L9 Medicare

Question 1

“Don’t write _____; write something that means ______”

Answer 1

MORE
SOMETHING

-by noridian medicare may 2016

Question 2

See through the eyes…

Answer 2

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?

Question 3

Medicare Part B

Answer 3

• optional insurance that 65+ or disabled can purchase
• outpatient services, x-ray, MDE, labs, medically necessary services, etc
• deductible = $240/year
• premiums = $175/month

Question 4

Medicare Part C

Answer 4

• 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

Question 4

Shared risk model

Answer 4

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

Question 4

___ of all medicare advantage enrolless have one of two plans

Answer 4

47%

united healthcare
humana

Question 5

Medicare part D

Answer 5

drug and prescroption coverage
have to sign up for part a or part b before d

Question 6

Drugs are divided into

Answer 6

tiers –> drugs in each tier have different cost

Question 7

Formulary

Answer 7

list of covered prescriptions drugs, varies between plans

Question 8

Re-evaluations

Answer 8

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

Question 9

For a patient who is currently receiving therapy services and develop a new diagnosed related condition…

Answer 9

it is reasonable to perform a re-eval of the patient for the related condition

Question 10

Patients who is currently receiving therapy services and demonstrates a significant…

Answer 10

improvement, decline, or change in condition or functional status which was not anticipated in POC

can do another eval

Question 11

Medically Unlikely Edits

Answer 11

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

Question 12

MUEs prevent

Answer 12

• 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

Question 13

Guiding Principles of billing

Answer 13

Medical Necessity
Skilled Service
Reasonable and Necessary

Question 14

Medical Necessity

Answer 14

New Onset
Change from level of function
Risks/Deficits/Impairments result

Question 15

Skilled Services

Answer 15

knowledge
skills
judgement

has to be at a complexity that only a PT could provide

Question 16

Reasonable and Necessary

Answer 16

• Reasonable Time
• Reasonable Goals
• Generally Predictable

Question 17

Impairment eval (ROM/msk)

Answer 17

• assess all movements
• PROM vs AROM
• joint monility
• presence of pain or crepitus
• reason for impairments

Question 18

Impairment Eval (Aerobic Capacity)

Answer 18

• vital signs before, during, after
• RPE during, after
• aerobic capacity test
• analysis of cardiopulmonary response, tolerance, recovery time

Question 19

Function”al” assessment

Answer 19

Transfers
Gait

both can be tied back to impairments that can be billable

Question 20

Standardized test requirements

Answer 20

• 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

Question 21

Concurrent Therapy Part A

Answer 21

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

Question 22

Private Pay/Facility Pay/Medicaid

Answer 22

concurrent treatment should be billed and documented using Part A guidelines

(there is no part B, just divided vs undivided attention)

Question 23

Co-treatment Therapy Part A

Answer 23

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

Question 24

Co-Treatment Therapy Part B

Answer 24

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

Question 24

Private pay/facility pay/medicaid

Answer 24

concurrent treatment should be billed and socumented using part a guidelines