The 8 Minute Rule in Pediatric Therapy Billing
Many insurance companies use the 8 minute rule. And it can be confusing when first starting out as a therapist. Whether you are a pediatric occupational therapist, physical therapist, or speech therapist knowing how many units to bill based on the time spent with the child and the 8 minute rule is imperative. It affects insurance company reimbursement for the company and possibly also your pay depending on your employment contract.
The eight minute rule is a calculation method for estimating the total units allowed in timed codes. It requires therapists to round up or down their units when they cross 8 minutes of service. The 8-minute rule was created to help ensure patients are seen for the amount of time allowed.
One of the most important tasks that therapists do is to bill for services. This article will discuss the 8-minute rule in therapy billing so you can use it properly.
I did not learn about the 8-minute rule in therapy billing However, for best practices, I always saw a child for all their scheduled minutes and billed in 15 minute true units.
What is the 8 minute rule?
The 8 minute rule is a rule for calculating the number of units to bill in timed CPT codes.
Every 15 minutes count as one unit. However, since rounding is allowed 8 minutes count as the initial unit.
How do I calculate billable units based on the 8 minute rule?
You can calculate the number of units by dividing by 15 then rounding up or down.
For example. If a child is on your schedule for 1 hour, but you only saw the child for 52 minutes.
51 minutes divided by 15 = 3.4 = 3 Units
The easiest way to understand the rule of 8 is a chart which is provided at the end of this post.
When did the rule start?
Introduced in December 1999, the 8-minute rule became effective on April 1, 2000
What is the difference between the 8 minute rule and the rule of 8?
According to the rule of 8, a therapist can bill one unit only if they spend at least an eight-minute period with a patient. The Rule of 8 is not important in most pediatric OT settings as we are usually only billing one code of more than one unit in a session.
It comes into play when providers are billing more than service and thus more than 1 code at the same time. Especially when one is a time based code and another is a service based code.
What insurances follow 8 minute rule?
All federally funded plans—including Medicare, Medicaid, and TriCare—require the use of the 8-Minute Rule, as do many commercial payers.
In my practice, I find it best to follow the rule for all children on your caseload.
Do you need help writing SOAP notes?
Not sure what you should be in your daily SOAP notes? Want an easy, reproducible format to use for your notes? Check out the template!
Designed for students, fieldwork students, and new therapists.
What is a CPT code?
CPT is a system of numerical codes used to identify medical, diagnostic, and therapeutic procedures performed by healthcare providers as well as supplies furnished in connection with these services. Each service has a unique CPT code.
Time based vs. service-based codes
Common OT Service-based Codes
Some codes are not timed. Such as the OT evaluation codes:
97165 – low complexity Occupational therapy evaluation
97166 – moderate complex Occupational therapy evaluation
97167 – high complexity Occupational therapy evaluation,
97168 – Occupational therapy re-evaluation
Billable time units and the 8 minute rule do not apply to these untimed codes.
Pediatric OT Time based CPT Codes
I almost exclusively use 97530 as the code for my treatment sesions in my pediatric practice. With this code, we can bill multiple units of a time based cpt code when treating a child.
97530 Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes
There may be other CPT codes that are appropriate in your practice such as:
97535 Self-care/home management training (e.g., activities of daily living [ADLs] and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/ adaptive equipment), direct one-on-one contact, each 15 minutes
See more at AOTA's Pediatric Billing and Coding Tips and Tools
The 8 minute rule applies to these time based codes.
Summary
The 8 minute rule is a rule that has been around since the year 2000. The 8 minute rule is used by OT providers when billing time based service codes. It is usually best to follow the 8-minute rule for all children on your caseload if you are an OT provider.
How do I make sure I adhere to the 8-minute rule?
Just follow this chart or think about rounding!
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