Insurance Flashcards
How would medicare A cover a SNF stay?
3d hospital stay w/in past 30 days
- physician order
- need to be seen 5x/wk
- pays 100% first 20days, after there is a coinsurance
- there are MDS assessment periods
how is PT billed in med A?
billed by minutes - RUG category Ultra high -720 mins Very high - 500 mins High - 325 mins Medium - 150 mins Low - 45 mins
How is PT billed under med B?
timed units 8-22, 23-37, 38-52, 53-67, 68-82 - physician ordered - pays 80%, 20% is self-paid or supplemental insurance - must have G codes, KX modifier
How is basic care paid for in ND?
minimal care is given, lowest tier of ALF; meals provided and light housekeeping, activities and transportation
- paid by medicaid or private pay
- if paid by medicaid, toiletries and haircuts are covered
How is ALF paid?
private pay
- tiered levels of service
- need to be able to transfer, amp, take car of toileting
How is PT covered in basic care, ALF, and independent senior living?
medicare B
How is concurrent therapy billed under med A?
50% of minutes counted
- 2 patients doing DIFFERENT activities, needs to be recorded as concurrent
How is group therapy billed under med A
4 pts doing similar activities
- only counts 25% of minutes; only 25% of total minutes can be group
How is group therapy billed under med B
2-4 pt present and treated simultaneously excluding supervised modalities
- billed as group therapy unit
How is co-tx time billed in med A?
Entire time can be counted towards treatment minutes. It must
be documented and kept track of on MDS
How is co-tx time billed in med B?
Split treatment time with other discipline. Document
overall rules for Med A on individual or multiple pts?
- 1 pt= Individual, no hot packs
- 2 pt DIFFERENT ACTIVITIES= Concurrent (MDS software
will reduce mins by 50%) - 2 or 3 pts SIMILAR ACTIVITIES=MDS does NOT qualify
these minutes as skilled - 3+pts DIFFERENT OR SIMILAR ACTIVITIES=MDS does
NOT qualify these minutes as skilled service - 4 pts SIMILAR ACTIVITIES as per POC=Group (MDS
software will reduce minutes by 75%, allows up to 25% of
mins in group)
Do you need direct supervision of students in medicare A and B?
does not need to be line of site for med A
does need to be direct line site for med B
explain billing process for med B
Physician order is required for therapy services; POC needs to be signed after eval; initial cert for 90d, recert every 30d; bill medicare and supplemental insurances; must have G code; MDS quarterly or start/end; therapy cap no longer valid but review after $3000
What are admission require for inpatient rehab
must tolerate 3h/d of intense therapy
- need for PT, OT, SLP, or OandP
- expected to make gains
What covers inpatient rehab?
medicare part A (own thing, not the hospital stay thing)
Explain the billing process for inpatient reahb
- preadmission screen
- postadmission physical evaluation - establishes package (CMG)
- FIM must be documented
- individualized overall plan of care
- admission orders by physician
Who administers OASIS?
RN
Explain billing process for HHC
OASIS must be performed, package is determined (PPS)
- medicare A benefit
- must have face to face visit with doc prior to, must be reassessed every 30 calendar days
What covers hospice?
Medicare part A with coinsurance or hospice
- PPS, must meet medicare requirements and be homebound
How is DME covered under hospice?
Med A will cover full DME cost
- if it were med B, 80% covered, 20% self pay
What illnesses have criteria for hospice?
- cancer
- ALS
- AD
- Heart disease
- HIV
- Liver disease
- pulmonary disease
- renal disease
- Stroke
- coma
What are therapy goals in hospice?
- Maintain or adapt to functional abilities.
- Reduce burden of care for family/caregivers.
- Assist in pain control.
What is the hospice model of therapy?
Evaluate present functional status.
PT- Gross functional mobility, bed mobility, transfers, ambulation or gait and body mechanics.
Additionally, a PT addresses limitations that influence transitional movements such as pain, weakness, ROM and SOB
What are the 3 types of pain seen in pts on hospice?
- Social Pain- identified through loneliness such as panic attacks, demand for attention etc.
- Psychological Pain- manifests itself as patient tries to maintain a mental balance while coping with new experiences and decrease stress.
- Spiritual Pain- exists for each patient according to their religious background.
