PPT - Documentation for Reimbursement

Question 1

Reimbursement Basics

Answer 1

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

Question 2

Medicare enacted in ___

Answer 2

Medicare enacted in 1965

Question 3

Budget Reconciliation Act

Answer 3

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

Question 4

Tax Equity and Fiscal Responsibility Act (TEFRA)

Answer 4

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

Question 5

Effects of payments changing from retrospective to prospective with diagnostic-related group (DRG) system

Answer 5

made LOS shorter and patients were being discharged sooner to SNF and rehab units – OT clients are now more medically complicated

Question 6

DRG

Answer 6

a code system that categorizes a diagnosis into a payment group. This system allows for a lump sum paid for a specific diagnosis

Question 7

Balanced Budget Act (BBA)

Answer 7

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

Question 8

Balanced Budget Refinement Act (BBRA)

Answer 8

1997-98 Balanced Budget Refinement Act (BBRA) called for the development of a prospective payment system (PPS) in inpatient rehab units/hospitals

Question 9

PPS

Answer 9

2002: PPS est. in in inpatient rehab hospitals

- to balance the budget, PPS predetermined the amount of money paid based on a diagnosis/condition.

Question 10

Medicare

Answer 10

• 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

Question 11

Medicare Part A

Answer 11

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

Question 12

Medicare Part B – Medical Insurance

Answer 12

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

Question 13

Medicare Part C – Medicare Advantage Plans (like HMO or PPO)

Answer 13

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)

Question 14

Medicare Part D – Medicare prescriptions drug coverage

Answer 14

Run by contracted private companies

Must register 3 months prior to turning 65 yo to qualify

Question 15

Medicare reimbursement requires:

Answer 15

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

Question 16

Error’s in Physician’s Orders – Beware of:

Answer 16

Non-specific: orders, span of duration, treatment plans

Question 17

There are 3 major areas where OT services are provided

Answer 17

Inpatient, outpatient, and home health

Question 18

Short Term Acute Hospital (STAH)

Answer 18

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

Question 19

Inpatient Rehab Facility (IRF)

Answer 19

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)

Question 20

Payment: Case Mix Group (CMG), flat rate payment/discharge

Answer 20

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

Question 21

Skilled Nursing Facility (SNF)

Answer 21

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!

Question 22

Outpatient

Answer 22

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)

Question 23

Home Health

Answer 23

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

Question 24

OASIS – Outcome and Assessment Information Set

Answer 24

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

Question 25

Extended Care Facility (ECF) or Long-Term Care (LTC)

Answer 25

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

Question 26

Assisted Living (AL)

Answer 26

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

Question 27

Coding and Billing

Answer 27

Local Coverage Determination (LCDs) provide guidance that supports submissions of claims for payment

Question 28

CPT

Answer 28

CPT: the code used to describe the treatment/procedure provided for that diagnosis

Question 29

Private Insurance

Answer 29

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

Question 30

OT service must:

Answer 30

Be necessary, reasonable – and require the skills of an OT

Either improve, maintain, or prevent/slow further deterioration of the patient’s condition

Question 31

List of Documentation Requirements

Answer 31

• 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