Payment: LTACH, IRF, SNF, Home Health, OPT, Cash-based, Edu. Setting - Week 5

Question 1

How is an LTACH paid?

Answer 1

• paid via Long-Term Hospital Prospective Payment System
–> is a predetermined, fixed amount based on the
admitting diagnosis

Question 2

How is are LTACH paid patients classified into payment groups?

Answer 2

Classifided into: Medicare Severity Long-Term Care Diagnosis-Related Groups (MS-LTC-DRGs)
–> once placed into group this is what determines how much the hospital will get paid for that patient
(same DRG as acute care but the higher cost of care in LTACH is incorporated into the rate)

• Patient classification system that is the same as MS-DRGs used under the Inpatient Prospective Payment System
• place into group based on diagnoses (including secondary diagnoses), age, discharge status, procedures performed, gender
• Rates based on patient diagnosis and severity of illness

Question 3

What is the maximum number of days that this beneficiary will be fully covered by Medicare at the LTACH?

Answer 3

• A stay in an LTACH is covered under the 90 days of inpatient hospital care with an additional lifetime reserve of 60 days
** any inpatient hospital includes acute care, LTACH, & IRF….so any day spent in LTACH come from same pot as the 90 days for aloted for inpatient hospitle stay

–> Stay counts towards beneficiary’s Part A inpatient hospital stay allotment per “spell of illness”

Question 4

How is an Inpatient Rehab Facility paid?

Answer 4

paid via IRF Prospective Payment System

• Pre-determined payment for goods and services
provided during an IRF stay

• medicare bases these rates on patient case mix (based on resources needed to provide care base on pt clinical condition)

Question 5

In Inpatient Rehab how are patients classified into payment groups?

Answer 5

Placed into category based on their primary admitting diagnosed
–> then grouped into “Case Mix Group” based on the functional, motor, cognitive scores, & age

–> within each CMG placed into 4 possible tiers based on co-morbiditiesies

• IRF-PAI (Patient Assessment Instrument)

• -> considers pt clinical needs & demographics to classify into a payment group
• -> Payment determination & quality measure calculation
• -> Admission & Discharge

Question 6

LTACH Quality Reporting Program

Answer 6

• must submit annually report quality data

- if LTACH fails to submit on time then they get a 2% point reduction in their annual payment

Question 7

What is the maximum number of days that this beneficiary will be fully covered by Medicare at the IRF?

Answer 7

• First 60 days fully covered (once deductible is met) if meets criteria including transfer from acute care hospital
–> Co-insurance for days 61-90

** any days spent prior in acute care are included in 60 days **

Question 8

For IRF, what happens on days 61-90?

Answer 8

Co-insurance for days 61-90

Question 9

How many times does the beneficiary pay their deductible?

Answer 9

• the beneficiary does not have to pay their deductible twice
• if they meet their deductible while in the acute care hospital they do not have to pay again if they are admitted to IRF within 60 days of leaving the acute care hospital
• if admitted to IRF from the community they must pay their medicare part A deductible before their days are fully covered (part A bucket of money covers stays in acute care, LTACH, and IRF)

Question 10

What is the Medicare 60% compliance rule for IRF?

Answer 10

Medicare 60% Compliance Threshold Rule

• 60% of facility’s patient population must meet one
or more specified pathological conditions by CMS

13 conditions including:
• stroke
• amputation
• major multiple trauma 
• hip fracture
• brain injury
• neurological disorders 
• burns

Question 11

What is the IRF-PAI used for?

Answer 11

• -> considers pt clinical needs & demographics to classify into a payment group
• -> Payment determination & quality measure calculation
• -> Admission & Discharge

Question 12

What happens if an LTACH or IRF fails to submit their quality report annually?

Answer 12

fails to submit on time then they get a 2% point reduction in their annual payment

Question 13

Medicare Administrative Contractors (MACs)

Answer 13

• Review the IRFs compliance percentage
• look at 12 month periord of time to determine if each IRF meets the 60% compliance rule

• If the facility does not meet the 60% compliance rule, the facility will be paid via the Acute Care Hospital Inpatient PPS

Question 14

IRF quality reporting program

Answer 14

⎯ CMS requires submission of specific quality
measures determined annually

⎯ Use the IRF-PAI to assess: Functional status, cognitive functions, impairments, medical conditions & comorbidities, & special services, treatments, & interventions

⎯ 2 percentage point reduction in annual payment update penalty for not submitting the required quality data

Question 15

How is PT billed and paid in LTACH and IRF?

Answer 15

• Physical Therapy is paid from the pre-determined lump sum payment that the facility gets from their respective Prospective Payment System


However, PTs use CPT codes to document their sessions
• To justify productivity
• To justify staffing needs
• Private Insurances
• Out of pocket charges

Question 16

What system is used to pay a SNF?

Answer 16

SNF Prospective Payment System

⎯ Payment is an all inclusive rate (determined at beginning)

⎯ Case mix classification system: type & intensity of resources used to determine the rate

⎯ Geographic variation in wages to adjustment for amount of payment

⎯ Medicare Administrative Contractor (MAC): middle man that process Medicare claims

Question 17

What is the Minimum Data Set used for?

Answer 17

Minimal Data Set (MDS) determines the reimbursement or classification they fall into
** only for Mediacare part A **

⎯ Screening, clinical assessment & functional
status elements

⎯ Functional capabilities and health problems

⎯ Determines amount of reimbursement for patient’s care

⎯ Quality indicators

Question 18

The Payment Classification used in SNFs is called

Answer 18

PDPM: Patient Driven Payment Model

• A shift in payment from volume-based payment to quality-based payment
• Determined by 6 payment components (PT, OT, SLP, NTA, Nursing, Non-case mix component
• Based on functional abilities on admission, comorbidities, and skilled nursing care needed
• Payment rates are different for rural and urban providers

Question 19

In SNFs PDPM when is the assessment given

Answer 19

• assessment is compleded within the first 5 days of admission into SNF

complete section GG (what is used to determine patients functional ablities) :

• PT eval looking at bed mobility, function, gait
• OT eval looking at ADLs
• Speech eval looking at cognition level and diet
• This assessment (GG) puts the patient into a classification category to determine the payment group.
• This will be the payment group throughout the entire length of stay.

Question 20

In SNFs using PDPM how is the payment adjusted?

Answer 20

• per diem (day) to reflect varying cost throughout the stay

- get a 2% decrease each week after day 20

Question 21

In SNF

Starting on Day 21, the beneficiary must pay

Answer 21

• Medicare Part A will fully cover days 1-20

• Starting on Day 21, the beneficiary must pay the
daily co-payment until day 100.

• After 100 days, the patient will then be covered by Medicare Part B.

Question 22

In SNF
need to be admitted?

what will medicare part A cover?

Answer 22

• must have Qualifying 3-night hospital stay
• will cover up to 100 days per spell of illness as long as the patient shows progress
• need “skilled therapy” or nursing services

Question 23

SNF:

Individual Treatment

Answer 23

Treatment of 1 patient at a time

Question 24

SNF:

Concurrent Treatment

Answer 24

Treatment of 2 patients at the same time, when the patients are not performing the same or similar activities, regardless of the payer source, both of whom must be in line-of-sight of the treating therapist or assistant

Question 25

SNF:

Group Treatment

Answer 25

Treatment of 2-6 patients, regardless of payer source, who are performing the same or similar activities, and are supervised by a therapist or an assistant who is not supervising any other individuals

Question 26

SNF:

Co-treatment

Answer 26

2 clinicians from different disciplines treat 1 patient at the same time and perform different treatments
Limited use; only appropriate for special circumstances-require complex intervention; support with documentation; not used to provide additional support

Question 27

SNF:

What percentage of a patient’s total PT treatment time can be used for Concurrent AND Group Treatment?

Answer 27

• Only 25% of a patient’s total treatment time can be provided as Group Therapy AND Concurrent Therapy

Example:
if a patient is seen for total of 1,000 minutes of PT during their stay, a therapist can only provide 250 TOTAL minutes of Group Therapy and Concurrent Therapy combined for that patient.

Question 28

SNF:

STUDENT THERAPISTS

Answer 28

• Only 1 patient may be treated by therapist & student at a time
• The therapist cannot be engaged be treating or supervising other individuals
• The student does not have to be in line-of-sight but needs to be on sight

• Therapist must determine the appropriate level of
supervision for student (although must be on-site)

• Time will be billed as if the therapist was providing the services
• All state and professional practice guidelines for student supervision must be followed

Question 29

SNF:

If a CI and a student see two different patients at the same time, what mode of treatment can be billed?

Answer 29

?

Question 30

Home Health:

Medicare Part A Coverage

Answer 30

• coverage after you are in a hospital or SNF for at least 3 consecutive days as a hospital inpatient or have a Medicare- covered SNF stay
• must receive home health services within 14 days of discharge
• Covers first 100 days of home health care per spell of illness
• Part B covers home health care after the 100 days

Question 31

Home Health:

Medicare Part B Coverage

Answer 31

• No hospital stay requirement
• No deductible, coinsurance, or copayment
• DME requires 20% coinsurance
• Unlimited coverage of home health visits if meet criteria

Question 32

Home Health:

What is used to determine how much a Home Health Agency is paid for each episode of care?

Answer 32

• Home Health Prospective Payment System
• Patient Driven Groupings Model – Started January 1, 2020
• Home Health Plan of Care covers 60 days of care

• Payment is determined by a 30-day episode of care
⎯ Includes all covered home health services: nursing and therapy services routine & non-routine medical supplies, home health care aide, and medical social services
⎯ ExcludesDME
⎯ Geographic differences in wages
⎯ Adjusts for beneficiaries with most expensive needs ⎯ No limits on number of episodes of care

Question 33

Home Health:

What is the maximum number of 30-day episodes of care?

Answer 33

Can have multiple 30-day episodes
• 1st episode is “Early”
• Subsequent episodes are “Late”

Question 34

Home Health:

What services are covered in the 30-day episode of care rate?

Answer 34

Includes all covered home health services: nursing and therapy services routine & non-routine medical supplies, home health care aide, and medical social services
⎯ Excludes DME
⎯ Geographic differences in wages
⎯ Adjusts for beneficiaries with most expensive needs ⎯ No limits on number of episodes of care

Question 35

Home Health:

Case Mix Adjustment

Answer 35

Placed into one of 432
possible payment groups determined by:
• Admission source
• Primary Diagnosis
• Functional Impairment
Level
• Comorbidity Adjustment

Question 36

Home Health:

Do Medicare beneficiaries have cost-sharing for home health care services?

Answer 36

• Medicare A: fully covers first 100 days
• Medicare B: will pay coinsurance/copayments

??

Question 37

Home Health:

What is the OASIS and what is it used for?

Answer 37

OUTCOME AND ASSESSMENT INFORMATION SET:
• Patient specific, standardized assessment used to plan care, determine reimbursement, and measure quality

• Demographic information, clinical status, functional status, service needs
• Admission, discharge, transfer, and change in condition
• Home Health Resource Group (HHRG)

• Quality of Care Outcome Indicators
⎯ Monitors HHA performance
⎯ Modify HHA practice via quality improvement programs

** only PT, Speach, and nurse can complete initial OASIS (NOT an OT) **

Question 38

Home Health:

Who pays for DME?

Answer 38

-

Question 39

Home Health:

Who pays for palliative care?

Is maintenance therapy covered for patients receiving palliative care?

Answer 39

• Billed under Home Health Medicare Part A
• Skilled Maintenance Therapy
• Medicare does not use the term Palliative Care

Question 40

Home Health:

What is the difference between routine and continuous care under the Medicare Hospice Benefit plan?

Answer 40

Routine Home Care:
⎯The beneficiary has elected to receive hospice care at his/her residence, which can include a private residence, assisted living facility or nursing facility

Continuous Home Care:
⎯ Care provided between 8-24 hours/day only during periods of crisis to maintain the beneficiary at home to manage pain and other acute medical symptoms

Question 41

OUTPATIENT:

Where are Medicare Part B services provided for PT?

Answer 41

• Outpatient PT Clinics
• Hospital Based Outpatient Clinics

• Skilled Nursing Facilities
–> When a patient has reached their 100 days under Med A
–> A Long Term Care resident that lives in a SNF that needs
therapy and did not have a hospital stay

• Home Health
–> When a patient receives Home Health services, but did not have a qualifying hospital stay

Question 42

OUTPATIENT:

How are outpatient PT services billed under Medicare Part B?

What system is used?

Answer 42

• Medicare Physician Fee Schedule: (same as emergency department)

• -> Fee for Service
• -> use CPT Codes


• Retrospective Payment System

- bc services are paid after they are provided

• POC must be certified by a physician or non-physician practitioner within 30
days
 of evaluation

• must be Re-certified every 90 days

Question 43

OUTPATIENT:

What is the time period for certification of the plan of care by the physician or nonphysician practitioner for outpatient PT services?

How often does the plan of care need to be recertified?

Answer 43

• POC must be certified by a physician or non-physician practitioner within 30
days
 of evaluation

• must be Re-certified every 90 days

Question 44

OUTPATIENT:

KX modifier:

Answer 44

Soft Cap
• $2,110 for PT and SLP services combined, annually

• Facilities must use a KX modifier for services billed

• KX states that continued therapy is necessary for patient

Question 45

OUTPATIENT:

Targeted Medical Review:

Answer 45

Threshold: meets $3,000
• Facilities must submit documentation that support medical
necessity for the services provided


Question 46

OUTPATIENT:

Payment for PTA services:

Answer 46

• Proposed reduced payment for services provided by PTA over 10% (pay 85% of service cost) starting in 2022


–> so reduce by 15%

Question 47

OUTPATIENT:

Quality Payment Program:
What is MIPS?

Answer 47

Merit-Based Incentive Payment System (MIPS):
Quality Payment Program

Looks at:
⎯ Quality
⎯ Improvement activities
⎯ Advancing care information ⎯ Cost

Question 48

OUTPATIENT:

Quality Payment Program:
What are Alternative Payment Models?

Answer 48

Alternative Payment Models (APMs):
incentive payments for improving quality & reducing costs

⎯ Specific clinical condition, episode of care, patient population
⎯ Comprehensive Care for Joint Replacement Model (CJR)

• Advanced APMs: earn more for taking on some risk related to patient outcomes

Question 49

OUTPATIENT:

Define medical necessity and skilled care.
Why is it important?

Answer 49

Medical necessity:
• Determined by the licensed PT based on the results of a PT evaluation
–> “Skilled care” (how you show why medicare should pay you for the services instead of another unskilled provided)

• Provided for the purpose of preventing, minimizing, or eliminating impairments, activity limitations, and/or participation restrictions
• If the type, amount, and duration of services outlined in the POC ↑ the likelihood of meeting one or more of these stated goals:
• -> to improve function
• -> minimize loss of function
• -> decrease risk of injury and disease

• Maintenance Therapy: coverage does not depend on potential for improvement

** medicare part B will only reimburse for skills that are medically necessary **

Question 50

OUTPATIENT:

What is the Advance Beneficiary Notice (ABN) form?

When should it be issued?

Answer 50

• Notifies a Medicare beneficiary that Medicare might not cover the services and the possibility of having to pay for services out of pocket

issued When:
• Before providing items or services the PT believes/knows
Medicare may not cover
• Before providing items or services that Medicare usually covers, but may not be considered medically reasonable and necessary for a particular Medicare beneficiary in a particular case
• Before providing services that Medicare never covers

• Can’t be issued after Medicare denies a claim; must be completed
prior to the time of service

• Medicare strictly prohibits providers from issuing ABNs on a regular routine basis (only if provider thinks medicare won’t cover services)
• If PT doesn’t issue an ABN and Medicare denies the claim, the beneficiary cannot be billed for the services (so clinic would loose money)

Question 51

OUTPATIENT:

What is a Notice of Exclusion from Medicare Benefits (NEMB)?

Answer 51

• States that the patient will be financially liable for the services he/she is about to receive
• Only given when the service is statutorily non- covered

issued when:
• In the past, when therapy services exceeded
the therapy cap
• Service will not meet Medicare’s medical necessity requirements such as fitness/ wellness programs

Question 52

OUTPATIENT:

Can a clinic bill for services provided to a Medicare Part B beneficiary that were provided by a student?

What are the requirements?

Answer 52

Services are billable when the qualified practitioner is:

“The qualified practitioner is recognized by the Medicare Part B beneficiary as the responsible professional within any session when services are delivered.”

“The qualified practitioner is present and in the room for the entire session. The student participates in the delivery of services when the qualified practitioner is directing the service, making the skilled judgment, and is responsible for the assessment and treatment.”

“The qualified practitioner is present in the room guiding the student in service delivery when the student is participating in the provision of services, and the practitioner is not engaged in treating another patient or doing other tasks at the same time.”

“The qualified practitioner is responsible for the services and as such, signs all documentation (A student may, of course, also sign but it is not necessary since the Part B payment is for the clinician’s services, not for the student’s services).”

Question 53

OUTPATIENT:

Explain Medicare Part B rules/regulations for co-treatment.

Answer 53

• Cannot bill separately for the same or different service provided to the same patient at the same time
• Therapists must limit total billing time to the exact length of the session, so a therapist of one discipline may bill for the entire service or co-treating therapists of different disciplines may divide the service units
• Therapists should only co-treat a patient when coordination between two disciplines benefits the patient
• Documentation must clearly indicate the rationale for co- treatment and specify the goals each therapist will address through this method of intervention

Question 54

OUTPATIENT:

Discuss Medicare Part B rules/regulation for direct access to PT services in

private practice:

Answer 54

• Can go directly to PTs without a referral or visit to a physician
• Patient must be under the care of a physician

• Plan of care must be certified by a physician or non-physician practitioner within 30 days of initial PT visit
–> Plan of care can be good for up to 90 days

• Recertification of plan of care needed:

• -> changes in patient’s condition requires revision of long- term goals
• -> within 90 calendar days from date of initial visit
• -> Plan of care has expired

• PT must comply with state law

Question 55

OUTPATIENT:

Discuss Medicare Part B rules/regulation for direct access to PT services in

outpatient hospital settings:

Answer 55

Outpatient services may be ordered by a practitioner who is:

• Responsible for the care of the patient
• Licensed in, or holds a license recognized in the jurisdiction where he/she sees the patient
• Acting within his/her scope of practice under state law
• Authorized by the medical staff to order the applicable outpatient services under a written hospital policy

Question 56

OUTPATIENT:

Discuss payment by private insurance for PT services provided via direct access.

Answer 56

• Legal direct access to PT services doesn’t guarantee payment for services provided in the absence of a referral
• Payment policy is determined by the insurer & is highly variable
• Inaccurate to say that most insurance companies won’t pay for services without physician referral
• Always verify individual coverage for each patient

Question 57

OUTPATIENT:

PAYMENT: NON-MEDICARE/MEDICAID

Answer 57

Other types of Insurances
• Private Payers
• Managed Care Organizations
• Provider Networks
• Direct Contracts with employers 
• Worker’s Compensation 


• All will use the Physician Fee Schedule

• All other insurances will use CPT codes and ICD-10 codes

• Important to understand each companies billing and payment policies

Question 58

CASH-BASED:

What are some of the different types of Cash Based Practices?

Answer 58

• All Cash-Based
- Out-of-Network Provider

• Hybrid

• Cash + Private Insurances
• Cash + Medicare

• Mobile/Concierge

Question 59

CASH-BASED:

List the different places a Cash Based Practice can reside:

Answer 59

Cash Based Clinics can be located anywhere you want it to be!
• Mobile
• In your own home
• Within a gym or fitness center (most common)
–> Rent space
• Within other healthcare facilities
• A stand alone clinic

Question 60

CASH-BASED:

How is payment received in a Cash Based Practice?

Answer 60

• Accept all forms of payment: cash, check, credit, debit
• Can also accept Flexible Spending Accounts and Health Savings Accounts

• All Fee for Service
–> Rate determined by the therapist, set your own fees

• Usually 2 options for payment:

• -> Purchasing individual sessions: paid at time of service
• -> Purchasing Programs: paid in full at the first visit

Question 61

CASH-BASED:

What is a SuperBill?

Answer 61

• A bill listing ICD-10 codes, CPT codes, and number of units for each code
• Bill includes how much patient was charged for each visit
• All PT documentation included (Eval, Referral, Daily Notes, Discharges, etc)
• out of network claim submitted to the patient’s insurance
• -> can be done by PT/clinic or by patient

Question 62

CASH-BASED:

Can Medicare Beneficiaries pay cash for PT services covered by Medicare?

Answer 62

• This can be tricky and there is a lot of gray area

3 Options for relationships with Medicare
• No Relationship with Medicare
• Participating Provider (Par) - agree to accept medicare approved reinbursement amount for all services to medicare benificiary
• Non Participating Provider (Non-Par)
–> Limiting Charge

• You can NOT charge Medicare beneficiaries cash for PT services

• -> Basically, if a patient is a Medicare beneficiary, you must bill Medicare. This is known as the Mandatory Claims Submission rule.
• ——> This also applies to patients with Medicare Advantage Plans

Question 63

CASH-BASED:

relationships a cash PT clinic can have with Medicare

No Relationship:

Answer 63

-

Question 64

CASH-BASED:

relationships a cash PT clinic can have with Medicare

Participating Provider:

Answer 64

-

Question 65

CASH-BASED:

relationships a cash PT clinic can have with Medicare

Non-Participating Provider:

Answer 65

• If you are a Non- Participating Provider, have billed Medicare, and Medicare paid you 95% of the fee schedule. You can then bill the patient an extra 15%.

Question 66

CASH-BASED:

What is a Limiting Charge?

Answer 66

-

Question 67

CASH-BASED:

What is the Mandatory Claims Submission Rule?

Answer 67

• You can NOT charge Medicare beneficiaries cash for PT services

• -> Basically, if a patient is a Medicare beneficiary, you must bill Medicare. This is known as the Mandatory Claims Submission rule.
• ——> This also applies to patients with Medicare Advantage Plans

Question 68

CASH-BASED:

When can you accept cash from a Medicare beneficiary

Answer 68

• If you are a Non- Participating Provider, have billed Medicare, and Medicare paid you 95% of the fee schedule. You can then bill the patient an extra 15%.
• You issued an ABN to the patient prior to providing services, you billed Medicare, and they denied payment for the claim because the services were not considered to be reasonable and necessary
• You are providing a service that is normally not covered by Medicare, such as Wellness Services

Question 69

CASH-BASED:

BENEFITS TO A CASH BASED PRACTICE

Answer 69

• You can save on administrative costs by not dealing with insurance negotiations
• Can have very little “overhead”
• Much more autonomy and freedom
• You get to make all of the decisions
• You set your own fee schedule/charges
• You set your own hours
• You get to decide the treatment, the frequency, the duration for each patient
• You often get clients that are compliant
• You can create your own niche

Question 70

EDUCATIONAL SETTING:

How are Early Intervention Services funded?

What is the cost to parents?

Answer 70

• Medicaid with parent consent
• Private Insurance with parent consent
• Reimbursement procedures and policies are determined by the state
• Early intervention services are free to the parent, except when federal or state law provides for a system of payments by families, including a schedule of sliding fees

Question 71

EDUCATIONAL SETTING:

How are School Based Services funded?

Should parents pay for PT services in the educational setting?

Answer 71

Funded by various sources:
• Medicaid
• State and local educational resources for allowable medical services delivered at school

• Reimbursement procedures & policies are set by the state
• Third party funding should not be used
• -> Any service that requires copayments, decreases lifetime maximum amount or results in loss of other services cannot be used without voluntary, informed parental permission
• -> Falls under IDEA part B, there should be no cost to the parent for PT services