There are certain aspects of Medicare it is important to understand as a beneficiary, especially when it comes to how Medicare is charged for any care you receive.

Although rare, errors that result in billing issues or delayed reimbursement can happen, and knowing how the process works is a huge benefit in getting things back on track. All billing and claims procedures use Current Procedural Terminology (CPT) rules, one of which is the 8 minutes rule.

What is the Medicare 8 minutes rule?

The Medicare 8 minutes rule has been in effect since 2000 and applies to time-based CPT codes for any outpatient care. It allows practitioners to bill Medicare for "units" of services, with the unit being the amount of time the service takes. To be considered a billable unit, it must be at least 8 minutes, but fewer than 22 minutes. Each unit consists of 15 minutes each. So an appointment that lasts between 8 and 22 minutes is considered one unit, an appointment lasting between 23 and 37 minutes is two units, and so on. Medicare is not billed for a service if it takes less than 8 minutes.

The 8 minutes rule only applies to care or services where the practitioner has direct contact with the patient, so any services that are not in-person do not go through the 8 minutes rule. If you receive multiple services, Medicare is billed based on the total timed minutes per discipline.

Who has to follow the 8 minutes rule?

Multiple providers follow the Medicare 8 minutes rule when billing for services, including:

• Home health agencies that provide Medicare-covered therapy in the beneficiary's home
• Hospital outpatient departments
• Private practices
• Rehabilitation facilities
• Skilled nursing facilities

Practitioners that follow the 8 minutes rule typically provide both in-patient and out-patient services. The 8 minutes rule applies, not only to Medicare, but to other federally funded plans, such as:

• Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)
• Medicaid
• TRICARE

There are also some commercial plans that follow the 8 minutes rule; they do not have the choice of another billing method since Medicare requires the rule to be followed for any in-person, outpatient services.

Examples

If a provider does not know the full range of services they should bill for, this can result in Medicare being underbilled, which in turn results in beneficiaries being overbilled. This is why it is crucial to understand the things Medicare can and should be billed for- so you know that charges on both ends are what they should be.

Let's say Jane goes to the hospital where her physical therapist's office is. She has therapeutic exercises for 40 minutes, followed by 20 minutes of manual therapy. Afterwards, she gets an ultrasound that takes 10 minutes. That is a total of 70 minutes of service, so her Medicare plan will be billed for five total units of service. Since none of the services were less than 8 minutes, they are all added together to reach the total unit count.

Another example: Sarah goes to her physical therapist's office. Her physical therapist spends 15 minutes assessing her needs, 35 minutes conducting manual therapy, and five minutes answering Sarah's questions. Since only services lasting at least 8 minutes count towards billing, the visit is only considered 50 minutes. Her Medicare plan would be billed for three units of service.

Again, understanding how the 8 minutes rule works gives you direct insight into how billing works for your Medicare plan. With this knowledge, it is easier to act if you or your plan are ever overbilled or underbilled.

Additional resources

CMM: Find a Medicare Plan