The 8-Minute & 15-Minute Rule
In order to seek reimbursement for a unit of service for a constant attendance modality or a therapeutic procedure, the provider must spend at least eight minutes (just past the halfway point of 15 minutes) providing that service to the patient. According to CMS (Medicare) guidelines, if the service is performed for less than eight minutes, do not bill for the code. The 8-Minute Rule further dictates that in order to bill for additional time-based units, you must spend at least eight minutes providing one-on-one service to the patient to warrant the additional code. For any single timed CPT code on the same day, measured in 15-minute units, providers must bill a single 15-minute unit for treatment greater than or equal to 8 minutes through (and including) 22 minutes. If the duration of any single modality or procedure completed in a day is greater than or equal to 23 minutes (through and including 37 minutes) then 2 units are billed.
Total Billable Units
The units per number of minutes are calculated as follows:
||Greater than or equal to 8 minutes through 22 minutes
||Greater than or equal to 23 minutes through 37 minutes
||Greater than or equal to 38 minutes through 52 minutes
||Greater than or equal to 53 minutes through 67 minutes
If multiple time-based services are performed on the same day in increments of 7 minutes or less and the total time is 8 minutes or greater, bill one unit for the service performed for the most minutes. This is allowed because the total time for all services was greater than the minimum time for one unit.
Note: only direct, one-on-one time with the patient is considered for timed codes.
Another easy calculation for billing multiple timed codes performed during the same visit is:
If 8 minutes or more are leftover, bill one additional unit. If 7 minutes or less are leftover, do not bill an additional unit.
 Medicare Claims Processing Manual, 100-4, Chapter 5, Sections 10, 20, 30, 40, 100 Medicare Benefit Policy Manual, 100-2, Chapter 15, sections 220 and 230
Identify & Follow the Requirements
Practices that dispense and bill Durable Medical Equipment (DME) to third-party payers must pay close attention to the billing requirements of the carrier being billed as they often vary from carrier to carrier. Several factors come into play when billing directly to third-party payers:
- What diagnosis codes are considered medically necessary, and therefore payable, according to the carrier’s Medical Review Policy (MRP)? Is the diagnosis/condition the doctor assigned for your patient included?
- Are the billing codes that describe the orthotics your office dispensed listed in the MRP as covered billing codes?
- After verifying the patient’s third-party coverage, are orthotics a covered benefit? If so, how often can they be dispensed and paid for by the carrier?
- Will the carrier pay for more than one pair of orthotics in a period of time?
- Do you know the allowable fee for the orthotics according to the provider fee schedule? If so, is it going to cover the cost of the orthotics?
- Does the carrier you’re billing require that a certified DME provider or company bill all DME? If so, are you considered this type of provider? If not, there may be no coverage for the patient for DME dispensed directly by the doctor.
Billing orthotics on your CMS-1500 billing form is not very different from billing other services. Figure 1 shows an example of the billing section of the form and how it might look if billing for a diagnosis of Plantar Fascial Fibromatosis. Notice that one pair of orthotics was prescribed and dispensed for a total actual fee of $250 for the pair. The bill includes both the left and right orthotic, and each line item represents one unit of the pair. (Example provided for educational purposes only)
If the carrier’s allowance included coverage for two pairs of orthotics and each pair cost $250.00, Figure 2, below, illustrates how billing might differ. Notice that each line item represents two units each for the left and right orthotic, for a total of two pairs.
It’s important to understand the meaning of a Medically Unlikely Edit (MUE). An MUE is a Medicare unit of service claim editapplied to healthcare claims against a procedure code for services rendered by one provider/supplier to one patient on a single day. An MUE for an HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. Commercial carriers sometimes use these edits to screen for unlikely circumstances that should not be paid (e.g., It may be unlikely to dispense two pairs of orthotics to the same patient on the same day.) The edit might capture the service and automatically deny it, but if the coverage has been verified, and it allows for two pairs, and they are medically necessary, don’t hesitate to appeal the denial. The documentation in the patient’s clinical record should reflect the medical necessity for more than one pair and outline the details needed to justify the order.
All codes are not the same – just because a code is covered by a health plan, it doesn’t mean it describes the functional orthotic being prescribed in your practice. Likewise, although we know that functional orthotics are proven to make a difference in lower back and other spinal pain that doesn’t mean the patient has a benefit for that diagnosis. This overview tutorial outlines best practices for proper HCPCS coding, modifiers, and ICD-10 coding necessary for payment.
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