Medicare’s 8-Minute Rule

As a Medicare recipient, you may need services like physical therapy or other hands-on manual treatments. That’s no surprise. But did you know that how these kinds of services are billed by your provider can make a difference?

Your doctor or provider bills Medicare for care they provide to you, so it’s important that they are submitting items correctly to avoid delays in payment or denials of coverage. This is where the Medicare 8-minute rule can be a factor. Let’s take a look at how it works!

What Is the Medicare 8-Minute Rule?

The Medicare 8-minute rule is designed to protect patients and help providers with straightforward guidance for billing certain kinds of in-person services.

Despite the name, the rule is based on 15-minute increments of time as provided by the health care professional. So, how does the 8-minute name come in? Simple. To ensure that a minimum amount of time is spent on in-person therapy, a provider may only claim billable time once the time spent with the patient is 8 minutes or more.

This removed any previous incentive that a provider may have had to perform 1 minute of covered services for their patient and then bill them for a full 15-minute “unit.” It was determined that very short sessions (a few minutes or less) may be of little to no value to patients. Under the 8-minute rule, the service minimum is 8 minutes, then 15-minute increments begin and go up from there. This means a “one unit” service can take between 8 and 22 minutes, a “two unit” service is from 23 and 37 minutes and so on.

Which Services Apply to the Medicare 8-Minute Rule?

The Medicare 8-minute rule applies to “time-based” billing codes, such as physical therapy, occupational therapy and speech therapy services provided in outpatient settings. The service must be in-person and requires the constant attention of the provider, such as ultrasounds or gait training.

It does not apply to “service-based” codes, which are billed as one unit no matter how long the service lasted, and does not necessarily require the provider to be in-person. These include physical therapy evaluations or unattended electrical stimulation, to name a few.

The 8-minute rule is intended to ensure that Medicare is only billed for the services that were actually provided and that providers are not overbilling for services that did not meet the minimum time requirement.

Protections for you Under the 8-Minute Rule

While the Medicare 8-minute rule is intended to ensure accurate billing for therapy services, it also helps to protect patients. Here are some ways in which the rule works in the patient’s favor:

1. Protection from over-treatments: Helps to guide providers from extending therapy sessions beyond what is needed. For example, a 10-minute session may be plenty, while 20 minutes could be too much. Both of these times would be billed as one unit under the 8-minute rule. This can prevent the patient from receiving unnecessary therapy, which may not be beneficial or could even cause harm.
2. Protection from under-treatment: Providers must spend 8 or more minutes on direct treatment for their patients. Sessions of just a few minutes are not acceptable — this helps to ensure a critical mass of treatment that will help the patient progress.
3. Correct documentation of services: When providers accurately document their time spent on patient services, they are able to have their billing claims processed quickly and without delays. This helps them to serve their patients better!
4. Less risk of billing and payment delays. As a patient, it is still important that covered services are billed correctly so that there are no delays in your longer course of treatment. The 8-minute rule makes submitting accurate claims simpler for your provider.

Risks to the Patient Under the 8-Minute Rule

The Medicare 8-minute rule is meant to ensure minimum treatment times for patients, but it could also be used negatively by providers. As a Medicare recipient, it helps to know these risks so that you can have frank conversations with your provider if you do not feel comfortable with your course of treatment.

1. Over-billing: Providers may extend therapy sessions beyond a particular minute mark to bill for an additional unit of service — for example, extending a session from 20 minutes to 25 minutes in order to bill two units instead of one. This could cause the patient to receive unnecessary therapy, which may waste their time or could even cause harm.
2. Under-treatment: Providers may be incentivized to limit therapy sessions to just 8 minutes — when, for example, 20 minutes would be better — in order to minimize the amount of care they provide and maximize their profits. This could result in the patient receiving insufficient therapy, which may delay their recovery or worsen their condition.
3. Documentation errors: Inaccurate documentation of the time spent on each therapy service can lead to incorrect billing, which could result in overpayment by Medicare or under-treatment of the patient. If a provider fails to accurately document the time spent on each service, they may also be subject to audits and penalties.
4. Focus on billing instead of taking care of their patient: Providers may be focused more on meeting the minimum time requirement for billing than on providing quality care that meets the patient’s needs. This could result in the patient receiving suboptimal therapy that does not meet their health needs or goals.

Despite these caveats, the 8-minute rule has been useful for patients and their providers over the last 20 years. The 8-minute rule has helped to avoid billing and payment delays, and to ensure that patients are receiving minimum levels of care for time-based services.

Conclusion

Medicare is guided by many rules, checks and balances that help to create a better experience for everyone. The Medicare 8-minute rule is just one of many formal rules that help you get the care you need, and your health care provider is compensated for their services to you.

The whole topic of Medicare rules can feel overwhelming, especially when they affect providers as well as patients! We hope we’ve given you some understanding of the Medicare 8-minute rule and how it works.

If you have any questions about Medicare or Medicare coverage, please feel free to give us a call. One of our PlanEnroll agents will be happy to help you. Call us to speak with a licensed insurance agent today.

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