12 - September 2003
How much time can you bill?
If you want to be paid,
you have to understand the rules
D. Miscoe BS, CPC, CHCC, CRA
Time is money.
This is especially true when it comes to coding therapeutic
procedures or attended modalities correctly, particularly
as they relate to time-based procedures.
is twofold: Use the coding policies required by insurance
carriers and report your time correctly.
Three possible reporting standards are used: the Centers
for Medicare and Medicaid Services (CMS) rules, as published
in Transmittal AB-00-14; the American Medical Association
guidance as published in the AMA CPT Assistant; and individual
Note: CMSs usage rules are not part of the national
standard code set stipulated in the Health Insurance Portability
and Accountability Act of 1996 (HIPAA). Commercial carriers
can follow CMS policy, AMA policy or adopt more/less restrictive
coding policies of their own.
When no policy is specified, a time-tested adage in billing
states that if you are right with Medicare you are right
with the rest of the world.
Because many commercial insurance plans currently follow
Medicare Coding Guidelines or will agree that your application
of those guidelines is a reasonable approach, this article
focuses on the CMS standard.
The 8-minute rule
The AMA CPT-4/HCPCS Level I allows you to bill procedures
in increments of 15-minute units of time. But what should
you do when you dont use the entire 15-minute block?
How do you bill?
A CMS coding rule called the 8-minute rule
governs when and how many units of a procedure that you
can bill, based on the time of performance of that and
associated procedures. (The CMS transmittal that defines
the 8-minute rule is AB-00-14 and was published in March
According to CMS, you can only report the time spent in
the actual delivery of a therapeutic procedure. You must
exclude rest periods, bathroom breaks, time spent waiting
for access to a piece of equipment and similar non-therapeutic
time from your time calculation.
Does this mean you need a stopwatch to time the patient?
That seems ridiculous, but essentially, that is what the
policy states. It also excludes pre- and post-delivery
services, per its directive: Pre- and post-delivery
services are not to be counted in determining the treatment
This would seem to indicate that the time involved in
preparatory therapy or post-therapy cool-down procedures
cannot be counted toward the total time of delivery of
a primary service.
The transmittal does not clarify services.
However, it states that intra-service time
begins when treatment services begin. The examples that
are provided in the transmittal establish that the time
involved with non-treatment activities is the time that
must be excluded.
In some circumstances one service may actually be considered
an intra-service component of another. Consider the following:
The patient is receiving Post Isometric Relaxation (PIR)
for the single purpose of improving flexibility [CPT Code
During the conduct of this therapy, trigger points are
worked (manual therapy techniques) as needed and the PIR
continues. In this context, the manual therapy would be
considered as an intra-service component of the therapeutic
exercise. It would not be reported separately, but the
time of performance would be included in the total intra-service
time reported for the therapeutic exercise procedure.
And what about rest periods? The transmittal says rest
time between sets should be excluded from reporting. But
do you exclude all rest time or just some periods
of rest time?
Based on published rehabilitation literature, the rest
periods between repetitions (30 seconds maximum) and the
rest period between sets (60 90 seconds maximum)
of the same exercise as in a DeLorme, Watkins or McQueen
protocol, are as important to the achievement of an appropriate
outcome as the exercise itself.
Therefore, I recommend including this time in the total
time calculation. Rest periods between different exercises,
however, should be excluded from your time of service
Finally, remember that the pre-, intra- and post-service
cognitive assessment (evaluation and management) is bundled
into the therapy procedure according to CCI edit 7.2 and
later. It is therefore important, in circumstances in
which a significant and separately identifiable E/M service
is not reportable, that you add the assessment time to
the treatment time to determine the total intra-service
the transmittal says
The CMS transmittal dictates time reporting of 8 minutes
Several CPT codes used for therapy modalities,
procedures and tests and measurements specify that
the direct (one on one) time spent in patient contact
is 15 minutes. Providers report procedure codes for
services delivered on any calendar day using CPT codes
and the appropriate number of units of service. For
any single CPT code, providers bill a single 15 minute
unit for treatment greater than or equal to 8 minutes
and less than 23 minutes. If the duration of a single
modality or procedure is greater than or equal to
23 minutes to less than 38 minutes, then 2 units should
be billed. Time intervals for larger numbers of units
are as follows:
3 units: 38 minutes up to 53 minutes
4 units: 53 minutes up to 68 minutes
5 units: 68 minutes up to 83 minutes
6 units: 83 minutes up to 98 minutes
7 units: 98 minutes up to113 minutes
8 units: 113 minutes up to 128 minutes
The pattern remains the same for treatment times in
excess of 2 hours. Providers should not bill for services
performed for less than 8 minutes. If more than one
CPT code is billed during a calendar day, then the
total number of units that can be billed is constrained
by the total treatment time, see examples below.
Example 1: If 24 minutes of 97112 and 23 minutes of
97110 were furnished, then the total treatment time
was 47 minutes; so only three units can be billed
for the treatment. The correct coding is two units
of 97112 and one unit of 97110, assigning more units
to the service that took more time.
Example 2: If a therapist delivers 5 minutes of 97035
(ultrasound), 6 minutes of 97140 (manual techniques),
and 10 minutes of 97110 (therapeutic exercise), then
the total minutes are 21 and only one unit can be
paid. Bill one unit of 97110 (the service with the
longest time) and the clinical record will serve as
documentation that the other two services were also
forget to consider total time!
According to the policy, for the first unit of a time-based
code to be reported, at least 8 minutes of the procedure
must be performed. In Example #2 in the sidebar, when
you perform less than 8 minutes of a time-based service,
you are to bundle the time of performance into another
Additionally, as detailed in Example #1 of the transmittal
below, the total number of individual time units billed
cannot exceed the total number of units permissible based
on the total time of service.
To illustrate: Assume that 25 minutes of Therapeutic Exercises
(CPT 97110) and 23 minutes of Therapeutic Activities (CPT
97530) were performed. You might think that you could
bill two units of each service. However, because the total
time is only 48 minutes, only three total units could
Therefore, you would report two units of 97110 and one
unit of 97530. Code 97110 was reported in two units because
it had the most total time of the two.
For guidance on reporting multiple units we should refer
to the transmittal. (See sidebar.)
What about a 7-minute service?
The only scenario not addressed in the transmittal is
the circumstance in which only one time-based therapy
is performed and the time of performance is less than
For example: Assume that a patient received only 7 minutes
of ultra-sound (CPT 97035) in a treatment encounter and
that no other time-based therapy service was performed
on that visit. According to the policy above it would
seem that this service should not be reported at all.
The CMS examples bundle the time into another time-based
procedure. But in this case, since there is no other time-based
therapy, I recommend following AMA guidance and report
the 97035 with a -52 modifier, indicating
a reduced service.
This method of reporting clearly shows that you performed
less than the full amount of service (as indicated by
the code description). The reporting removes you from
a challenge related to fraudulent misrepresentation.
No matter what the carrier rules are, be certain to document
the total time of performance of each time-based procedure
in your daily notes. Time is money. Your ability to document
and report these services accurately is the key to getting
properly reimbursed for time-based procedures.
Michael D. Miscoe is a Certified Professional Coder,
Certified Healthcare Compliance Consultant, Certified
Rehabilitation Assistant and the President of Practice
Masters, Inc. He has more than 12 years of billing experience
and six years of consulting experience with Chiropractic
providers. He can be reached at 814-754-1550 or firstname.lastname@example.org