97163) or re-evaluation (97164)
hot/cold packs (97010)
electrical stimulation (unattended) (97014)
Time Based codes are codes that are billed in 15 minute increments and billed based on how long the procedure takes.
Examples:
therapeutic exercise (97110)
therapeutic activities (97530)
manual therapy (97140)
neuromuscular re-education (97112)
gait training (97116)
ultrasound (97035)
iontophoresis (97033)
electrical stimulation (manual) (97032)
Now to the fun stuff... How do CMS and AMA guidelines differ?
CMS:
Per CMS, in order to bill one unit of a timed CPT code, you must perform that associated modality for at least 8 minutes. Medicare takes the total time spent in a treatment session and divides by 15 to figure out how many units are rendered on a given service date. If eight or more minutes are left over, you can bill that time as an additional unit. If 7 or less minutes are left over, you must drop those minutes and not bill for them. Simply put, Medicare takes total time and uses the chart below to determine how many units were rendered on a particular treatment session.
8-22 minutes : 1 unit
23-37 minutes : 2 units
38-52 minutes : 3 units
53-67 minutes : 4 units
68-82 minutes : 5 units
83 minutes+ : 6 units
American Medical Association (“AMA”):
The main difference under AMA guidelines is that the AMA does not calculate the total time or cumulative time of a treatment session. They consider each unit and each unit must be at least 8 minutes in order to bill for it. This is why some people call the AMA guidelines the “Rule of 8’s.”
Some Examples for Understanding:
You bill 97530 for 8 minutes and then bill 97110 for 8 minutes = 2 units billed under AMA guidelines. *1 unit billed under CMS guidelines.
You bill 97530 for 16 minute and then bill 97110 for 7 minutes = 1 unit billed under AMA guidelines. *2 units billed under CMS guidelines.
You bill 97530 for 8 minutes, 97110 for 8 minutes and 97112 for 8 minutes = 3 units billed under AMA guidelines. 2 units under CMS guidelines.
Avoiding 8 Minute Rule Mistakes:
First and foremost, you want to make sure you have customized your software so that it can handle all the intricacies of accurate billing. Since payers are unique to each region, it is imperative you determine which rounding rule various insurances are following.
This determination is one component of the strategic assessment LRS provides its clients, along with continuous updates and adjustments to stay ahead of the curve.
Contact us to Set up a free assessment of your practice.
