how to bill units of therex for medicare

Basically, when calculating the number of billable units for a particular date of service, Medicare adds up the total minutes of skilled, one-on-one therapy and divides that total by 15. If eight or more minutes are left over, you can bill for one more unit; if seven or fewer minutes remain, you cannot bill an additional unit.

Full Answer

How does Medicare calculate billable units?

Basically, when calculating the number of billable units for a particular date of service, Medicare adds up the total minutes of skilled, one-on-one therapy and divides that total by 15. If eight or more minutes are left over, you can bill for one more unit; if seven or fewer minutes remain, you cannot bill an additional unit.

How do I Bill for more than one unit of treatment?

If you look up 40 minutes on the chart, you can bill for a maximum of 3 units (38 to 52 minutes). Each of the codes were performed for more than 15 minutes so each should be billed for 1 unit. You can then assign the extra unit to either 97110 or 97712 since they were treated for the same amount of time.

What are the Medicare billing rules for medical billing?

The rule allows practitioners to bill Medicare for one unit of service if its length is at least eight (but fewer than 22) minutes. A billable “unit” of service refers to the time interval for the service.

How do physical therapists bill Medicare for services?

Physical therapists and other service-based providers bill Medicare for the services beneficiaries receive. Billing and claims procedures involve the use of CPT (Current Procedural Terminology) codes and rules. The 8-minute rule, which is followed by Medicare, is one of these rules.

How many units can you bill Medicare?

That's where the 8-Minute Rule comes in: Per Medicare rules, in order to bill one unit of a timed CPT code, you must perform the associated modality for at least 8 minutes....Minutes and Billing Units.8 – 22 minutes1 unit23 – 37 minutes2 units38 – 52 minutes3 units53 – 67 minutes4 units68 – 82 minutes5 units1 more row•Sep 13, 2018

How do you bill units in physical therapy?

For this patient, the total treatment time for all timed CPT codes is 60 minutes. Per the chart below (i.e., the Medicare 8-Minute Rule chart), that means you can bill four units....The Rationale.8 – 22 minutes1 unit38 – 52 minutes3 units53 – 67 minutes4 units68 – 82 minutes5 units83 minutes6 units1 more row•Aug 4, 2020

How many minutes is 3 units Medicare?

40 minutesAppropriate billing for 40 minutes is for 3 units. Bill 2 units of 97110 and 1 unit of 97140. Count the first 30 minutes of 97110 as two full units.

What is the 8 minute rule and how is the time billed for two units?

Introduced in December 1999, the 8-minute rule became effective on April 1, 2000. The rule allows practitioners to bill Medicare for one unit of service if its length is at least eight (but fewer than 22) minutes. A billable “unit” of service refers to the time interval for the service.

What is physical therapy service units?

MTUs are outpatient clinics located in designated public schools. PT is provided primarily to address mobility and ambulation needs. PT is provided by a Physical Therapist who is licensed to practice Physical Therapy in California.

How many minutes is a therapy unit?

Unlike service-based CPT codes, time-based CPT codes can be billed as multiple units in 15-minute increments. Meaning that one unit would represent 15 minutes of therapy. A therapist must provide direct one-to-one therapy for at least 8 minutes to receive reimbursement for a time based treatment code.

How many minutes is 5 units?

For example, 68 total billable minutes/15 = 4 units + 8 minutes. Since the 8 minutes are more than 7 minutes, those 8 minutes are converted to one unit. Therefore, 68 total billable minutes = 5 units of service.

How many therapy units is 45 minutes?

3 billable unitsTimed Minutes: 45 However, billing is based ultimately on total timed minutes – 45 in this case, and equivalent to 3 billable units. Those 7 minutes spent on therapeutic activity still count toward timed minutes because Therapeutic Activity is a timed code.

How many units can you bill for 97530?

*1 unit billed under CMS guidelines. You bill 97530 for 16 minute and then bill 97110 for 7 minutes = 1 unit billed under AMA guidelines. *2 units billed under CMS guidelines. You bill 97530 for 8 minutes, 97110 for 8 minutes and 97112 for 8 minutes = 3 units billed under AMA guidelines.

What is the Medicare 8-minute rule?

The 8-minute rule is a stipulation that allows you to bill Medicare insurance carries for one full unit if the service provided is between 8 and 22 minutes. As such, this can only apply to time-based CPT codes. But, the 8-minute rule doesn't apply to every time-based CPT code, or every situation.

Do Medicare Advantage plans follow 8-minute rule?

Medicare requires providers to adhere to the 8-Minute Rule; MA plans may not.

What insurances follow 8-minute rule?

Please note that this rule applies specifically to Medicare Part B services (and insurance companies that have stated they follow Medicare billing guidelines, which includes all federally funded plans, such as Medicare, Medicaid, TriCare and CHAMPUS). The rule does not apply to Medicare Part A services.

How long is Medicare billing?

The rule allows practitioners to bill Medicare for one unit of service if its length is at least eight (but fewer than 22) minutes. A billable “unit” of service refers to the time interval for the service. Under the 8-minute rule, units of service consist of 15 minutes each.

How long does Medicare bill for in-person services?

The 8-minute rule applies only to services where the practitioner has direct contact with the patient. Therefore, the service must be in-person for the 8-minute rule to apply. If you’ve received more than one service, Medicare will be billed based on total timed minutes per discipline. If an individual service takes less than eight minutes, ...

How long does Medicare require for outpatient services?

Since Medicare requires the 8-minute rule to be followed for these in-person, outpatient services, providers do not have the choice of using another billing method.

How many minutes does Medicare take?

The services are then billed in 15-minute units. Therefore, if a service or services take (s) 20 minutes, Medicare will be billed for one unit, because the number of minutes falls between eight and 22. If 23 to 37 minutes is spent on the service (s), Medicare can be billed for two units. If the service (s) take (s) 38 to 52 minutes, ...

What is the 8 minute rule for Medicare?

What is the Medicare 8-Minute Rule? Medicare’s 8-minute rule is a stipulation that applies to time-based CPT codes for outpatient services, such as physical therapy. Introduced in December 1999, the 8-minute rule became effective on April 1, 2000.

Is an ultrasound billed separately?

As shown in the above example, the ultrasound is not billed separately. Since each service takes longer than eight minutes, the minutes are added together and billed to Medicare as the total number of units. As another example, Gregory visits his physical therapist’s private practice.

Is Medicare overbilled?

This results in underbilling. Therefore, patients should understand what Medicare can and should be charged for, so they can be confident they are not being overbilled.

How many visits to do ultrasound?

Documentation must clearly support the need for ultrasound more than 12 visits. For proper supportive documentation for ultrasound treatment, you need to include the area (s) being treated, the frequency and the intensity of the ultrasound and the type of Ultrasound (pulsed or continuous).

Is tens unit billable?

Instructing the patient on the tens unit is billable under 970 32. Typically speaking, most payers are only going to pay for a couple of visits to achieve a favorable response from the patient . After those couple of visits, generally speaking, they're going to ask you to carry that over to the patient or the caregiver.

Is phonophoresis reimbursable by Medicare?

Phonophoresis is reimbursable by Medicare. Phonophor esis is using Ultrasound to enhance the delivery of that topically applied drug. Separate payment is not made for the contact medium or for the drug that is being utilized but you can bill your phonophoresis as ultrasound and that is reimbursable by Medicare.

Can you use multiple heating modalities on the same day?

Of course, there are some exceptions there, such as wound care. Additionally, multiple heating modalities would not be used on the same day. Exceptions again are rare and usually would involve musculoskeletal pathology or injuries where we're treating both superficial and deep structures.

Is Medicare the most regulated payer?

Medicare is probably the most highly regulated venue or payer if you will, that we work with in therapy and oftentimes our commercial payers will follow the local coverage determinations or the national coverage determinations from Medicare so their oftentimes the most strict.

Is time spent on documentation covered by Medicare?

Under Medicare, time spent in the documentation of services (medical record production) is part of the coverage of the respective CPT code; there is no separate coverage for time spent on documentation (except for CPT Code 96125).

Can you use more than one modality?

The use of more than two modalities is pretty unusual and you'll need to justify that in your documentation. Additionally, Medicare says that the use of modalities as a stand-alone treatment is rarely therapeutic and usually not required as the sole treatment approach.

How many minutes of treatment do you need to be on Medicare?

For time-based codes, you must provide direct treatment for at least eight minutes in order to receive reimbursement from Medicare. Basically, when calculating the number of billable units for a particular date of service, Medicare adds up the total minutes of skilled, one-on-one therapy and divides that total by 15. If eight or more minutes are left over, you can bill for one more unit; if seven or fewer minutes remain, you cannot bill an additional unit.

How long do you have to be on Medicare for a treatment?

For time-based codes, you must provide direct treatment for at least eight minutes in order to receive reimbursement from Medicare. Basically, when calculating the number of billable units for a particular date of service, Medicare adds up the total minutes of skilled, one-on-one therapy and divides that total by 15.

What is the rule of 8?

The Rule of Eights—which can be found in the CPT code manual and is sometimes referred to as the AMA 8-Minute Rule—is a slight variant of CMS’s 8-Minute Rule . The Rule of Eights still counts billable units in 15-minute increments, but instead of combining the time from multiple units, the rule is applied separately to each unique timed service. Therefore, the math is also applied separately. (Keep in mind that the Rule of Eights only applies to timed codes that have 15 minutes listed as the “usual time” in the operational definition of the code.)

What is the 8 minute rule for rehab?

Rehab therapists use the 8-Minute Rule—or the slightly variant “Rule of Eights”—to determine the number of units they should bill Medicare for the therapy services provided on a particular date of service. Prev.

How many minutes of 97110 are in a single visit?

For example, say a therapist bills 10 minutes of 97110 and 10 minutes of 98116 in a single visit. Those codes are considered unique services, and are counted separately. Each service lasted longer than eight minutes, so the therapist can bill for two units total: one unit of 97110 and one unit of 98116.

What are the codes for a therapist?

Time-based (or constant attendance) codes, on the other hand, allow for variable billing in 15-minute increments. You would use these codes for performing one-on-one services such as: 1 therapeutic exercise (97110) 2 therapeutic activities (97530) 3 manual therapy (97140) 4 neuromuscular re-education (97112) 5 gait training (97116) 6 ultrasound (97035) 7 iontophoresis (97033) 8 electrical stimulation (manual) (97032)

How long is a manual therapy session?

Let’s say that on a single date of service, you perform 30 minutes of therapeutic exercise (EX), 15 minutes of manual therapy (MT), 8 minutes of ultrasound (US), and 15 minutes of electrical stimulation unattended (ESUN). To correctly calculate the charge in accordance with the 8-Minute Rule, you would add the constant attendance procedures ...

How often is 97150 billed?

In private practice settings for physical and occupational therapists and in physician offices where therapy services are provided incident to the physician, Medicare expects the group therapy code (97150) to be billed only once each day per patient. In the facility/institutional therapy settings, the group therapy code could be applied more than once. However, the occasional situation where group therapy is billed more than once each day would require sufficient documentation to support its medical necessity and clinical appropriateness of providing more than one separate session of group therapy.

How long can a therapist bill for a supervised modality?

In the same 15-minute time period, one therapist may bill for more than one therapy service occurring in the same 15-minute time period where "supervised modalities" are defined by CPT as untimed and unattended -- not requiring the presence of the therapist (CPT codes 97010 - 97028). One or more supervised modalities may be billed in the same 15-minute time period with any other CPT code, timed or untimed, requiring constant attendance or direct one-on-one patient contact. However, any actual time the therapist uses to attend one-on-one to a patient receiving a supervised modality cannot be counted for any other service provided by the therapist.

Can a therapist bill a patient separately?

Therapists, or therapy assistants, working together as a "team" to treat one or more patients cannot each bill separately for the same or different service provided at the same time to the same patient.

What is a KX modifier?

The KX modifier is part of the therapy soft cap exceptions process. If you believe it is medically necessary for a patient who has already reached the cap to continue therapy—thus qualifying the patient for an exception—you would attach the KX modifier and clearly document your reasons for continuing treatment.

Why do you need to bill for physical therapy?

But in order to stay in business long enough to actually make a difference in your patients’ lives, you absolutely must bill—and collect payment— for your services.

What software do providers use to submit claims?

Software. A lot of providers use a billing software to prepare and submit their claims. The really smart ones use an electronic medical record system that includes (or integrates with) a top-notch therapy billing software (hello, WebPT ).

When to use modifier 59?

Practices and facilities that offer their patients both physical and occupational therapy may need to affix modifier 59 or modifier XP to claims when patients receive same-day services that form NCCI edit pairs. According to Castin, modifier XP would be appropriate if, say, “an OT takes over treatment in the middle of a PT session” and modifier 59 would be appropriate if the payer doesn’t yet recognize X modifiers or there’s another reason to provide “otherwise linked services that should, given the circumstances, be reimbursed separately.” For example, you would use modifier 59 if, say, a PT provides gait training (97116) and an OT provides therapeutic activity (97530). As such, you’re notifying Medicare that the services—97116 and 97530—were performed separately and distinctly from one another and thus, should both be paid.

What is the most common claim form?

However, some payers—a dwindling few—do still accept paper ones. The most common form is the Universal Claim Form ( CMS 1500 ), although some payers may request that you use their own.

What is CPT medical?

Developed by the American Medical Association (AMA), the Current Procedural Terminology (CPT®) is “the most widely accepted medical nomenclature used to report medical procedures and services under public and private health insurance programs.”.

How long does it take for a physician to sign a plan of care?

Initial certification: Medicare requires ordering physicians to “approve or certify the plan of care via signature in a timely manner (within 30 days of the evaluation).”. The initial certification covers the first 90 days of treatment.

How many minutes can you bill for untimed codes?

For example, it you spent 38 minutes on timed codes and 30 minutes on untimed codes, the maximum number of units you can bill for is 3 units (38 to 52 minutes) based on the table. Remember, you only count the timed code minutes and you must ignore the untimed code minutes.

How long is a 97712 treatment?

Example 1: 24 minutes of neuromuscular reeducation, code 97712. 23 minutes of therapeutic exercise, code 97110. Total timed code treatment time is 47 minutes. If you look up 47 minutes on the chart, you can bill for a maximum of 3 units (38 to 52 minutes).

How long is a 15 minute timed code?

For the individual codes, you need to code based on the following rules: If a service represented by a 15 minute timed code is performed in a single day for at least 15 minutes, that service shall be billed for at least one unit.

What is fixed rate billing?

The term “fixed rate” is a bit of a misnomer, and it leads many rehab therapy professionals to believe they will always receive the same amount of reimbursement, regardless of time spent with the patient . This often results in underbilling, because the therapist leaves out unit numbers for timed codes. The truth is that these payers usually reimburse up to a certain capped amount, so if you’re billing for a total reimbursement amount that’s less than the cap, you could be leaving money on the table. The moral of the story: Always apply the appropriate number of units to reflect the amount of time spent with the patient, even if the insurance provider has a so-called “fixed rate.”

What does modifier 59 mean?

In a nutshell, this modifier indicates that two linked services were actually performed separately and independently of one another. So, to get paid for both codes in an edit pair, providers typically must append modifier 59 to one of the codes.

Can you bill for telehealth consultation?

However, depending on the rules set forth by your state and the insurance payer, you may be able to bill for a telehealth consultation if you consult with him or her over the phone. I recommend looking into the telehealth rules for rehab therapists in your state as well as the insurance payer's policies.

Introduction

What Are Service-Based Cpt Codes?

• You would use a service-based (or untimed) code to bill for services such as: 1. physical therapy evaluation (97161, 97162, or 97163) or re-evaluation (97164) 2. hot/cold packs (97010) 3. electrical stimulation (unattended) (97014) In such scenarios, you can only bill for one code, regardless of how long you spend providing treatment.

See more on webpt.com

What Are Time-Based Cpt Codes?

What’s The Deal with Mixed Remainders?

So What Is The Rule of Eights?

Does Assessment and Management Time Count Toward The 8-Minute Rule?

What’s The Best Way to Avoid 8-Minute Rule Mistakes?