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Semester 3 PID Exam 4 > CMS - Medicare and Medicaid > Flashcards

CMS - Medicare and Medicaid Flashcards

1
Q

Medicare eligibility - Provides hospital and medical coverage for these categories

A

Persons age 65 or over
Persons entitled to railroad disability benefits
Persons entitled to disability benefits for 24 months
Persons entitled to SSI due to Lou Gehrigs Disease
Persons with end state renal disease

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2
Q

Medicare Part A

A 
Hospital Insurance
Inpatient
SNF*
Home health services*
Hospice
Acute rehab
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3
Q

Medicare Part B

A 
Medical Insurance
Outpatient rehab
Physician services
Durable medical equipment
Mental health services
Ambulance
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4
Q

Medicare C

A 
Medicare plan - private insurers - Advantage Plans
HMO
PPO
PFFS
POS
MSA
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5
Q

Medicare D

A

Prescription drug plan
Voluntary enrollment with A or B coverage
Late enrollment = higher premium
Medicare contracts with private companies

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6
Q

Medigap benefits

A

Supplemental health insurance policy
Fills gaps within original medicare plan
Available through private insurance companies
Basically covers some or most of out of pocket expenses
Must enroll in both part A and B within 6 months of eligibility of medicare

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7
Q

Medicaid

A

Medical programs for eligible individuals and families with low income and resources
Largest source of funding for health services for people with limited incomes

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8
Q

When did medicaid get passed

A

Passed congress as title XIX of social security act in 1965

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9
Q

Who manages Medicaid

A

Centers for medicare and medicaid services (CMS)
Federal gov. monitors programs and establishes general guidelines and policies
Dept. of health and human services - individual states administermanage specific guidelines
State funded with federal match for some programs - amount vary by state

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10
Q

Medicaid eligibility

A

Pregnant women and children under 6 whose income is at or below 133% of the federal poverty level
Children 6-19 with family income up to 100% FPL
Certain children in foster care, adoption assistance programs, with disabilities
Non-elderly low income parents/caretaker relatives
Adults with disability under 65
Medicare recipients with low income

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11
Q

Medicaid Expansion

A

Started in 2014 - state choice
Coverage to non-elderly, non-disabled adults
Covers the gap of people who might be making just over but not enough for private coverage
Churning

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12
Q

Acute Care Hospital

A

Inpatient prospective payment system (IPPS) - DRG (diagnostic related group)
Medicare Part A
Covers all services provided in hospital, including PT

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13
Q

Inpatient Rehab Facility (IRF)

A

IRF PPS (IRF PAI)
Collection and reporting therapy amount - determine what medicare is paying for and is it appropriate
Need to report amount and mode of treatment

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14
Q

IRF - Mode of treatment - Concurrent therapy

A

One PT/PTA with 2 patients, performing different activities

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15
Q

IRF - Mode of treatment -Co treatment

A

More than one therapist from different disciplines to one patient at a time

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16
Q

IRF - Mode of treatment - Group therapy

A

One PT/PTA to 2-6 patients at a time performing the same activities

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17
Q

IRF - Mode of treatment - Individual therapy

A

one PT/PTA to one patient at a time

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18
Q

SNF

A 
Case mix PPS - med A
MDS
RUGs
30 day rule
100 calendar days benefit
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19
Q

Home health

A

Med A
Homebound status - need to meet two criteria
Can also be covered by Med B

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20
Q

Two criteria for being “confined to home”

A
  1. Need the aid of supportive devices or assistance of another person to leave home OR leaving home is medically contraindicated
  2. a normal inability to leave home AND leaving home must require a considerable and taxing effort
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21
Q

Outpatient Care

A

Med B
FFS
ACO
PTPPs placed in moderate risk category and require a site visit prior to enrollment

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22
Q

Medicare Physician Fee schedule

A

How medicare decides what you will get paid

Resource Based Relative Value Scale (RBRVS) - based on difficulty of work, practice expense, and malpractice expense

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23
Q

Therapy Cap – Med Part B

A

Cap for PT and SLP combined (OT is separate)
$1940 paid per calendar year –> use KX modifier and show medical necessity
$3700 exception to therapy cap limit - manual medical review

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24
Q

Therapy Cap - Med Part B
extended through =
Does not apply to =

A

Ext. through 2017

Doesn’t apply to Medicare Advantage

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25
Advanced Beneficiary Notice of Non-coverage (ABN)
Procedures not eligible for reimbursement Provide before providing the items or services Formal documentation notifying the patient that they are responsible for payment of service Patient may request to not receive the service
26
Requirements with ABN
Specify frequency and/or duration of service Explain why believe the service may not be covered Beneficiary cannot or will not make a choice, the notice should be annotated
27
Collecting out of pocket
Must give the beneficiary and ABN | Submit claim with GA modifier
28
Medicare quality reporting programs - CMS vision for quality measurement
Align measure with national quality strategy | Triple aim = better experience of care, improve health of population, lower cost of care
29
Medicare quality programs ensure that
the services they pay for are high quality | Quality reporting is tied to payment adjustments
30
Improving post-acute care transformation act of 2014 (IMPACT)
Expands reporting requirements for post-acute providers
31
Quality measures for acute and post acute care
``` Pressure ulcers Infections Re-admissions Pain management Falls rate/risk ADLs Consumer assessment of healthycare providers and systems Use of ER with no hospitalization ```
32
Physician quality reporting system - outpatient services
System to report quality indicators Utilizes incentive and payment adjustment program to promote participation Successful reporting included 6 measures on 50% or more of eligible medicare patients
33
Physician quality reporting system - outpatient services - Two different ways to report and Future changes
Claims based reporting - 6 items Registry based reporting - 15 items Merit based incentive payment system (2017)
34
CMS functional limitation reporting applies to
All outpatient therapy services
35
Functional limitation reporting - categories
``` To be submitted with severity modifiers Mobility Changing and maintaining body positions Carrying, moving, handling objects Self care Other - other score from functional assessment tool is used, service not intended to treat a functional limitation ```
36
Functional limitation reporting - when to report
``` Onset of the therapy episode Minimum every 10th visit Eval or re-ecal codes being used Reporting of a functional limitation is ended and further therapy is needed for another limitation Discharge ```
37
Functional limitation reporting - modifiers
Indicate extent of severity/complexity of the functional limitation
38
How to determine functional limitation
use valid and reliable assessment tool and/or objective measures
39
How to determine functional limitation - how to choose the primary limitation if more than 1
Most clinically relevant to successful outcome Yield the quickest or greatest functional progress Greatest priority for the patient
40
Functional Limitation Reporting - Each category has how many codes
3 Current functional status Projected goal for functional status Discharge functional status
41
When to report - Current functional status G code
Initial eval Every 10th visit Re-eval during episode of care
42
When to report - Projected goal for functional status G code
Every reporting interval
43
When to report discharge functional status G code
Discharge from therapy | End reporting for that functional limitation
44
Severity of functional limitation
You decide from assessment tools, other objective data, and other considerations like age, comorbidities, prognosis...
45
Severity modifiers =
``` CH CI CJ CK CL CM CN ```
46
CH severity modifier
0% impaired, limited or restricted
47
CI severity modifier
at least 1% but less than 20%
48
CJ severity modifier
At least 20% but less than 40%
49
CK severity modifier
At least 40% but less than 60%
50
CL severity modifier
At least 60% but less than 80%
51
CM severity modifier
At least 80% but less than 100%
52
CN severity modifier
100% impaired, limited or restricted
53
MACs
Medicare administrative contractors | FIs or Carriers
54
Certs
Comprehensive Error Rate Testing - checking mistakes by carriers - looking for under billing
55
RACs
Recovery Audit Contractors - also looking for over and under billing - they get percentage of what they fine
56
ZPICs
Zone program integrity contractors - policeman - looking for fraud detection - will conduct complex audits and investigatons - never random, they have a reason
57
Regulations and Guidelines
Federal CMS rules and regulations State licensure acts APTA professional guidelines The most strict regulation supersedes all others
58
Transmittals - National coverage decisions
policies apply to all contractors
59
Transmittals - local coverage decisions
Medicare administrative contractors
60
Levels of supervision - General supervision
PT is not required to be on site for direction and supervision, but must be readily available (telecommunication)
61
Levels of supervision - Direct supervision
PT is physically present and immediately available for direction and supervision. PT will have direct contact with the patient during each visit - line of sight supervision
62
Levels of SUpervision - Direct personal supervision
PT is physically present and immediately available to direct and supervise tasks related to patient care/management. The direction and supervision is continuous throughout the time of tasks performed
63
Supervisory issues - Med A
Student PT is considered extension of the PT Direct supervision - PT intern can perform interventions and procedures under line of sight supervision Documentation - PT intern can write documentation for medical record
64
Med A - modes of therapy
Individual therapy = 1:1 Concurrent therapy = 1:2 (performing separate treatments) Group therapy = 2-4 patients doing same activity
65
Med B - supervisory issues
Direct Personal Supervision Criteria for billing Only able to treat one patient if it is a med B patient Billing must be completed by PT
66
Med B - supervisory issues - Criteria for services by student to be billed - the qualified practitioner
1. Is present and in the room 2. Directing the service 3. Making the skilled judgment 4. Responsible for the assessment and treatment
67
PT student, Clinical Instructor, and Med B
PT must be with intern during treatment PT can allow intern to provide services under direct personal supervision Keep intern involved but patient knows who is directing care Don't treat other patients during scheduled time frame
68
Documentation - Med B - student
Student not solely document in chart Student can write a practice SOAP and PT can use it with edits and state that the qualified practitioner is responsible for assessment and treatment
69
Medicare coverage guidelines
Patient is under care of physician Services require skill of PT Expectation that condiiton will improve in reasonable amount of time Amount, freq, and duration must be reasonable Documentation reflects interventions that are medically necessary and justifiable
70
Payable therapy services -
Medical record and info on the claim form is consistent and accurate Services are covered therapy services
71
Payable therapy services - documentation
Is legible, relevant, and sufficient to justify the services billed Must comply with all legal/regulatory requirements applicable to medicare claims
72
Individuals who read our records
``` Accrediting agencies Other therapists Other health professionals Insurance companies Lawyers/Judges ```
73
Evaluation - must be
``` medically necessary and justifiable - Decline in status - Potential for functional improvement - Need for skilled intervention - Maintain updated goals - Be thorough and complete Warranted ```
74
Re-eval
Separately payable and periodically indicated during an episode of care when the clinician indicates: Significant imprvement Decline Change in condition or functional status that was not anticipated
75
Plan of Care
``` Diagnoses Long term tx goals Type of rehab therapy services Amount of therapy Duration of therapy Frequency of therapy Signature and professional identity Date ```
76
Initial certification of plan
Physicians/nonphysician practitioner approval of POC Obtain certification as soon as possible after POC is established As soon as possible = certify initial plan as soon as it is obtained or within 30 days of the initial therapy treatment
77
Verbal certification
Must be signed within 114 days of verbal A dated notation of the order to certify the plan should be made in patients medical record Recertification is not required if the duration of initially certified plan is more than the length of the entire episode of tx
78
Treatment Encounter Note
Documentation is required every treatment day, every therapy service
79
Treatment encounter note must include
Date of tx Total tx time Total time spent delivering timed code services Each specific intervention provided and billed Detail of tx provided Sig of PT Modification of tx
80
Progress report
Sig by physician or NPP is NOT required | Must be completed once every 10 tx days OR at least once through each 30 calendar days (whichever is less)
81
Progress note must include
``` Relevant subjective statements Review progress (or lack of) - pt response and potential Describe skilled tx Update or progress toward goals Plan for continued tx ```
82
Recertification of plan - should be signed when
When there is need for significant modification to plan At end of certification period and need for continued therapy At least every 90 days after initiation of treatment under that plan
83
Discharge Summary
Elements covered are same as progress report Last opportunity to justify medical necessity - May include summary of entire episode - Justify service that extended beyond what would be expected for pt condition
84
Documentation tips (4 of them)
Document skilled care provided, progress towards goals and patients response to tx Document changes in pt condition and functional limitations that support need for skilled therapy Document instructions given to pt Use skilled language
85
More documentation tips (2 of them)
Report status as related to function | Measurable objectives to justify progression
86
Documenting Minutes - Skilled Part A
RUG codes | All therapy minutes need to be clearly documented in the record
87
Documenting Minutes - Outpatient Part B
CPT codes and G codes | Documentation of minutes to support the CPT codes billed must be included in the record
88
Documenting Minutes - Home health
Per visit Documentation of visists to support medical necessity OASIS documentation
89
Medical Necessity - interventions should be
Complex enough to require a PT Provided by or under direction of PT Amount, freq, dur must be reasonable and nec Intervention/plan should be described in details Supported by documentation Patient must show progress
90
Skilled therapy
Skills of PT are necessary to safely and effectively furnish a recognized therapy service Need the expertise, knowledge, clinical judgment, decision making, and abilities of a therapist to complete activites
91
Improvement Standard
End to MAC interpretation of needing to show medical improvement Now can continue to receive care to maintain condition or prevent or slow decline
92
Improvement standard - Outpatient - to get paid for service...
Services must be provided by PT
93
Improvement standard - Home health - to get paid for service...
Services must be provided by the PT
94
Improvement standard - SNF - to get paid for service...
Does NOT exclude PTAs to provide skilled maintenance therapy So can be PT or PTA to get paid for service
95
Red flags for PT
Frequent use of KX modifier In private practice, using one PT provider number rather than one for each PT Excessive number of codes billed per session
96
Risk areas for PT
``` Missing certifications Billing for things done by techs Providing inadequate supervision Billing 1:1 instead of group Failing to comply with 8 min rule Failing to comply with CCI edits Submitting claims for services that are not necessary Unbundling codes Upcoding Billing for excessive duration Use of stamped signatures or signature not legible ```
97
Appeals
Right to appeal when your carrier/intermediary/MAC determines an overpayment occurred on prepayment or post payment review

Semester 3 PID Exam 4 (3 decks)

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