What is the 8-Minute Rule in Medicare?

8-Minute Rule in Medicare
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The team with Malhotra & Assoc. Insurance is ready to help you understand the Medicare program and how it works. If you are nearing Medicare eligibility or are currently enrolled, you may have heard of something called the 8-minute rule, but what is this rule?

Well, we have the answers!

What is the 8-Minute Rule?

Medicare has an 8-minute rule that applies to time-based Current Procedural Terminology (CPT) codes for certain outpatient providers. Medicare uses these codes to classify different procedures and services. Providers use these specific codes when they submit claims to Medicare.

The time-based 8-minute rule uses fifteen-minute increments to segment services and procedures into billable units. Eight minutes marks the beginning of the first billable unit. If a service lasts between eight and 22 minutes, Medicare can be billed for one unit. Between 23 and 37 minutes is two units, between 38 and 52 minutes is three units, and so on.

If you receive multiple services in one visit with your provider, your provider will bill Medicare based on how long each individual service takes. If any service lasts for less than eight minutes, Medicare will not be billed for that service.

Which Providers Follow the 8-Minute Rule?

The 8-minute rule with Medicare is used for in-person services where the provider is in direct contact with the patient. 

Medicare’s 8-minute rule applies to outpatient providers, including those with private practices, skilled nursing facilities, rehabilitation facilities, home health agencies providing therapy covered under Medicare Part B in the home of the Medicare beneficiary, and hospital outpatient departments.

The rule also applies if you have another federal type of health insurance, including Medicaid, TRICARE, and CHAMPUS.

How Does the 8-Minute Rule Work?

When you visit your in-person outpatient healthcare provider, it falls under Medicare Part B. Medicare Part B covers medically necessary and preventive care services, which can include things like clinical research, ambulance services, mental health care, doctor visits, and emergency room visits.

At every visit, you show your providers your red, white, and blue Medicare card. The providers will know to bill Medicare for your visit. They do this by filing a claim for the specific services they provided. In this case, they use the Current Procedural Terminology codes that apply to each service. For each service, they track how many minutes were spent performing the procedure, whether that meant treatment or a conversation to answer your questions. Any segment of the appointment that lasted fewer than eight minutes does not count as a billable unit, so those minutes spent in that segment are not added to the rest. The rest of the in-person procedure minutes are used to count how many billable units that your provider can claim payment from Medicare for.

Say you visit your physical therapist. They fall under outpatient Medicare Part B services. During your appointment, you spend six minutes describing your current condition and any changes since the last appointment before the physical therapist begins your treatment protocol. The protocol itself lasts 27 minutes. Because the initial conversation took less than eight minutes, that time does not count toward the billable units. The remaining 27 minutes add up to two billable units, which is what your provider will bill Medicare for.

Call Our Medicare Experts Today

Malhotra & Assoc. Insurance has a team of experts ready to answer all of your Medicare questions. Reach out to our team today for more information about Medicare billing and keeping track of your claims statements.

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