Billing and Coding

Question 1

CMS

Answer 1

Medicare version
Focuses on total time
Accepts mixed remainders

Question 2

AMA

Answer 2

Private payer system
Does not allow mixed remainders
<8 minutes not billable

Question 3

Low Complexity evaluation

Answer 3

No personal factors/comorbidities
1-2 elements of Body structure, Activity lim, participation lim
Stable/uncomplicated clinical presentation

Question 4

Moderate Complexity Evaluation

Answer 4

1-2 personal factors/co-morbidities
3 or more elements of mid ICF
Evolving clinical presentation with changing features

Question 5

High Complexity Evaluation

Answer 5

3 or more personal factors/comorbidities
4 or more mid ICF
Unstable and unpredictable clinical presentation

Question 6

Re-Evaluation

Answer 6

Revised plan of care using a standardized patient assessment
Not following 15 minute rule

Question 7

Progress Report

Answer 7

Evaluation of progress towards goals
Objective measurement
Professional judgement about continued care
Any changes to goals
Cannot be generated by a PTA

Question 8

4 Components of Medical Necessity

Answer 8

Authority (medical necessity, skilled)
Purpose (medical condition, functional ability, reasonable expectation of progress)
Scope (Does not exceed appropriate supply or level of service)
Evidence based

Question 9

POC recertification

Answer 9

must be recerted in 90 days max
If care goes beyond 90 or there is a substantial change to the POC the therapist must have the new POC certified

Question 10

Targeted medical review

Answer 10

$3000 threshold for combined PT and SLP services
Only reviewed if high claims denial, pattern established
Part of a group with above factors

Question 11

CPT vs ICD-10 codes

Answer 11

Current Procedural Terminology - treatment codes

Diagnosis codes

Question 12

Therapeutic exercise description and duration

Answer 12

Using exercise to develop strength, endurance, ROM, and flexibility - 15 mins

Question 13

NM re-ed description and time

Answer 13

Re-ed of movement (pattern), balance, coordination, kinesthetic sense, posture, and/or prooprioception for sitting and/or standing activities - 15 mins

Question 14

Where does PROM belong when coding/billing?

Answer 14

Ther ex

Question 15

What is the “ing” code?

Answer 15

Therapeutic activities

Question 16

T/F Medicare pays for concurrent 1:1 care as long as a PTA is assisting

Answer 16

False - Medicare doesn’t reimburse this. Have to charge Group Ther Procedures

Question 17

Jimmio Vs Sebelius Case

Answer 17

Allowed for skilled therapy services to be covered by Medicaid for maintenance of function in the case of a degenerative condition (as long as justification is presented for SKILLED services)

Question 18

KX modifier threshold?

Answer 18

Used to support continued medical necessity

$2230 for PT and SLP combined
$2230 for OT

*specifically document rationale for continuing therapy above threshold

Question 19

CQ modifier

Answer 19

Medicare reimburses 85% for PTA services

Question 20

Original POC can be written for a max of?

Answer 20

90 days

Question 21

The POC must include? (5)

Answer 21

Medical treatment and diagnoses
Long term functional goals
Type of services or interventions planned
Frequency of treatment (no ranges)
Duration of treatment (no ranges)

Question 22

4 components of medical necessity

Answer 22

Authority
Purpose
Scope
Evidence

Question 23

Reimbursement in order from most to least

Answer 23

Ther act
NM re-ed
Self-care/home management training
Ther ex
Manual therapy

Question 24

What modality is timed unlike most?

Answer 24

Ultrasound

Question 25

Medicare daily note requirements (4)

Answer 25

Date of service
ID of each intervention provided
Time treated
Signature and professional designation