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515 > Medicare part b > Flashcards

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

A

68-82 min

24
Q

what is 6 units of time

A

83-97 min

25
Q

what is 7 units of time

A

98-112 min

26
Q

What is total treatment time

A

total time pt. was in clinic (untimed and timed codes combined)

27
Q

What you document

A

total treatment tie

time spent providing time-based codes

28
Q

Why should clinicians document each service provided

A

since unbilled services may impact the billing

29
Q

What are modifiers used for

A

differentiate bt PT OT ST

30
Q

what are splints paid under

A

L code

31
Q

what are 59 modifiers

A

separate but distinct services regarding CPT codes

attach to clarify it separates from other codes

32
Q

What are KX modifiers

A

have to do with therapy caps

attach after you meet therapy cap

33
Q

What do you attach for functional limitation reporting

A

G code
applicable to OP
mandatory for reimbursement

34
Q

What are the 4 sets of categorical for part b

A 
Mobility
changing and maintaining body position 
carrying, moving, and handling objects
self-care 
(2 additional-other primary, other subsequent)
35
Q

What are the 7 sets of categorical g codes

A 
swallow
motor speech
spoken language/comprehension
spoken language expression
attention
memory
voice
36
Q

hat is the modifier for 0% imipaire, limited, restricted

A

CH

37
Q

What is the modifier for at least 1% impaired but less than 20%

A

CI

38
Q

What is the modifier for at least 20% impaired but less than 40%

A

CJ

39
Q

what is the modifier for 40% but less than 60% impaired

A

CK

40
Q

What is the modifier for at least 60% but less than 80% impaired

A

CL

41
Q

What is the modifier for at least 80% but less than 100% impaired

A

CM

42
Q

What is the modifier for 100% impaired, limited, restriced

A

CN

43
Q

What do you have to do every10th visit

A

report your G code modifier

44
Q

What are recent changes in requirements for SNFs

A

line of sight is no longer required

supervisor determines student abilities and readiness to treat

45
Q

what is the concern for affordable health care act

A

generalist vs. specialist
wellness and health-telehealth
need to justify why we should be included

46
Q

What is medicare part c

A

medicare advantage plan

47
Q

What is the medicare advantage plan

A

managed care:both part a and b
usually requires specific providers w/in the system
prior approval is often required

48
Q

What is medicare part d

A

prescription drug coverage

49
Q

Who is medicaid for

A 
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
Q

in billing denials who is the first line of review

A

not done by a therpist

51
Q

in billing denials who is the 2nd line of reviw

A

done by an outsider reviewer

could be nurse, PT or OT

52
Q

What are common pitfalls in initial eval documentation

A

lacks pertinent medical hx
objective data has no interpretation
doens’t contain prior level of function

53
Q

What are common pitfalls in plan of care and certification

A

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
Q

What are common pitfalls in daily treatment/progress notes

A

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
Q

What are documentation pitfalls in discharge notes

A

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
Q

What is our responsibility as a therapist

A

be knowledgable about how your facility is reimbursed
provide skilled therapy and document and bill ethically
do your part: become memeber of aota

57
Q

What does medicare part b cover

A 
OP therapy
physician visits 
DME
OP hospital services
mental health services
blood and diagnostic tests
meds

515 (4 decks)

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