PTICP

Question 1

What is the triple AIM of healthcare?

Answer 1

Better care - experience!
Better health
Lower costs

Question 2

What is the “Iron Triangle” of Health Policy?

Answer 2

Quality
Access
Cost

(Also affected by work force)

Question 3

What are some things that affect quality?

Answer 3

Structure
Process (best prax?)
Outcome (more typical)

Question 4

What is the difference between underuse and overuse?

Answer 4

In underuse people are undertreated (or can’t get the care they need). In overuse, people are overtreated and get care they don’t need.

Question 5

What are some things that need to be determined when testing a new outcome measure?

Answer 5

Validity
Reliability - between measures and between raters
Sensitivity
Relevant Population

Question 6

Clinically, what do we need to know when using a new outcome measure?

Answer 6

Purpose?
Content?
Pt. pop (or, on what sample it was validated)
References used (what other gold standard?)
Expected error/variance (SEM, MDC, MCID)
Sensitivity to Change

Question 7

How do establish reliability?

Answer 7

Measure Day 1 and Day 2 for test/retest reliability. With different raters for interrater reliability.

Question 8

What are the 4 main types of validity and how are they tested?

Answer 8

Construct Validity: compare w/ gold standard (convergent) / discriminating validity (does it test what it’s NOT supposed to test for poorly?) / Known Groups validity (does it seem like it makes sense given known groups? - this also establishes sensitivity to change (floor/ceiling effect).

Criterion Validity: Compare to Gold Standard

Face Validity: Does it look like it does what it says it does?

Content Validity: Does it contain items that are important to the pt?

Question 9

What is the alpha coefficient?

Answer 9

It is a ratio that determines whether all your questions are relevant. You don’t want it to be 1 because if it is that means all your questions are literally the same.

Question 10

What is the anti-kick back statute?

Answer 10

You can’t take money from people.

Question 11

Stark Law?

Answer 11

You can’t refer to something you own.

Question 12

False Claims Act?

Answer 12

You can’t bill for things you didn’t do but you also can’t NOT bill for things you did do.

Question 13

What is the corporate compliance plan?

Answer 13

It protects whistleblowers.

Question 14

What are complexity based codes based on?

Answer 14

PMH
Exam
Clinical presentation (stable vs. unstable)
CDM (low vs. high)

Question 15

What are some examples of never codes?

Answer 15

IE & RE
Aquatic and Whirlpool
Manual + Massage***

Question 16

What are some examples of unlikely codes?

Answer 16

You can use modifier 59 to show that although something was unlikely, you did two treatments that should be billed separately bc they did NOT overlap, except this won’t work for edit pairs because they are treatments that are mutually exclusive.

Question 17

What is a KX modifier and when is it used?

Answer 17

When you’re treating and past $2040 (though still out of medical necessity).

Question 18

MC will deny payment when more than _____________ units of one CPT code are used in a day.

Answer 18

5

Question 19

What does the fairness in copay act do?

Answer 19

Prevent most insurances from collecting more than one copay a day for ST, OT, PT.

Question 20

What facilities use DRG mostly?

Answer 20

Acute Care and the LTACH (which you only go to if you need +25 days of care).

Question 21

What system is used in Inpatient Rehab? When is a place eligible to use it?

Answer 21

IRF PAI, when they are following the 60% rule.

Question 22

What system is used in a SNF?

Answer 22

The RUG

Question 23

What system is used in Home Health?

Answer 23

HHRG which you know from Oasis

Question 24

What is used in OP?

Answer 24

OPPS/Fee for service

Question 25

When can pre-service work be billed?

Answer 25

Only when the patient is physically present.

Question 26

For FFP, what is the total time rule?

Answer 26

1 unit = 8-22 min
2 unit = 23-37 min
3 unit = 38-52 min

Each individual code is not billed, only those with Direct Contact that are also TIMED.

Timed codes = TE/TA/NMR/GT/Aquatics/Ionto/US
THIS DOES NOT INCLUDE: unattended estim, WP, fluidotherapy, paraffin, HP/CP.

Question 27

What is the payment model for non-federal insurance companies?

Answer 27

Mid-point!

1 unit = 0-15min
2 units = 16-30min
3 units = 31-45 min

They will bill service codes and each individual code (as long as it’s over 8 minutes).