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Introduction
For those of us in the physical therapy field, understanding the nuances of coding can feel a bit like solving a Rubik’s cube. The complex world of coding is made even more complicated by different rules for different insurance types, all with their own jargon. Today, let's unravel two crucial AMA billing rules: the Total Minute Rule and the AMA Rule.
Often dubbed the Medicare "8-min Rule," the Total Minute Rule is one of the key methodologies employed by Medicare and other federal payers. Conversely, commercial insurance providers usually lean towards the AMA Rule, also known as the Substantial Portion Methodology (SPM) or Rule of 8s.
However, in the throes of a bustling clinic, we sometimes find it difficult to distinguish between these two methodologies and make sure all therapists within our organization understand the rules and are using them correctly. This is where PredictionHealth steps in, offering a clear, user-friendly way to determine if your therapists understand and apply the appropriate coding rules. The Coding Efficiency feature within the PredictionHealth platform allows practice groups to easily track how therapists are coding and helps to identify where there may be opportunities to more efficiently code visits to ensure no units are being left uncaptured.
Understanding The AMA Total Minute Rule
The Total Minute Rule calls for billing based on the overall time spent with the patient, regardless of the various CPT codes that could be involved. We simply total the minutes to calculate the number of units we can bill. Here's a quick breakdown:
- 8-22 min = 1 unit
- 23-37 min = 2 units
- 38-52 min = 3 units
- 53-67 min = 4 units
- 68-72 min = 5 units
Understanding The AMA Rule
The AMA Rule, on the other hand, hinges on the time spent on each unique CPT code rather than the total time with the patient. For each unique CPT code, 8-22 minutes equates to one unit, 23-37 minutes equates to two units, etc…. This incentivizes therapists to bill multiple unique codes, each clocking at least 8 minutes.
Total Minute Rule vs. AMA Rule: A Comparison
To clarify the difference between these two rules, let's delve into a few scenarios:
Scenario 1
|
Total Minute Rule |
AMA Rule |
|
10 min Therapeutic Activity |
10 min Therapeutic Activity |
|
8 min Manual Therapy |
8 min Manual Therapy |
|
Total: 18 min, 1 Unit |
Total: 18 min, 2 Units |
- Under the Total Minute Rule, 18 min fits in the 8-22 min range so it is billed at 1 unit
- Under AMA Rule, there are 2 different codes that fall within the 8-22 min range so you will charge 1 unit for each or 2 total units.
Scenario 2
|
Total Minute Rule |
AMA Rule |
|
6 min Therapeutic Activity |
6 min Therapeutic Activity |
|
6 min Therapeutic Exercise |
6 min Therapeutic Exercise |
|
6 min Manual Therapy |
6 min Manual Therapy |
|
Total: 18 min 1 Unit |
Total: 18 min 0 Units |
- Under Total Minute Rule, 18 min fits in the 8-22 min range so it is billed at 1 unit
- Using AMA Rule, the patient would not be charged since none of the CPT codes were greater or equal to 8 minutes. 0 units will be charged.
Scenario 3
|
Total Minute Rule |
AMA Rule |
|
10 min Therapeutic Exercise |
10 min Therapeutic Exercise |
|
10 min Manual Therapy |
10 min Manual Therapy |
|
10 min Neuro Re Education |
10 min Neuro Re Education |
|
Total: 30 min 2 units |
Total: 30 min 3 units |
- Under Total Minute Rule, 30 min fits in the 23-37 min range so it is billed at 2 units
- Under AMA Rule, there are 3 different codes that fall within the 8-22 min range so you will charge 1 unit for each
Scenario 4
|
Total Minute Rule |
AMA Rule |
|
30 min Therapeutic Activity |
30 min Therapeutic Activity |
|
4 min Therapeutic Exercise |
4 min Therapeutic Exercise |
|
7 min Manual Therapy |
7 min Manual Therapy |
|
Total: 41 min 3 units |
Total: 41 min 2 units |
- Under Total Minute Rule, 41 min fits in the 38-52 min range so it is billed at 3 units
- Under AMA Rule, there are 2 different codes that did not fall within the minimum 8-22 min range so you would not charge any units for those 2 codes. You would charge 2 units for the code containing 30 min.
Scenario 5
|
Total Minute Rule |
AMA Rule |
|
25 min Therapeutic Activity |
25 min Therapeutic Activity |
|
10 min Manual Therapy |
10 min Manual Therapy |
|
Total: 35 min 2 units |
Total: 35 min 3 units |
- Under Total Minute Rule, 35 min fits in the 23-37 min range so it is billed at 2 units
- Under AMA Rule, there are 2 different codes one falls within the 23-38 min (2 units) range and the other in the 8-22 min (1 units) range for a total of 3 charged units
Scenario 6
|
Total Minute Rule |
AMA Rule |
|
8 min Therapeutic Activity |
8 min Therapeutic Activity |
|
8 min Therapeutic Exercise |
8 min Therapeutic Exercise |
|
8 min Manual Therapy |
8 min Manual Therapy |
|
8 min Neuro Re Education |
8 min Neuro Re Education |
|
Total: 32 min 2 units |
Total: 32 min 4 units |
- Under Total Minute Rule, 32 min fits in the 23-37 min range so it is billed at 2 units
- Under AMA Rule, there are 4 separate codes that fall within the 8-23 min (1 unit) range and for a total of 4 charged units
Conclusion
Navigating the intricate landscape of CPT codes and billing can be daunting, but understanding the rules and knowing how to apply them can significantly streamline the process. Remember, the key lies in optimizing your time spent on each CPT code and documenting it accurately. PredictionHealth’s Coding Efficiency feature will help you ensure that your therapists are managing their time and coding during their visits optimally. To learn more, click here or Book a Demo.