The 8-minute rule is a term and a billing protocol used by pediatric therapists, including occupational therapists, physical therapists, and speech therapists, to determine how many units they should bill to Medicaid for any outpatient services they provide.

Occupational Therapy is a service based on codes. Each treatment, procedure, or examination has a CPT Code, which is used to identify it at the moment to bill each service applied. Each timed code is supposed to represent 15 minutes of treatment. Since not all treatments can be perfectly divided into 15-minute increments, the 8-minute rule exists to determine how many units you should bill for in those cases.

It is referred to as the 8-minute rule in Occupational Therapy because that’s the minimum length of therapy a professional must provide in order to receive reimbursement from Medicaid. 

The 8-minute rule allows therapists to bill Medicare insurance for one full unit if the service provided is between 8 and 22 minutes. Note that this can only be applied to existing time-based CPT codes.

The rule does not apply to service-based codes or untimed codes. Time is not the primary factor in determining the procedure’s value. And it’s billed the same whether the treatment lasts 5 or 30 minutes. Let´s see both types of CPTs:

  • Service-based CPT codes do not charge by the hour or minute. It is set by a flat rate regardless of how long or short the PT provides the treatment. 
  • On the other hand, time-based CPT codes are billed by the hours the treatment session took. The longer the Physical Therapist spends with the patient, the more units or increments of time can be billed. 

For example, if the Physical Therapist provided therapeutic exercises and the session lasted 15 minutes, then it would be 1 billable unit. But if the therapist added 15-minute gait training to that, it would be 2 units

Why the 8-Minute Rule?

The 8-minute rule seeks to protect all parties, including the service provider. This clear format of billing units for physical therapy will reduce denials of claims and grant the patient their treatment is well provided. Here we can connect you with healthcare providers without worrying you about the amount of time provided to your treatment.

The purpose of the 8-minute rule in Occupational Therapy is to: 

  • Ensure patients get the adequate that they need 
  • Protect the patient’s rights
  • Avoid overcharging to Medicare

When the 8-Minute Rule Applies

 These are some cases where the rule is applied:

  • If the specialist performs a 35-minute initial evaluation and a 7-minute therapeutic exercise, you can only bill one unit for the initial evaluation.

In this case, the initial evaluation is not considered a time-based CPT code, and the 7 minutes of therapeutic exercise did not reach the 8-minute threshold. The provider needs to spend a little more time with the patient in order to bill for the therapeutic exercise successfully.

  •  If the specialist performs 30 minutes of therapeutic exercise, 15 minutes of manual therapy, and 9 minutes of ultrasound, then the provider has seen the patient for 54 minutes and is eligible to bill for 4 units. The time spent performing the ultrasound was greater than 8 minutes, so they’re able to bill for one full unit.

For example, when only one service is provided in a day, providers should not bill for services performed for less than 8 minutes. For any single-timed CPT code in the same day measured in 15-minute units, providers bill a single 15-minute unit for treatment greater than or equal to 8 minutes through and including 22 minutes.

In Conclusion 

Accurate service billing is essential, as it fosters fair compensation and patient trust. Documenting treatment anytime decreases the chances of overbilling or undercharging. By utilizing this billing protocol, our professionals and healthcare providers reinforce transparency in their services; as a patient, you will get the proper treatment and Medicare bills for what is fair for the services provided.