Pathway of Billing Flashcards
There are 5 pathways to billing, what are they?
- outpatient
- inpatient/acute care
- SNF/rehab units
- home health
- school therapy
Describe the pathway of billing in outpatient physical therapy
All CPT codes are electronically placed on a HCFA 1500 form that is electronically submitted through your company’s billing software to the billing software clearing house to process for errors. The clearing house then forwards it on to Medicare or other insurance providers. After the insurance company pays or processes the claim a check is cut to the provider. If the patient has not met their deductible the clinic has to bill the patient.
What is a requirement of a diagnosis that is submitted through Medicare?
It must be functionally appropriate. For example you must use shoulder weakness instead of RTC tear
What type of modifier do Medicare patients need?
G-codes
What are G-codes?
They are basically predictions of how much improvement you expect from the patient
What are the 4 categories in which a G-code may fall?
- mobility and walking
- changing and maintaining body position
- carrying/moving handling objects
- self care
For a Medicare patient admitted into an acute care setting who controls their payment process?
DRG (diagnosis Related Group)
Who controls how the DRG is formulated?
the Admitting Physician
Describe how much is paid for a patient in an acute care setting
One lump sum payment is received, therefore it makes sense to D/C the patient as quickly as possible
Do PT charges affect hospital reimbursement?
No, they are simply recorded into the documentation and support medical necessity
True or False
DRG’s are always associated with private commercial insurance carriers in the acute care setting
False
In what situation does therapy billing effect reimbursement in the acute care setting for a patient with private commercial insurance?
When they are paid in a discounted fee for service
When are patients in the acute care setting eligible for short-term skilled care (nursing or rehab services)?
following at least 3 days on the acute side of things
Reimbursement in a rehab unit or SNF is paid on a ___ ____ rate
per diem
The daily rate paid in a skilled facility is the sum of 3 parts, what are the three parts?
1) Nursing intensity of care
2) Therapy intensity of services
3) Room and board and administrative cost adjusted for the geographical areas (urban areas get more money than rural areas)
What is the most important aspect of therapy in a skilled setting?
minutes of skilled service
What are the 5 RUG levels? And what are the minute requirements for each level?
- Ultra High: at least 720
- Very High: 500-719
- High: 325-499
- Medium: 150-324
- Low: 149-45
The minute requirement for an ultra high level patient is 720 minutes, how many minutes of PT is required per day in order to meet these minutes?
48
720 divided by 3 disciplines 5 days per week
Is home health considered a part A or B service under Medicare?
Part A
What is the evaluation form called for home health?
OASIS
What are the 3 factors that affect home health reimbursement?
1) Clinical Symptoms/needs
2) Functional scores
3) Service Utilization (number of therapy visits performed)
The OASIS form is similar to what form in the outpatient setting?
HCFA 1500
What is the difference between the OASIS form and the HCFA 1500?
OASIS is 24 pages long
What does HHRG stand for?
Home health resource group
What is a home health resource group (HHRG) and how is it determined?
It is a way to determine Medicare reimbursement
It takes into account the patient characteristics and health status information that was obtained from the OASIS form which is then combined with a home health base rate and then is adjusted for geographic factors
After the HHRG amount is determined what are the 3 options that can be taken for payment?
1) The HHRG rate can be paid
2) If the patient was extraordinarily costly they get a high cost outlier (full payment + outlier payment)
3) If the patient was seen less than 5 visits they are not paid at the full rate, instead the HH agency gets a per visit payment
If a patient is seen less than 5 times in a home health setting they are billed per visit, what is this termed?
LUPA (low utilization payment adjustment)
What are the 2 options for school therapy billing?
1) Contracted rates of therapy per hour, which is an hourly rate that varies for each district (no charges are submitted to insurance)
2) School Employee at Teacher Salaries, in which the PT is paid a lower rate but they receive benefits and retirement options
