Health Record, Terminology and Billing

Question 1

Purpose of health record

Answer 1

• Exchange of info among providers in order to determine client’s problems and strengths,
• Establish plan of care,
• Record treatment,
• Facilitate continuity of care upon discharge/future, and
• Fulfill legal doc requirements.

Question 2

Things to remember while documenting:

Answer 2

• If I’m absent, will another OTP be able to take over where I left off?
• If I were a funding source, would I pay for OT services I’m reading about?
• Am I relating what I did to FUNCTION/Occupation?
• Are my notes professional?
• Could my clients or other parties read this and find it appropriate/accurate?

Question 3

Skilled vs. Nonskilled Services

Answer 3

• SKILLED have specific criteria: professional education, decision making, complex competencies with well-defined knowledge base of human functioning/occ performance
• NONSKILLED are routine maintenance types of therapy, could be carried out by others. Medicare does not reimburse for non-skilled!

Question 4

Types of Health Record Notes:

Answer 4

• Initial evaluation reports
• Contact, encounter, treatment, visit notes (“dailies”)
• Progress notes or report
• Re-evaluation notes
• Transition notes
• Discharge notes or discontinuation
• Incident reports/other special reports

Question 5

Initial Evaluation Report

Answer 5

• Prior to OT treatment, client evaluated to see if OT is appropriate, and if so, what kind of intervention would be most useful
• Different at each facility
• OT directs initial eval process, documents results, establishes intervention plan (OTA may contribute)

Question 6

Progress Note

Answer 6

• Written at end of specific time period (ie: 2 weeks)
• Incl client’s progress toward goals and details any changes made in intervention plan
• Usually weekly or monthly
• May be in SOAP format
• Often required for reimbursement

Question 7

Re-evaluation Notes

Answer 7

• Also called Reassessment Notes
• OT directed; OT modifies intervention plan according to client’s needs
• OTA may contribute
• Monthly at some facilities
• Where managed care is involved, client may need re-eval to be recertified for treatment after # of initially allocated visits

Question 8

Transition Notes

Answer 8

• When client transfers from one service setting to another (ie: acute to in-patient rehab)
• To ensure client’s intervention plan remains intact thru move and services already provided aren’t duplicated
• Responsibility of OT
• OTA may contribute

Question 9

Discharge Summary or Discontinuation Notes

Answer 9

• Describe changes in client’s ability to engage in meaningful occupation as result of OT intervention
• Summarize course of treatment, progress toward goals, status at time of DC, AE/splints provided, referrals, or follow-up required
• Directed by OT
• OTA may contribute

Question 10

Healthcare Funding Sources

Answer 10

• 3rd Party Payers: insurance, managed care plans (HMO/PPO); govt. programs
• Medicare: 65+, end stage renal disease, or eligible ppl under 65 w/permanent disability.
• Medigap: offered by private ins to “bridge the gap”
• Medicaid: Joint fed/state program for low-income ppl
• Early Intervention/Schools: Developmental Delay or at-risk for delay due to disease/condition

Question 11

Parts of Medicare

Answer 11

• Medicare Part A: Inpatient hospital care
• Part B: Outpatient care
• Part C: Medicare advantage plans
• Part D: Prescription drug coverage

Question 12

What OTPs Bill For:

Answer 12

• Rehabilitative Therapy
• Maintenance Programs
• Safety Concerns
• Prevention of Secondary Complications

Question 13

Examples of Justifications for Skilled Therapy

Answer 13

OTs (with contrib from OTAs):
• Evals/re-evals; identify problems; establish goals; develop intervention, transition, discontinuation plans.
• Assess/reassess effectiveness of AE, compensatory techniques, etc. to modify intervention plan.

OTs and OTAs:
• Modify/adapt activities/environment for safe performance
• Enhance performance of activities through intervention
• Promote well-being; safety
• Teach adaptation/compensation
• Improve/enhance skills
• Set up orthotics/AE
• Design exercise programs; skilled training; skilled coord. of care
• Implement skilled group interventions

Question 14

ICD-10 Codes

Answer 14

WHO created International Classification of Diseases (ICD) codes, used by 117 countries. Used in medical billing.

Question 15

Healthcare Common Procedure Coding Systems

Answer 15

CMS (Centers for Medicare and Medicaid Services) uses this system to enable physicians/health care providers to use common language and standardized codes.
• CPT=Current Procedural Terminology codes

Question 16

Billing Forms and Procedures

Answer 16

Provides “submit a claim” form to third party payers for payment

Question 17

Timed Service Billing (Units)

Answer 17

• Many CPT (Current Procedural Terminology) codes for therapy are based on time using 15-minute increments (15 min = 1 unit).
• Other CPT therapy codes are based on untimed procedures/fixed amounts (ie: OT eval billed as 1 unit)
• Medicare considers 8 min-22 min as 1 unit.

Question 18

Durable Medical Equipment (DME)

Answer 18

Equipment that can be used repeatedly; only some are covered by Medicare.

Question 19

Define Fraud and Abuse per CMS

Answer 19

Centers for Medicare and Medicaid define as:

FRAUD: making false statements or representations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist…and performed knowingly and willfully, and intentionally

ABUSE: Practices that either directly or indirectly result in unnecessary costs to Medicare program.

Question 20

What are the mechanics (basic rules) of documentation?

Answer 20

• Use black, waterproof ink
• Never use correction fluid/tape
• Correct errors by a single line through it, date/initial the correction
• Do not leave blank spaces/lines, as they could be used falsely. Draw a line through the empty space like on checks (and sign/date)
• Be sure all required data is present
• Sign and date every note
• Be prudent using abbreviations
• Refer to yourself in third person
• Adhere to ethical/legal guidelines
• Use people-first language
• Review chart beforehand; communicate/clarify

Question 21

Weak Information

Answer 21

AVOID:
• undefined reference to time (instead of “often,” use “6x per hour”)
• undefined quantities (instead of “some,” use “four pounds”)
• judgment of behaviors/labeling. (Say “patient clenched fists” instead of “hostile”)
• leaving out objective basis for judgment (Say “Pt stated he likes trains and will read anything on the subject” vs. “Pt likes trains.”)

Question 22

Contact/Treatment/Daily Note

Answer 22

Note taken each time OTP does an intervention.
• May also include telephone convos, meetings with family/other professionals
• Filled out as setting requires
• May only be an attendance sheet, checklist, informal log, or jotted-down notes for later
• ** Includes SOAP note format! **

Question 23

Medicaid

Answer 23

A combined federal-state health program with income eligibility guidelines.

Question 24

IDEA Part B vs. IDEA Part C

Answer 24

PART B: Mandates an appropriate and free public education in the least restrictive environment for children with disabilities.

PART C: Establishes early intervention services up to age 3.

Question 25

CMS-1500

Answer 25

A claim form.

Question 26

Deductible vs. Coinsurance vs. Copayment

Answer 26

DEDUCTIBLE: The initial out-of-pocket expenses an individual must pay to providers before the insurance company begins paying for those covered services.

COINSURANCE: The 20% out-of-pocket expense that a Medicare Part B beneficiary pays for a covered service.

COPAYMENT: A set amount individuals pay to a health provider at each visit in addition to what the insurer pays.

Question 27

Medicare Part A, B, C vs. D

Answer 27

PART A: Hospital insurance.

PART B: Medical insurance (what covers OT).

PART C: Medicare Advantage Plan (contracted with private insurance companies like HMO/PPO to provide Medicare Part A and B.

PART D: A prescription drug program.

Question 28

CPT Codes

Answer 28

Used on claim forms to identify specific therapy services provided based on units of time.

Question 29

KX Modifiers

Answer 29

Used to indicate any services that exceed the yearly Medicare Part B limits.

Question 30

Third-party-payer

Answer 30

An entity that pays for health services that is not the individual or provider.

Question 31

ICD Codes

Answer 31

Used to indicate a client’s specific diagnosis or condition.

Question 32

Therapy Cap

Answer 32

The maximum yearly amount for Medicare Part B covered therapy services.

Question 33

Medigap Insurance

Answer 33

A plan that helps pay for out-of-pocket Medicare expenses.

Question 34

Advanced Beneficiary Notice of Noncoverage (ABN)

Answer 34

This must be provided prior to therapy exceeding Medicare Part B financial limits (therapy cap). After this, client pays out-of-pocket.