L9 Medicare Flashcards
“Don’t write _____; write something that means ______”
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SOMETHING
-by noridian medicare may 2016
See through the eyes…
if you were going to hand over your soap note to someone, would they be able to understand your patient and your point of view?
Medicare Part B
- optional insurance that 65+ or disabled can purchase
- outpatient services, x-ray, MDE, labs, medically necessary services, etc
- deductible = $240/year
- premiums = $175/month
Medicare Part C
- medicare advantage plans
- beneficiaries can obtain benefits via private and medicare companies
- must cover the same services as medicare, and over additional coverage
- can be more economical than medicare
Shared risk model
plan manage a group of lives and are paid per life managed
usually a set cost of prices, and providers agree to cover more if necessary
___ of all medicare advantage enrolless have one of two plans
47%
united healthcare
humana
Medicare part D
drug and prescroption coverage
have to sign up for part a or part b before d
Drugs are divided into
tiers –> drugs in each tier have different cost
Formulary
list of covered prescriptions drugs, varies between plans
Re-evaluations
separately reimbursable when medical record supports that the pts clinical status or condition required the additional eval service
when medical necessity is supported, a re-eval is appropriate and is separately billable
For a patient who is currently receiving therapy services and develop a new diagnosed related condition…
it is reasonable to perform a re-eval of the patient for the related condition
Patients who is currently receiving therapy services and demonstrates a significant…
improvement, decline, or change in condition or functional status which was not anticipated in POC
can do another eval
Medically Unlikely Edits
used by medicare to reduce improper payments for Part B claims
max units of service reported for CPT code on vast majority of reported claims by same provider for same beneficiary on same date of service
MUEs prevent
- more than 1 PT eval code per day
- one serviced based unit set as maxmum for day (modalities, group tx
- four units of time-based therex set as max for day
Guiding Principles of billing
Medical Necessity
Skilled Service
Reasonable and Necessary
Medical Necessity
New Onset
Change from level of function
Risks/Deficits/Impairments result
Skilled Services
knowledge
skills
judgement
has to be at a complexity that only a PT could provide
Reasonable and Necessary
- Reasonable Time
- Reasonable Goals
- Generally Predictable
Impairment eval (ROM/msk)
- assess all movements
- PROM vs AROM
- joint monility
- presence of pain or crepitus
- reason for impairments
Impairment Eval (Aerobic Capacity)
- vital signs before, during, after
- RPE during, after
- aerobic capacity test
- analysis of cardiopulmonary response, tolerance, recovery time
Function”al” assessment
Transfers
Gait
both can be tied back to impairments that can be billable
Standardized test requirements
- administration of standardized test during eval/day #1
- at minimum reporting at each progress report and tehn again at discharge
- must include analysis of results
Concurrent Therapy Part A
treatment of two residents, when residents are not performing the same or similar task, regardless of payer source, both of whom must be in line-of-sifht of the supervising PT/PTA
Private Pay/Facility Pay/Medicaid
concurrent treatment should be billed and documented using Part A guidelines
(there is no part B, just divided vs undivided attention)
Co-treatment Therapy Part A
two clinicians, each from different discipline, treat one resident at the same tiem with different treatments, both disciplines may code session in full
decision to co-treat should be made on a case by case basis and need for co-treatment should be well-documented for each pts
use should be limited
Co-Treatment Therapy Part B
Clinicians working together as a team to treat one or more patients cannot each bill separately for the same or different service provided at the same time to the same patient
time must be billed in full by one clinician or split between clinicians
Private pay/facility pay/medicaid
concurrent treatment should be billed and socumented using part a guidelines
