Medicare Documentation and Reimbursement

Question 1

Fraud

Answer 1

making false statement or representations to
obtain some benefit or payment for which it was not
entitled

Question 2

Examples of fraud

Answer 2

– Knowing altering claims forms and/or billing logs to receive
a higher payment
– Knowing billing services that were not furnished including
Medicare for appointments that the patient failed to keep

Question 3

Abuse

Answer 3

unintentionally follows practices that result in unnecessary Medicare program costs

Question 4

examples of abuse

Answer 4

– Claims for services not medically necessary
– Improper or sloppy billing practices

Question 5

4 aspects of medicare audits

Answer 5

• Appropriate Patient
• Appropriate Services
• Appropriate Outcomes
• Appropriate Billing

Question 6

Appropriate Patient - Medical necessity supported by:

Answer 6

• trigger
• diagnosis
• PMH
• current medical history
• PLOF and CLOF
• recent change in function

Question 7

ICD- 10 is a numeric description of:

Answer 7

• Laterality (right/left)
• Traumatic vs non-traumatic injury
• Dominant vs. non-dominant side
• Single or bilateral condition
• Cause of traumatic injury, place of occurrence of injury, activity pt was performing when injury
  occurred
• Initial encounter vs. subsequent encounter vs. sequel

Question 8

ICD-10 Codes for:

Answer 8

– Code the medical diagnosis
– Code the cause of an injury if caused by trauma
– Code the reason for therapy

Question 9

Jimmo vs. Sibelius settlement

Answer 9

• Medicare changed from needing to show IMPROVEMENT to needing to show PROGRESSION

Question 10

what should be included in analysis

Answer 10

Stability/Instability of signs/symptoms should be included to justify choice in new evaluation code

Question 11

outcome measures

Answer 11

• level of care specific
• diagnosis specific