Health Information Management

Know how to apply the eight-minute rule for time-based outpatient therapy codes

JustCoding News: Outpatient, January 13, 2010

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A lack of understanding about the eight-minute rule often leads to billing errors for outpatient therapy.

“This is an area that can often trip up therapists and billing professionals alike,” said Kate Brewer, PT, MBA, GCS, president and owner of Progressive Rehab Services, LLC, in Hartland, WI, during a November 18, 2009, HCPro, Inc., audio conference, “10 Common Billing Problems for Outpatient Therapy.”

The eight-minute rule applies to direct contact, time-based codes (i.e., codes that require the one-on-one attendance of the provider). For timed CPT codes, coders should bill the appropriate number of units based on the time intervals outlined in the code descriptions.

When billing more than one timed CPT code on a calendar day, the total number of units that providers may bill is constrained by the total treatment time, Brewer said.

Note that there are two categories of codes: Time-based and service-based. To determine how many time-based units to bill, you need to look at the sum of total treatment time spent for time-based codes.

Coders should not count minutes of time spent on service-based codes into the total treatment time because they are separate, Brewer added.

When a therapist performs multiple services with time-based codes in a single day for a particular patient, the total number of minutes determines the number of units that providers may bill. For example, when a therapist spends 30 minutes administering treatment that has a time-based code, he or she may bill two units.

Note that when a therapist performs any 15-minute timed service for seven minutes or less on the same day as he or she performs another 15-minute timed service for seven minutes or less, and the time spent performing the two services totals at least eight minutes, then providers may bill one unit for the service the therapist performed for the most minutes, Brewer said.

For example, both ultrasound and therapeutic exercise are timed codes. A therapist spends five minutes performing an ultrasound, which alone is not a billable amount because it’s fewer than eight minutes. But if in addition to that five minutes of ultrasound, the therapist performs 20 minutes of therapeutic exercise, combined these two services total 25 minutes. Therefore, you can select the code for which you would bill two units, Brewer said.

“Choose the code that constituted the majority of your treatment time,” she said. For the example above, it would be appropriate to bill two units of therapeutic exercise.

“It’s important to document that you did perform the ultrasound treatment because from a liability, risk management patient treatment standpoint, you need to document what you did, but you don’t have to use that ultrasound code,” Brewer said.

Note the following guide for how many units to report for different total treatment times:

  • 8–22 minutes = 1 unit
  • 23–37 minutes = 2 units
  • 38–52 minutes = 3 units 
  • 53–67 minutes = 4 units
  • 68–82 minutes = 5 units
  • 83–97 minutes = 6 units
  • 98–112 minutes = 7 units
  • 113–127 minutes = 8 units 

One of the more common errors providers make related to the eight-minute rule is that they include the time spent on service-based codes in the total treatment time.

“The time we spend on service-based codes needs to be pulled out separately. It cannot be lumped in because it’s giving you an inflated total treatment time,” Brewer said.

Also, providers should not start determining which codes to report by looking at the individual codes first. “You could possible trip yourself up and miss out on some reimbursement if you say you spent 20 minutes on one service and 20 minutes on another,” Brewer said.

Instead, look at the total treatment time and then determine what code(s) and how many units to bill, Brewer said. In other words, you could lose revenue because doing so might result in billing for only one unit of service A and one unit of service B, missing the third possible unit. So if you spent 20 minutes on therapeutic exercise and 20 minutes on gait training, you could take a different approach and look at the total treatment time, which in this case would be 40 minutes, or three units.

Recognize the value of ICD-9-CM codes

In addition to understanding the eight-minute rule when billing for outpatient therapy, providers also need to understand the importance of ICD-9-CM coding. Accurate ICD-9-CM coding: 

  • Helps facilitate faster payment because it’s a clean claim
  • Prevents therapy denials
  • Helps support medical necessity
  • Helps to demonstrate the level of skilled services provided
  • Plays a significant role in data collection for future policy-making

To understand the effect of ICD-9-CM coding in billing for outpatient therapy, you need to understand the typical progression for a patient.

For example, a physician or other practitioner documents one or more medical diagnoses (e.g., an illness, injury, or exacerbation of a chronic condition). This diagnosis results in a decline in function and affects the patient’s ability to live independently.

A therapist then performs an evaluation to synthesize that medical information with a physical assessment of the patient’s functional deficits, and then he or she develops a plan for treatment.

It’s important for physicians to list on the claim the diagnoses that have most contributed to the impairments for which the patient is receiving treatment, including both primary and comorbidities, Brewer said. Note that providers may list up to eight ICD-9-CM codes for Medicare Part B claims depending on the software.

By identifying comorbidities, ICD-9-CM coding may help support medical necessity when progress is more gradual, Brewer said.

The evaluating therapist then determines the treatment diagnosis based on his or her comprehensive evaluation of the patient when allowed by state licensure. The treatment diagnosis should closely relate or attempt to illustrate the impairment that he or she has identified in the plan of care. This may be the same as the medical diagnosis, for which providers may find codes in the:

  • Hospital history and physical
  • Discharge summary
  • Physician progress notes
  • Consultation notes
  • Physician orders

When there are no reports, you can list potential diagnosis on a clarification order and send this to the physician for a signature, Brewer suggested. Once the physician signs and dates the clarification order, you can use the medical diagnoses, she added.

The ICD-9-CM Official Guidelines for Coding and Reporting states:

For patients receiving therapeutic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses.

The only exception to this rule is that when the primary reason for the admission/encounter is chemotherapy, radiation therapy, or rehabilitation, the appropriate V code for the service is listed first, and the diagnosis or problem for which the service is being performed listed second.

Because V codes factor into the sequencing, review those specific to therapy: 

  • V57.1: Other physical therapy
  • V57.21: Encounter for occupational therapy
  • V57.3: Speech language therapy 
  • V57.89: Multiple training or therapy

When assigning an ICD-9-CM code, you must code the highest level of specificity, including fourth and fifth digits when appropriate. Do not use codes listed as “probable,” “possible,” or “rule out.”

Editors’ note: Interested in learning more about billing for outpatient therapy? Kate Brewer, PT, MBA, GCS, discusses the supporting documentation needed with modifiers -KX and -59, as well as tips for obtaining authorizations and coinsurances in HCPro’s November 18 audio conference, “10 Common Billing Problems for Outpatient Therapy.”

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