Medicare ADVISOR Q&A

Time Frame for Medicare Certification; Timed CPT Codes

Question: One of our PTs brought an article in that you had written regarding the time frame for certification for Medicare. The new regulations had increased the certification time to a maximum of 90 days before recertification. Per your article, as of January 29, 2008, the final guidelines had not been released. I called Medicare today to see if the guidelines had been released, and the representative was no help. She gave me a Website to go to and try to find the answer. I had no luck.

Have you received a final word on the change from 30 days to 90 days? If so, where can I find it in writing to forward to my supervisor?

Answer: As of the writing of this column, CMS has not issued any transmittal to its contractors. During a CMS audio-conference back in January, the speaker was asked when we could expect this transmittal to be published and her reply was "Sometime in Spring"!

There are two of the newly announced MACs that have it in their draft Part B policies, but neither of them are effective until sometime in July. In the meantime, carry on as normal and watch our Website.

Question: How would this case be billed. A patient is seen by OT for 20 minutes for therapeutic exercise (97110) and then works on ADL/Self Care (97535) for 20 minutes. Is it correct to add the total code treatment minutes as 40 minutes and then assume this is billable by 3 units? Or should we bill 2 units since only 2 separate procedure codes under the 23 minute Medicare rule?

The Medicare guideline tells us the treatment units are: 8-22 minutes = 1 unit; 23-37 minutes = 2 units; 38-52 minutes = 3 units; 53-67 minutes = 4 units, etc., with the first procedure being at least 8 min and each one thereafter 15 minute increments.

Answer: You are probably not the only one confused about Medicare's guidelines. In CMS's Internet Only Manual (IOM) Pub. 100-04 Claims Processing Manual, Chapter 5 - Part B Outpatient Rehabilitation and CORF/OPT Services, §20.2 - Reporting of Services Units with HCPCS, there are several examples of billing scenarios, along with the regulations of how to use the "8 minute rule" guidance. In subpart C. Counting Minutes for Times Codes in 15 Minute Units,  it states "If more than one 15 minute timed CPT code is billed during a single calendar day, then the total number of timed units that can be billed is constrained by the total treatment minutes for that day."

Your example is the same as identified in the manual. The therapist spent a total treatment time of 40 minutes which, based on the guidelines would indicate that 3 units can be billed. The instructions state that "appropriate billing for 40 minutes is 3 units. Each service was done for at least 15 minutes and should be billed for at least one unit, but the total allows 3 units. Since the time for each services is the same, choose either code for 2 units and bill the other for 1 unit. Do not bill 3 units for either one of the codes."

So now the dilemma: Which one to bill for 2 units: therapeutic exercise or self care ADLs? In our seminars we emphasize that, as therapists, we are entitled to the maximum legal reimbursement for the services we provide. So what do you think should be the answer? We say the one that utilizes the most skill, i.e. the one that pays the most, which in this scenario would be self care ADLs.

Pauline M. Franko, PT is owner of Encompass Consulting & Education, LLC; a consulting and education company specializing in Medicare Compliance and Training, based in Tamarac, FL. The company's "Direction on Demand" service specializes in providing the rehabilitation professional with a clear, easy way to understand how to provide Medicare compliant services to their patients in the SNF and Outpatient settings. As an associate in Comprehensive Medicare Consultants, LLC, she is responsible for assisting with and directing compliance programs to Rehab Agencies. Danna Mullins is an associate and lecturer with Encompass. You may contact the authors through the Encompass website at or by phone at 954-720-4087. 

Medicare Advisor Archives

Can you give me any info on medicare provider certification for pt clinics. I am a partner with a PT who has a medicare NPI # and is a current medicare provider, but there is a freeze on the clinic survey indefinitely, is there some way to continue seeing medicare patient's and somehow ge reimbursed by medicare?

Terry ,  MrSeptember 02, 2009

Can anyone comment on whether it is appropriate for Acupuncturists to bill insurance companies for treatments using Physical Therapy codes? For instance 97530 for instruction of QiGong? This is in regards to a Florida provider. Anyone out there familiar with Acupuncture billing in that state? Thanks in advance.

Sandy Hokanson,  Coding Specialist,  ConsultingAugust 22, 2008
Minneapolis, MN


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