PPT - Documentation for Reimbursement Flashcards
Reimbursement Basics
Everything OTs provide must be linked to a code
Codes describe a client’s condition or medical reason for services
Codes depend on the setting
Coding system used in the U.S. is the ICD 10-CM = International Classification of Diseases, 10th Revision, Clinical Modification
updated annually
Medicare enacted in ___
Medicare enacted in 1965
Budget Reconciliation Act
1981: Budget Reconciliation Act cut out of the qualifying services for home health care
PT, RN, SLP can evaluate a person in their home, but OTs cannot
Tax Equity and Fiscal Responsibility Act (TEFRA)
1982: Tax Equity and Fiscal Responsibility Act (TEFRA) allowed OT to work in hospice setting temporarily
- also limited payment of services by capping allowable costs while patient is hospitalized
- 1986: permanently allowed OT to work in hospice setting
Effects of payments changing from retrospective to prospective with diagnostic-related group (DRG) system
made LOS shorter and patients were being discharged sooner to SNF and rehab units – OT clients are now more medically complicated
DRG
a code system that categorizes a diagnosis into a payment group. This system allows for a lump sum paid for a specific diagnosis
Balanced Budget Act (BBA)
1997: Balanced Budget Act (BBA) included a prospective payment plan for Medicare Part A in SNFs
- created to control the growth of Medicare spending and allow Medicare beneficiaries w/ additional choices for care through private health plans
- also placed caps on outpatient therapy
Balanced Budget Refinement Act (BBRA)
1997-98 Balanced Budget Refinement Act (BBRA) called for the development of a prospective payment system (PPS) in inpatient rehab units/hospitals
PPS
2002: PPS est. in in inpatient rehab hospitals
- to balance the budget, PPS predetermined the amount of money paid based on a diagnosis/condition.
Medicare
- A national insurance program, has national standards for documentation
Is age-based. A major payer source in the geriatric physical disability setting - Eligibility: 65+ yo entitled to disability benefits for those 24+ yo
Medicare Part A
Part A – Hospital Insurance
100 day benefit periods that can be renewed throughout life. Psychiatric care is 190 for entire lifetime
Can be in hospital, acute SNF, hospice, or home health
Medicare Part B – Medical Insurance
Voluntary and requires a paid premium (scaled based on income)
Covers out of pocket costs like doctor’s service, ambulance service, preventative services, DME, home health, outpatient OT, PT, SLP
Covers 80% of the cost, patient pays 20% of the cost
Medicare Part C – Medicare Advantage Plans (like HMO or PPO)
Covers what’s in Parts A and B depending on the plan
Run by contracted private companies, so limited to the providers in the plan
Must be eligible for Parts A and B and NOT have and end-stage renal disease (ESRD)
Medicare Part D – Medicare prescriptions drug coverage
Run by contracted private companies
Must register 3 months prior to turning 65 yo to qualify
Medicare reimbursement requires:
Order from a physician
Proof that skilled services are needed and are unique to OT
Document patient limitations and that care is needed
Demonstrates patient significant functional progress
Error’s in Physician’s Orders – Beware of:
Non-specific: orders, span of duration, treatment plans
There are 3 major areas where OT services are provided
Inpatient, outpatient, and home health
Short Term Acute Hospital (STAH)
MD/RN on call 24/7
OT/PT/SLP per physician order. Focus on D/C planning
Flat rate per admission based on diagnosis related group (DRG)
- DRG categorizes a diagnosis into a payment group
Inpatient Rehab Facility (IRF)
MD/RN on call 24/7
Patient must have 3+ hours of therapy daily, 5 days/week. Must be seen by 2 out of 3 disciplines (OT, PT, SPL)
75% Rule – implemented as 60% rule
- 6/10 patients must fall within the 13 diagnostic categories
1. Fx of Femur (hip)
2. Stroke
3. Spinal cord injury
4. Brain injury
5. Burns
6. Congenital Deformity
7. Amputation
8. Major Multiple Trauma
9. Neurological Disorders (MS, MD, polyneuropathy)
Polyarthritis (including rheumatoid arthritis)
10. Systemic vasculitides w/ joint inflammation
11. Severe/advanced osteoarthritis
12. Hip or knee joint replacement (w/ special circumstances)
Payment: Case Mix Group (CMG), flat rate payment/discharge
CMG: Prospective Payment System (PPS) places patients into groups requiring similar healthcare resources. CMGs are determined by clinician’s assessments of patients’ functional level upon admission
Skilled Nursing Facility (SNF)
MD: seen by day 3, once a week for 30 days. Once every 30 days thereafter
- RN per shift
Payment: per diem based on Resource Utilization Group (RUG) level
LOS: up to 100 days
First recorded assessment must be w/in first 5 days (given 3 grace days to complete Minimal Data Set (MDS))
Reassessments on days 14, 30, 60, 90
- This allows patient to move to a different RUG level
- RUG levels are assigned to each SNF resident admitted for rehab services. The more therapy the resident receives, the higher the RUG level becomes -> the higher the reimbursement level becomes
- Business side of SNF will push for higher RUG levels = more money!
Outpatient
Hospital setting/outpatient clinic
- Must have medically justified plan of care (updated periodically)
- Reimbursement is capped
private outpatient clinic/free standing clinic
reimbursement is capped. $1960 a year for OT - Comprehensive outpatient Rehab Facility (CORF)/Day Treatment programs
– Hospital based
– NOT capped
– Extensive therapy – several hours a day
– All CORF services are paid under the physician fee schedule (PFS)
Home Health
OT, PT, SLP, and nurses provide care in client’s homes
OT can do admission visits, but only a qualifying service when there is “continuing need”
Payment: CMG, flat rate/60 days
Can be renewed
Patient must be homebound – patient’s condition keeps them from leaving the home
OASIS – Outcome and Assessment Information Set
A comprehensive assessment for an adult in home health care
Assesses outcome-based quality monitoring, improvement, and public reporting initiative
Data guides quality and performance improvement efforts
Extended Care Facility (ECF) or Long-Term Care (LTC)
Patient needs 24 hour care
LOS may be unknown and indefinite
- Functional recovery may not be possible
OT role: direct/consultative
Requires Medicaid or private pay
Assisted Living (AL)
Housing, personalized support for patients who need ADL help
For people who do NOT need skilled medical care
OT role: enhance habits and routines, safety, ADL assessments, social activities, education to staff
Coding and Billing
Local Coverage Determination (LCDs) provide guidance that supports submissions of claims for payment
CPT
CPT: the code used to describe the treatment/procedure provided for that diagnosis
Private Insurance
Most private insurance follows Medicare guidelines
May be used as a secondary insurance to cover whatever Medicare does not
Examples: HMO, PPO, Anthem, Kaiser, Blue Cross etc
OT service must:
Be necessary, reasonable – and require the skills of an OT
Either improve, maintain, or prevent/slow further deterioration of the patient’s condition
List of Documentation Requirements
- Referral from MD/DO
- Eval or re-eval
- Intervention plan (goals, type, frequency etc.)
- Certification from physicians (as appropriate)
- Treatment notes
- Progress reports
- Discharge summary
