Billing Flashcards
Acronyms Related to Billing
- ONLY work comp does not usually use codes
CMS: Centers for Medicare and Medicaid Services
MAC: Medicare Administrative Contractor
Medicare hires facilities to revue their claims, this is the second party they hire to revue for them, set up regionally
MIPs = Merit Based Incentive Payment System
Outpatient, get reimbursed based on how good you do, how many units you bill and what are your outcomes related to your provider number
AMPs = Average Manufacturer Price
Go with average price for region
*** sometimes employer try to spin it to push patients thru
the system, know the law, most times there is a
threshold NOT a limit
MACRA = Medicare Access and CHIP Reauthorization Act 2015
Kids, medicaid primarily
CHIP = Children’s Health Insurance Program
CPT = Common Procedural Terminology
????
HCPC = Health Care Common Procedural Coding System
Codes we use to bill
PPS = Prospective Payment Systems
How systems are reimbursed, set amount of reimbursement for course of treatment (SNF, hospital, home health) all bundled together
Always track what you did in units, but that is not how they are getting reimbursed for services
PPS (Prospective Payment Systems)
Being reimbursed a set amount for a course of treatment versus individual charges. Consolidated or bundled billing
A method of reimbursement in which payment is made based on a predetermined, fixed amount. The payment amount for a particular service is derived based on the classification system of that service
CMS uses different PPSs for reimbursement to acute inpatient hospitals, home health agencies, hospice, hospital outpatient, inpatient psychiatric facilities, inpatient rehabilitation facilities, long term care hospitals and SNFs
Inpatient Acute Hospitals PPS
Payment based on Diagnosis (Diagnostic Related Groups or DRGs) = economic context
resources used (include OT/PT/SLP)
these resources must now demonstrate
* outcome
* proof of need
- Recent changes implemented by CMS regarding the need to track function will continue to evolve.
- Acute care documentation is a breeze compared to OP
Home Health PPS
Care based on resources needed (disciplines such as nursing, PT, OT, speech, nurses aides, supplies, length of time and frequency)
Must track fees for service but bill is consolidated and agencies reimbursed a bundled fee based on the resources required
Utilizes an Interprofessional Evaluation form called the OASIS (Outcome and Assessment Information Set)
It has a section devoted to OT that we can open
With this Medicare has lumped all visits together, to make different visits it is hard on therapists b/c you have to negotiate which is more important at that time
Level of care comes with a price tag = this comes from OASIS eval
Skilled Nursing Facilities (PPS for Part A)
Part A (acute - up to 100 days)
- Must have a qualifying hospital stay to initiate Part A
Part A pays 100% of the stay
Resident Classification System RCS-1 = patient will be classified, inpatient driven payment models (PDPM groups)
Looks more at MDS and nursing components
ICD = 10 codes
Minimum Data Set (MDS) section GG to determine reimbursement, this is what a lot of the payment is based on = they want to see improvements on section GG (ADLs), how much assistance is required
For rehab (if they did not qualify for rehab in hospital b/c you must be able to tolerate at least 3hrs a day, instead they can go to a step down unit or SNF)
Medicare Part A covers for 100 days plus days in hospital ???
Nursing homes, people who have medicare, no fall, not hospitalized
Part B only pays 80% = so need another form of payment
Outpatient Billing and Part B Billing in SNFs
Part B pays outpatient services and pays 80% of the bill
Currently a fee for individual units of therapy
(fee for service)
CMS collecting data to transition to a fee per visit or possibly a fee for diagnosis or duration system
(PPS like system)
How do we currently bill for outpatient
American Medical Association (AMA) current procedural terminology (CPT codes)
Time based codes are billed in units of therapy (8-15 minutes of an intervention) must have intervention over 8 mins to bill it
Untimed codes are billed in units of service no matter how long the intervention was performed
ex: evaluations
some places were billing eval and treat in same session = unethical
Therapy codes are in the 9000 series
8 Minute Rule
Units Number of Minutes
0 Units < 8 minutes
1 Unit > or = 8 mins and < or = 22mins
2 Units > or = 23 and < or = 37
3 Units > or = 38 and < or = 52
4 Units > or = 53 and < or = 67
5 Units > or = 68 and < or = 82
6 Units > or = 83 and < or = 97
7 Units > or = 98 and < or = 112
8 Units > or = 113 and < or = 127
*** Just easier to always block out 15mins for service
Time based units = Medicare and blue cross blue shield follow this but other don’t
Control as much as you can by controlling all units
Untimed Code Examples
Untimed codes are billed one unit per date of service regardless of the number of anatomical body areas treated or time spent. It does not matter if you spend 2 mins or an hour treating the patient using these codes, you can only report one unit per code.
9165-67 = Occupational Therapy Evaluation
(3 levels - low, medium and high)
97168 = Occupational Therapy Re-Evaluation 97010 = Hot or cold packs 97012 = Traction, Mechanical 97014 (G0283) = Electrical Stimulation unsupervised 97024 = Diathermy 97028 = Ultraviolet 97150 = Group Therapy (2 or more patients are considered group)
Timed Codes
Timed codes are billed using Medicare’s 8 Minute Rule
The following codes are examples of timed codes:
97032 = Electrical Stimulation (Manual) (more skilled, you have to know where you are going) 97033 = Iontophoresis 97035 = Ultrasound 97110 = Therapeutic Exercise 97112 = Neuromuscular Reeducation 97535 = Self Care Training 97140 = Manual Therapy 97530 = Therapeutic Activity
*** Therapeutic exercise, neuromuscular reeducation, self care training, manual therapy and therapeutic activity = most used codes
Total Time Governs How Many Units You Can Bill Under Medicare
Must report what was done in minutes and in units
The units are determined based on the total time in therapy
You can not spend 8 mins in 4 interventions and bill 4 units because the total time would only equal 32 mins
32 mins is equivalent to 2 units
Medicare will reimburse the intervention that required the most skill or where more time was devoted
***This rule applies to Medicare only
Insurances vary greatly in how they reimburse
BCBS follows the Medicare 8 min rule but not the total time rule. Other insurances might reimburse even if only 5 mins were spent doing a time based modality
Ex: What could be billed in the scenario (what will you get reimbursed for)?
10 min of a hot pack (97010)
8 min of retrograde massage (97140 manual therapy)
15 min of exercises including tendon glides, AROM of wrist and digits (97110 therapeutic exercise)
10 mins of sorting beads and pushing them through a plastic lid in a container (97530 therapeutic activities)
8 mins of finding marbles in rice with vision occluded (97112 neuromuscular rehab)
3 Units b/c total time is 49mins
** Always make sure that everything is over 8 mins, otherwise it will go to a higher skill and be bundled with that
Reimbursement
Fees schedules * regionally determined * claims processed by a MAC (Medicare Administrated Contractor) * occasional misinterpretation issues can occur (knowledge and advocacy is power)
FYI: every insurance provider has diff reimbursement amounts they will pay per CPT code
it is an agreed upon fee schedule and the amount billed by provider will exceed that amount and the diff is what is reported as a loss at the end of the year and then used as a tax right off
Service based can only bill one cost = one price, doesn’t matter how much time you spend
L-codes are diff they are not 9000 codes
L-codes often used at free standing OP clinics
L-codes are bundle charged and are more specific to what we do
L-codes are used for orthodics (bill per units and the unit is a bundle of everything = training, fabrication, use and materials
SNFs need to use 9000 codes (time based) and can not use L-codes
2000 codes OP must have a doctor overseeing care of all patients but don’t reimburse as well as 9000 or L-codes
Proper Coding ICD-10 Codes
Diagnostic codes that identify what the diagnosis is and where the individual is in their recovery
In an outpatient setting the therapist is responsible for accurate coding based on info received from the physician, patient and clinical findings. We can not change a formal medical dx but we can list functional dx such as pain, weakness, reconditioning etc
For Medicare patients the primary dx = functional dx and the secondary dx = the condition
Ex: primary = M25.51 shoulder pain
secondary = M75.101 partial rotator cuff tear
any other insurance primary is what they are there for
(fracture etc)
It is our job to be certain that the codes are correct
Recent Changes in CPT Language and coding for Occupational Therapy Evaluation and Re-evaluation
OT evaluation = occupational profile, medical and therapy
hx, relevant assessments, and
development of a plan of care, which
reflects the therapist’s clinical reasoning
interpretation of the data
Coordination, consideration, and collaboration of care with physicians, other qualified health care professionals, or agencies is provided consistent with the nature of the problem and the needs of the patient, family, and/or other caregivers
*** Change to OT eval HCPC code, now three levels of evals (still presently get paid the same for each level) eventually this will change (just the eval) this effects your productivity
Ex: low = 30mins = 2 units
