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Issue 12 - September 2003

How much time can you bill?
If you want to be paid, you have to understand the rules
By Michael 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.

Your challenge 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 carrier policies.

Note: CMS’s 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 don’t 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 of 2000.)

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 service time.”

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 97110].

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 calculations.

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 time.

What the transmittal says
The CMS transmittal dictates time reporting of 8 minutes or less:

“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 performed.

Don’t 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 time-based procedure.

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 be reported.

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 8 minutes.

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

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