Final Exam Flashcards
What is the purpose of the ICF model?
The ICF integrates the major models of disability. It recognizes the role of environmental factors in the creation of disability, as well as the relevance of associated health conditions and their affects.
In the ICF model, what details will go in the “Body function and structure” portion?
(The impairment)
-Physiological functions of body system.
-Anatomical parts of the body
-Problems in body function and structure such as significant deviation or loss.
In the ICF model, what details will go in the “Activities” portion?
(The limitations)
-The execution of a task or action by an individual.
-Difficulties an individual may have in executing activities.
In the ICF model, what details will go in the “Participation” portion?
(Restrictions)
-Involvement in a life situation
-Problems an individual may experience in involvement in life situations.
In the ICF model, what details will go in the “Environmental factors or Personal factors”
These are either barriers to or facilitators of the person’s functioning
Why do we document?
It is the official record for the episode of care.
Why is documentation important?
(7 points)
-Utilized as a communication tool between PTs and others involved in patients care. **
-Provides a guidance system and assist in clinical problem solving.
-The clinical record to support reimbursement. **
-Proves care is reasonable and necessary, “Medically necessary”
-Shows proof of skilled care
-Takes part in legal record **
- Administrative duties, including patient outcomes and effectiveness.
**important
What is the Patient/Client Model?
Examination->Evaluation->Diagnosis
->Prognosis->Intervention->Outcome
In the Patient/Client Model, What goes into the Examination portion?
(Also POC)
-Short explanation summary for reason you are evaluating
-Medical diagnosis and history
-Review of systems (All major body systems)
-Test and Measures
POC
-Includes: amount, frequency and duration
-A summary of the plans for skilled intervention
-A specific list of interventions that will be provided with supporting rationale
In the Patient/Client Model, What goes into the Evaluation portion?
(II-DDD)
Interpret: Interpret the individuals response to test and measures
Integrate: Integrate the test and measure data
Determine: Determine a diagnosis
Determine: Determine a Prognosis
Develop: Develop a POC
-Diagnosis
—Summary statement/clinical impression
—PT diagnosis
—PT problem list
-Prognosis
—Rehabilitation potential
—Potential factors influencing patient progress
—Goals
In the Patient/Clinical Model, What goes into the Interventions portion?
-Communication and coordination with other health care providers
-Instructions and teaching to patient, family and caregivers
-Procedural interventions provided
What are some documentation guidelines?
Purpose:
-legal document
-communication
-reimbursement
-It is written in the third person.
- If handwritten, always write in pen and follow facility guidelines. (Pen color: Blue/Black)
What are the different types of PT documentation?
-Initial Evaluation
-Daily Encounter Note (Daily Note)
-Progress Report (Progress Note)
-Discharge Summary (D/C summary)
other:
-Missed visits
-Communication
-Occurrences outside of PT
treatment
What goes into the Initial Evaluation?
(Type of PT documentation)
This is completed at the time of initial PT visit. Includes: Finding of the interview and examination, Plan of Care, Goals and intervention planned.
What goes into the Daily Encounter Note or Daily Note?
(Type of PT documentation)
This is completed for each PT visit with details of treatment provided, patient status that day, assessment of the days treatment, and patient response to treatment.
What goes into the Progress Report or Progress Note?
(Type of PT documentation)
This is completed at regular intervals, based on facility policies and requirements for third party payers. Includes: summary of services provided and patients progress since evaluation or last progress report, as well as an assessment or progress towards goals, reasons for continued services and plans for future treatments
What goes into the Discharge Summary?
This is completed at the time of discharge or discontinuation of services. Includes: Summary of services provided and the patients progress since evaluation, the reason for discharge or discontinuation of services, and an assessment of patient progress towards goals, as well as plans for home program and any follow up.
What are the different documentation formats?
-Narrative
-POMR
-SOAP
-Functional Outcome Report
-Various electronic templets
What does SOAP stand for?
Subjective
Objective
Assessment
Plan
What information will go into the “Subjective” portion in the SOAP note?
(Long List)
-Information collected from patient/caregiver that is relevant to patient’s condition.
-“History-Taking” portion of the examination: verbal history (PMH, HPI, PLOF, MOI, L/S) Think of abbreviations we went over for exam
-Previous Therapy and results
-Pertinent quotes
-C/C and other complaints
-Patient and family goals
-Description of symptoms
-Response to treatment
-Patients view of progress
What information will go into the “Objective” portion in the SOAP note?
-System review: General screening of various body systems (HR, RR, BP)
-Relevant test and measures (General appearance, posture, MMT, ROM, gait analysis, reflexes, etc.)
-Interventions provided (modalities, manual therapy, wound care, functional training and therapeutic exercise)
-Patient education (content, type of instruction, result of education)
-Astute observations made with therapist eyes, ears, and hands
What information will go into the “Assessment” portion in the SOAP note?
(Big list)
-Interpretation or impression of
S & O
-PT and medical diagnosis (Evaluation)
-PT problem list (Evaluation, Progress report)
-Patients rehab potential (Evaluation, Progress report, D/C summary)
-Goals and Progress towards goals (Goals-Evaluation) (Progress towards goal - Daily notes, Progress report, D/C summary)
-Description of progress/Lack of progress (Daily note, Progress report, D/C summary)
-Justification of PT service to start or continue (Eval, Daily Note, Progress Report)
-Reasons for discontinued services (D/C summary)
-Recommendation for referral (All types of PT documentation)
What information will go into the “Plan” portion in the SOAP note?
-Specific treatment plan for the identified problems of the patient
-Intent to change treatment plan
-Plan for future treatment
-Plan to follow recommendations in Assessment
-Plan to D/C
-Plan after D/C from therapy (In D/C summary)
What are the goals in PT documentation?
-Goals guide the PT POC
-Show PTs vision for the patient
-Involves the patient (Better buy-in, more realistic and attainable goals)
-Track the outcome of our POC
What does SMART stand for?
(For SMART Goals)
Specific
Measurable
Attainable or achievable
Realistic or relevant
Time-bound
In terms of payment, how are providers paid?
-Document the necessary details for payment.
-Assign codes to represent services rendered and other pertinent details.
-Submit the claim
-Interpret payer’s response
-Prepare post-payment audit
How does Medicare/Medicaid work for us to get reimbursed for skilled care?
By determining:
-What is wrong with the patient
-How sick is the patient
-How you are going to help the patient
-How long the treatment will take
-How successful you are at your job
What is Medicare/Medicaid?
A federally ran health insurance plan.
How does insurance Medicare/Medicaid work?
The billing entity sends information to medicare/medicaid via a billing form
What does Medicare Part A program cover?
This plan covers Inpatient hospital stays, skilled nursing facilities stays, some home health visits, Hospital care.
What does Medicare Part B program cover?
Covers physician visits, outpatient services, preventive services, and some home health visits
What does Medicare Part C program cover?
This plan refers to the Medicare Advantage Plan, through which beneficiaries can enroll in a private health plan, such as a health maintenance organization or preferred provider organization, and receive all medicare-covered Part A/B benefits and typically Part D benefits
What does Medicare Part D program cover?
Covers outpatient private plans that contract with Medicare, including stand-alone prescription drug plans (PDPs) and medicare Advantage plans with prescription drug coverage
How does Medicare/Medicaid relate to therapy services?
Medicare A: Acute care, can return patient to PLOF only
Medicare B: Best the patient can be, can maximize patient’s function
Medicare C: Children, therapy services billed under Medicare C and Medicaid
Medicare D: Drugs
What are ICD-10 Codes?
International Classification of Disease (ICD) is a classification system developed by the World Health Organization (WHO)
What is the purpose of ICD-10 Codes?
Used to track care statistics/disease burden, signs and symptoms, abnormal findings, social circumstances and external causes of injuries and/or diseases, quality outcomes, mortality statues and billing
What are CPT Codes?
Current Procedural Terminology (CPT) are codes published and maintained by the American Medical Association (AMA)
What is the purpose of CPT codes?
Used to describe test, surgeries, evaluations, and any other medical procedures performed by healthcare provider on a patient.
–CPT codes tell the insurance payer what procedures the health care provider would like to be reimbursed for
What is the difference between ICD-10 and CPT codes?
ICD-10 is a 7-character, alphanumeric code. Begins with a letter, followed by two numbers.
-First three characters of ICD-10 represent the “Category”, which describes the general type of the injury or disease. The Category is followed by a decimal point and subcategory
CPT codes are normally a 5-digit number, which represents a procedure or service provided to the patient
Treatment DX: R29.89 is an example of which code?
ICD-10 code
Medical DX: Z96.641is an example of which code?
ICD-10 code
Service provided: 97116 is an example of which code?
CPT code
What are the types of Reimbursement systems?
-Fee-for-service (FFS)
-Capitation
-Bundled/Episode-Based Payments
What is Fee-For-Service (FFC)?
(Type of reimbursement)
(Give def.)
Providers paid for each every service
(Medicare part B, reimbursed for each CPT code)
What is Capitation?
(Type of reimbursement)
(Give Def.)
Providers are paid a prospective “cap”, or per member per month (PMPM) payment, to provide care for individuals enrolled in managed health plans.
(Used by HMO to control costs, similar to consolidated building)
What is Bundled/Episode-Based Payment?
(Type of reimbursement)
(Give Def.)
Providers are paid for all services within an episode of care
(Medicare Part A based on episode of care)
What is Health Common Procedural Coding System (HCPCS)?
CPT codes are used as “Time base codes” and “Event or service-based codes”
What are Time based codes?
Time base codes is with the therapist is reimbursed based on time
Ex:
e.g. 97116 Gait Training 1 unit/15 minute
e.g. 97530 Therapeutic Activities 1 unit/ 15 min
What are Event or service-based codes?
Event or service-based codes is when the therapist is reimbursed for the service or event
Ex.
e.g. 97161* PT Evaluation Low complexity regardless of time reimbursed once/occurrence
e.g. 97162* PT Evaluation Moderate Complexity regardless of time reimbursed once/occurrence
What is the 8-minute Rule?
-You take the total treatment for the day.
-You subtract total event or service-based minutes. (You can only give 1 unit for service, regardless of the time spent, the amount of time left you can allocate to your time based codes)
How many units will be billed for 8-22 minutes?
1 unit
How many units will be billed for 23-37 minutes?
2 units
How many units will be billed for 38-52 minutes?
3 units
How many units will be filled for 53-67 minutes?
4 units
How many units will be filled for 68-82 minutes?
5 units
In this example, How many units will be billed:
(Therapeutic activity) 97530 - 7 min
(Neuromuscular education) 97112 - 7 min
(Gait training) 96112 - 7 min
+ ________
Total 21 minutes, so we will bill 1 unit
