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Medicare part b Flashcards

1
Q

Who are services contracted by in medicare part b

A

medicare certified provider

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2
Q

What is payment made under

A

Medicare physician fee payment scale (MPFS) using CPT codes

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3
Q

What does part b require

A

copayment of 20%

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4
Q

What do therapy caps apply to

A

all part b outpatient setings

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5
Q

What is the OT therapy cap

A

1940

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6
Q

How to get an exception to the therapy cap

A

prove they need more service through documenting

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7
Q

What is the OT limit

A

3700 per year

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8
Q

Who gets the bill if the client goes over their cap

A

client

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9
Q

What must a provider provide if medicare won’t pay for a service

A

advance beneficiary notice of noncoverage

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10
Q

What codes do you use for OP reimbursement

A 
CPT codes
ICD 10 codes
evaluation codes
procedure codes 
modality codes 
untimed codes
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11
Q

what are procedure codes

A

timed or untimed

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12
Q

what are modality codes

A

supervised vs. constant attendence

supervised are not reimbursable

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13
Q

what is the code for eval

A

97003

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14
Q

what is the code for reeval

A

97004

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15
Q

What are untimed codes based on

A

a treatment day

typically limited to 1/day

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16
Q

Examples of untimed codes

A

evals and reevals
supervised modalities (hot pack, whirlpool, paraffin)
treatments (dysphagia tx, group tx)

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17
Q

What are time based codes

A

Modalities/procedure/activity codes that require constant attendance

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18
Q

Examples of time based codes

A 
ultrasound
iontophoresis
contrast bath
ther ex
ther act
self care
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19
Q

What is 1 unit of time

A

8-22 min

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20
Q

what is 2 units of time

A

23-37

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21
Q

what is 3 units of time

A

38-52

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22
Q

what is 4 units of time

A

53-67 min

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23
Q

what is 5 units of time

24
Q

what is 6 units of time

25
what is 7 units of time
98-112 min
26
What is total treatment time
total time pt. was in clinic (untimed and timed codes combined)
27
What you document
total treatment tie | time spent providing time-based codes
28
Why should clinicians document each service provided
since unbilled services may impact the billing
29
What are modifiers used for
differentiate bt PT OT ST
30
what are splints paid under
L code
31
what are 59 modifiers
separate but distinct services regarding CPT codes | attach to clarify it separates from other codes
32
What are KX modifiers
have to do with therapy caps | attach after you meet therapy cap
33
What do you attach for functional limitation reporting
G code applicable to OP mandatory for reimbursement
34
What are the 4 sets of categorical for part b
``` Mobility changing and maintaining body position carrying, moving, and handling objects self-care (2 additional-other primary, other subsequent) ```
35
What are the 7 sets of categorical g codes
``` swallow motor speech spoken language/comprehension spoken language expression attention memory voice ```
36
hat is the modifier for 0% imipaire, limited, restricted
CH
37
What is the modifier for at least 1% impaired but less than 20%
CI
38
What is the modifier for at least 20% impaired but less than 40%
CJ
39
what is the modifier for 40% but less than 60% impaired
CK
40
What is the modifier for at least 60% but less than 80% impaired
CL
41
What is the modifier for at least 80% but less than 100% impaired
CM
42
What is the modifier for 100% impaired, limited, restriced
CN
43
What do you have to do every10th visit
report your G code modifier
44
What are recent changes in requirements for SNFs
line of sight is no longer required | supervisor determines student abilities and readiness to treat
45
what is the concern for affordable health care act
generalist vs. specialist wellness and health-telehealth need to justify why we should be included
46
What is medicare part c
medicare advantage plan
47
What is the medicare advantage plan
managed care:both part a and b usually requires specific providers w/in the system prior approval is often required
48
What is medicare part d
prescription drug coverage
49
Who is medicaid for
``` those who cant pay those with dependent children those under the poverty level pregnant women with income below poverty level SSDI individuals in institutions spend down programs for medicaid ```
50
in billing denials who is the first line of review
not done by a therpist
51
in billing denials who is the 2nd line of reviw
done by an outsider reviewer | could be nurse, PT or OT
52
What are common pitfalls in initial eval documentation
lacks pertinent medical hx objective data has no interpretation doens't contain prior level of function
53
What are common pitfalls in plan of care and certification
frequency, duration, goals must be measurable and appropriate for dx must indicate skilled therapy goals change without documentation as to why certification or recertification must be evident
54
What are common pitfalls in daily treatment/progress notes
total tx min of times or untimed codes is inconsistent w/ those billed intensity of therapy is excessive or inadequate for functional outcome activity not described when bill for therapeutic activity or body part not described when billing for ther ex
55
What are documentation pitfalls in discharge notes
progress toward goals not identified no carryover training identified medical necessity not justified progress not clearly identified since last note (not showing need for skilled service)
56
What is our responsibility as a therapist
be knowledgable about how your facility is reimbursed provide skilled therapy and document and bill ethically do your part: become memeber of aota
57
What does medicare part b cover
``` OP therapy physician visits DME OP hospital services mental health services blood and diagnostic tests meds ```

515 (4 decks)

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