Billing

Question 1

How does billing occur

Answer 1

Part of the daily rate
-hospital, skilled nursing facility, some rehab
Per CPT code
-medicare/medicaid and most private insurance
Per diem rate
-flat rate for all rehab services/day (PT, OT, SLP)
-some states Medicaid & few private insurances
Per session Rate : medicare moving towards

Question 2

ICD

Answer 2

International classification of diseases

Used in billing to describe patients condition

Question 3

ICD 10 vs V-codes

Answer 3

ICD-10 mote specific (4x the # of codes)

V-codes : a type of CPT code used to describe a surgical procedure

Question 4

CPT CODES

Answer 4

Used for most insurances
Developed by AMA for describing services
-Level one of HCPCS: referred to as CPT code
Level 2 is DME: reffered to as HCPCS “hixpix”
Widely recognized by insurances and medicare & medicaid as standard coding
-time based codes
-service bases codes

Question 5

RVU

Answer 5

Relative Value Unit
Work RVU: level of time, level of skill & training, intensity of service
Practice expense RVU : counted at all full rate for 1st CPT & discounted 50% for all other CPT for gived day
Malpractice RVU
->modified for geographical price index

Question 6

• Time Based CPT Codes

Answer 6

15 minutes is the equivalent of 1 unit
Can ass unit any time you exceed 8 min,.
-so 8-22 min (15 min + 7 min) = 1 unit
Always reach the multiple of 15 min then add 8 min to get the next unit.
-15 + 8 min = 23 min or > = 2 units
-30 + 8 min = 38 min or > = 3 units

Question 7

Modality CPT

Answer 7

Supervised modalities : UNLIMITED service doesnt matter how long or how many body parts
Constant Attendance modalities: requires direct visual, verbal, or manual contact

Question 8

MUE

Answer 8

Modifies Unlikely Edits (2007)
Sets a max amount of a specific CPT you can charge in one day. Designed to prevent fraud in an automated system. So you will need to justify your charges by adding a modifier to your bill

Question 9

CPT for Othoses

Answer 9

Term to be used in documentation and billing

Splint is associated w/ fractures and casting : mainly used in MD office

Question 10

97760 Orthotic management and training

Answer 10

INcludes assessment and fitting and training
Does not include supplies
Includes teaching, wear, care, skin care, modifcation of splint and pt. instruction in exercise to be completed while wearing splint

Question 11

L codes

Answer 11

Charge for a specific type of splint

• includes assessment fabrication, supplies
• does not include wear, schedule, skin care, or exercise instruction

Question 12

CCI Edits

Answer 12

National Correct Coding Initiatives (NCCI)
Created to reduce fraud
Paired CPT codes billed on same day that insurance companies see as too similar or feel that one is included in the other

Question 13

CCI Edits and Modifier 59

Answer 13

Need to attach the modifier 59 to charges if you see a CCI edit
-this tells the insurance company that you did the code at a distinct and different time
-Doccumentation must back that up
CCI edits are updates every 3 mos.

Question 14

KX Modifier

Answer 14

Modifier applied when the pt. reaches the cap for medicare coverage
-currently $1920 for OT
-& $1920 for PT and SLP combined
Requires documentation
-needs are complex and medically necessary
-further therapy will achieve higher level of function in a reasonable period of time .

Question 15

Session codes

Answer 15

Will eliminate need for modifiers
allow more flexibility in what you do during the session
Reduces complexity
Pure evaluation codes do NOT allow you to provide treatment same day

Question 16

Documentation

Answer 16

outcomes that the payer wants 
consistent functional improvement 
to get payment you need to have documentation completed 
timeliness 
retrospective reviews

Question 17

Role of AOTA & NYSOTA

Answer 17

Fund a lobbyist in state and federal governments
-monitor new legislation  
Marketing to consumer 
Networking w/ other therapists 
Organize grassroots lobbying