New Year, New Rules Pt.1: Medicare Changes For 2022
In June of 2021, Centers for Medicare & Medicaid Services (CMS) proposed a new physician payment...
Welcome to part 2 of our “New Year, New Rules” #rtblogseries! With the finalized Physician Fee Schedule (PFS) rules for 2022, there’s a lot of changes to cover and explain. That's why we’ve gathered all the essential information regarding billable units and modifiers to make sure you aren’t caught off guard when it comes to receiving payments. Let’s go over the basics together.
What Is The 8-Minute Rule and Why Is It Important?
The 8-minute rule is a Medicare billing criteria that applies to time-based CPT codes for outpatient, in-person services. It’s important for providers to understand how this rule works, so that they can minimize billing errors and potentially avoid the enormous hassle of underbilling or delayed reimbursement issues.
What Is A Unit?
This particular rule requires providers to bill Medicare patients in units of service, where a single unit represents 15 minutes of clinical care. Of course, not every appointment can be perfectly divided into 15 minute units, so, fortunately, there is an official process on how to measure those in-between moments!
If a provider facilitates between 8 to 22 minutes of service, that visit will be rounded to 15 minutes or one unit for billing purposes. However, if a provider gives 23 to 37 minutes of service, this equates to 2 units while 38 to 52 minutes is 3 units and so on, so forth. Take a look at the table below for a visual representation of how these units are measured.
Minutes of Service |
Number of Units |
8 - 22 |
1 |
23 - 37 |
2 |
38 - 52 |
3 |
53 - 67 |
4 |
68 - 82 |
5 |
When Should The 8-Minute Rule Be Followed?
While dubbed as “Medicare’s 8-minute rule”, this rule is actually the standard for all federally funded plans, including Medicaid and Tricare. In fact, some commercially funded plans choose to use these billing rules as well. Furthermore, Raintree’s platform offers tools to track specific billing criteria as well as allows the ability to individually manage rules for each patient, no matter what plan they are on.
Modifiers and When To Apply Them
If you are an Occupational Therapist (OT), Physical Therapist (PT) or therapy assistant to either kind, you’re very likely going to run into modifiers. In 2020, CMS established two modifiers in particular for PT and OT assistants:
There are two situations that call for these modifiers:
Already Familiar With The 8-Minute Rule Basics?
Here are a couple of new changes you should be aware of:
Per the 2022 Physician Fee Schedule (PFS) rulemaking, several revisions have been made that introduce scenarios where the CQ/CO modifiers or the de minimus policy would be changed or not applicable at all.
CMS lists examples of these scenarios on their website as well as a more in-depth look at how to calculate de minimus (there’s more than one way!) and when to use modifiers. Review these amendments thoroughly to stay prepared for any billing situation that comes your way.
Next week we will be going over the finalized changes made to the No Surprises Act and what those adjustments will mean for providers and patients without insurance, so keep an eye out for our next post in this three part #rtblogseries!
As a Content Writer at Raintree, I enjoy writing in all forms, even script writing! Beyond my passion for the written word, I spend my free time reading, drawing and studying fungi. Please feel free to comment on and share any articles you enjoy, I'd love to hear from you!
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