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Medicare Total Time Rule v. AMA 8-Minute Rule |
Posted on January 11, 2023
The unit chart is the same for both systems.
|
> 8 minutes through 22 minutes |
1 Unit |
|
> 23 minutes through 37 minutes |
2 Units |
|
> 38 minutes through 52 minutes |
3 Units |
|
> 53 minutes through 67 minutes |
4 Units |
|
> 68 minutes through 82 minutes |
5 Units |
|
> 83 minutes through 97 minutes |
6 Units |
|
> 98 minutes through 112 minutes |
7 Units |
|
> 113 minutes through 127 minutes |
8 Units |
Medicare Total Time Rule
Step 1: Add together the time spent on all timed services during the therapy visit. That amount of time will determine the total amount of units you can bill based on the chart above.
Step 2: Allocate the units to each separate service. When determining the allocation of units, it is easiest to separate out each service first into “15-minute time blocks”. Any timed service provided for at least 15 minutes, must be billed one unit. Any timed service provided for at least 30 minutes, must be billed two units, and so on.
Step 3: If there are at least 8 extra minutes left over then you can allocate the extra unit to the service that you spent the most time on.
Example
20 minutes (1 unit) of Therapeutic Exercise (97110) and 35 minutes (2 units) of Neuromuscular Reeducation (97112) = 55 minutes or 4 units
Under Medicare’s Total-Time rule that extra unit is allocated to 97112, so 3 units instead of 2.
The AMA Rule
Instead of adding the total session time for all time-based codes used, each service is considered separately, extra minutes are discarded rather than added to one of the services.
Example
20 minutes (1 unit) of Therapeutic Exercise (97110) and 35 minutes (2 units) of Neuromuscular Reeducation (97112)
Under the AMA rule you do not add up the total time so each procedure is separate. You would only be able to bill for 3 units, 1 for 97110 and 2 for 97112.
Example 1
20 minutes of neuromuscular reeducation, 97112
20 minutes therapeutic exercise, 97110
= 40 minutes total treatment time
Each code contains one 15-minute block, therefore, each code shall be billed for at least 1 one unit. As 3 units is allowed, a review of the “remaining minutes” is required to determine which code should be billed the additional unit. Since the “remaining minutes” for each service are the same in this example, either of the codes may be billed for the additional unit.
The correct coding is either one of the following:
Medicare: 2 units 97112 + 1 unit 97110 OR 1 unit 97112 + 2 units 97110
AMA: 1 unit of 97112 + 1 unit of 97110
Example 2
24 minutes of neuromuscular reeducation, code 97112 (2 units)
23 minutes of therapeutic exercise, code 97110 (2 units)
= 47 total minutes.
Utilizing the chart above, 47 minutes falls within the range for 3 units. To allocate those 3 units determine the 15-minute blocks first:
24 minutes 97112 = one 15-minute block + 9 remaining minutes
23 minutes 97110 = one 15-minute block + 8 remaining minutes
Each code contains one 15-minute block; therefore, each code shall be billed for at least 1 unit. Since the total minutes allows for 3 units, the third unit shall be applied to the service with the most “remaining minutes” (97112 has 9 remaining minutes, whereas, 97110 has 8 remaining minutes).
Medicare: 2 units 97112 + 1 unit 97110
AMA: 2 units 97112 +2 units of 97110
Example 3
36 minutes therapeutic exercise (CPT 97110)
7 minutes manual therapy (CPT 97140)
= 40 total minutes
Utilizing the chart above, 40 minutes falls within the range for 3 units. To allocate those 3 units determine the 15-minute blocks first:
36 minutes 97110 = two 15-minute blocks + 6 remaining minutes
7 minutes 97140 = zero 15-minute blocks + 7 remaining minutes
Code 97110 must be billed for at least 2 units as it contains two 15-minute blocks. To determine the allocation of the third unit, compare the “remaining minutes”, and apply the additional unit to the service with the most remaining minutes.
Medicare: 2 units 97110 + 1 unit 9714
AMA: 2 units of 97110
Example 4
18 minutes of therapeutic exercise (CPT 97110)
13 minutes of manual therapy (CPT 97140)
10 minutes of gait training (CPT 97116)
8 minutes of ultrasound (CPT 97035)
= 49 total minutes
Appropriate billing for a total of 49 minutes is 3 units. To allocate those 3 units, determine the 15-minute blocks first:
18 minutes 97110 = one 15-minute block + 3 remaining minutes
13 minutes 97140 = zero 15-minute blocks + 13 remaining minutes
10 minutes 97116 = zero 15-minute blocks + 10 remaining minutes
8 minutes 97035 = zero 15-minute blocks + 8 remaining minutes
Code 97110 shall be billed for at least one unit as it contains one 15-minute block. The additional 2 units billable (for a total of 3 units for the day), must be applied to the services with the greatest remaining minutes.
Medicare: 1 unit 97110 + 1 unit 97140 + 1 unit 97116
AMA: 4 units, one each
Example 5
4 minutes assessing shoulder strength prior to initiating and progressing therapeutic exercise (CPT 97110)
32 minutes therapeutic exercise (CPT 97110)
7 minutes manual therapy (CPT 97140)
= 43 total minutes
Utilizing the chart above, 43 minutes falls within the range for 3 units. To allocate those 3 units determine the 15-minute blocks first:
36 minutes 97110 = two 15-minute blocks + 6 remaining minutes
7 minutes 97140 = zero 15-minute blocks + 7 remaining minutes
Code 97110 must be billed for at least 2 units as it contains two 15-minute blocks. To determine the allocation of the third unit, compare the “remaining minutes”, and apply the additional unit to the service with the most remaining minutes. The correct coding is:
Medicare: 2 units 97110 + 1 unit 97140
AMA: 2 units of 97110
Reference
Local Coverage Article:
Billing and Coding: Outpatient Physical and Occupational Therapy Services (A57067)
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