PTP 2 Exam 1 Flashcards
How are providers paid?
- Providers provide services
- Document the nesessary details for payment
- Assign codes to represent services rendered and other pertinent details
- Submit the claim
- Interpret payer’s response
- Prepare post-payment audit
What is the Purpose of ICD-10 Codes?
- They are used to track health care statistics/disease burden, S/S, abnormal findings, social circumstances and external causes of injuries and/or disease, quality outcomes, mortality statistics and billing
ICD-10 was developed by WHO
What is the Purpose of CPT Codes?
Who published and maintains CPT codes?
- CPT codes are used to describe tests, surgeries, evaluations and any other medical procedure performed by a healthcare provider on a patient
- CPT codes tell the insurance payer what procedure the heathcare provider would like to be reimbured for
American Medical Association (AMA)
What are the Characteristics of ICD-10 codes?
- 7 character, alphanurmeric code
- Begins with a letter, followed by 2 numbers
- First 3 characters of ICD-10 represents the “category”, which describes the general type of the injury or disease; the category is followed by a decimal point and the subcategory
What are the characteristics of CPT codes?
- Normally a 5-digit number, which represents a procedure or service provided to the patient
With ICD-10 codes, what 4 things are always needed?
- We need a Medical Dx:
(for example)
1.Z96.641
2.Presence righ artificial hip Joint - Also a Treatmetn Dx:
(for example)
3.R.29.98
4.Abnormality of gait and mobility
What is the difference between Medicaid and Medicare?
- Medicaid: Federal-state program that provides coverage to low income people, pregnant women and people with disabilities
- Medicare: Federally funded
Medicare Coverage Programs
What does Medicare Part A cover?
A, think Acute
- Covers inpatient hospital stays, skilled nursing facilities (SNF) stays, some home health visits and hospice care
- Can return patient to PLOF only
Medicare Coverage Programs
What does Medicare Part B cover?
B, think Best a patient can be
- Covers physicians visits, OP services, preventive services, and some home health visits
- Maximize patient’s function
Medicare Coverage Programs
What does Medicare Part C cover?
C, think children as it relates to therapy services
- Refers to the Medicare Advantage program, through which beneficiaries can enroll in a private health plane, such as a Health Maintenance Organization (HMO) or preferred provider organization (PPO), and receive all Medicare-covered Part A and Part b benefits and typically also Part D benefits
Medicare Coverage Programs
What does Medicare Part D cover?
D, think Drugs
- Covers OP prescription drugs through private plans that contract with Medicare, including stand-alone prescription drug plans (PDPs) and Medicare Advantage plans with prescription drug coverage
What are the different types of Reimbursement Systems?
- Fee-for-Service (FFS): Providers paid for each and every service (more common in Medicare Part B)
- Capitation: Providers are pain in a prospective “cap” or per members per month (PMPM) payment, to provide care for individuals enrolled in managed health plans
- Bundled Payments / Episode-Based Payments: Providers are pain for all service within an episode of care (Think Home Health
With Medicare Part A, what types of Reimbursement is used by setting?
- Hospital: Diagnosis-Related Goups (DRGs)
- Inpatient Rehabilitation Facility (IRF): Patient Assessment Instrument (PAI)
- Skilled Nursing Facility (SNF): Patient Driven Payment Model (PDPM)
- Home Health: Episode of Care
- Hospice: Daily Rate
With Medicare Part A, What is the Diagnosis-Related Groups (DRGs) Reimbursement?
DRGs is a patient classification system that standardizes prospective payment to hospitals and encourages cost containment initiative
- Each DRG has a payment weight assigned to it, based on the average resources used to treat Medicare patients in that DRG
Remember this is mainly for Hospitals
With Medicare Part A, What is the Reimbursement for Inpatient Rehabilitation Facility (IRF)?
The reimursement is paid under the IRF Prospective Payment System (PPS) via the IRF- Patient assessment instrument (IRF-PAI)
Medicare Part A
With the IRF-PAI Section GG, what is the intent of Functional Abilities and Goals?
To provide information about functional abilities and goals. It includes items focused on prior functioning, admission performance, discharge goals and discharge performance
With Medicare Part A, What is Patient Driven Payment Model (PDPM)?
This is a new case-mix calssification system for classifying skilled nursing facility (SNF) patients in a Medicare Part A covers 1 stay into payment groups under the SNF prospective payment system
Case Mix: A measure used by CMS to determine reimbursement rates for medicare and medicade beneficiaries, reflects the diversity, complexity and severity of patient illness treated at a given heathcare facility
With Patient Driven Payment Model, what is the Minimum Data Set (MDS)?
- The patient’s primary diagnosis for the SNF stay
- Each primary diagnosis is mapped to one of 10 PDPM clinical categorize, which is then used as part of the patient’s classification under PT, OT, and SLP
- ICD-10 codes are used to capture additional diagnoses and co-morbidities that the patient has
With the Patient Driven Payment Model, what is the Patient Functional Score?
This is another assessment that goes into the MDS
- The Functional Score for the PT and OT component is calculated based on ten section GG items found to be highly predictive of PT and OT costs per day:
What are Classifiers under PDPM?
There are monetary reimbursements
There are 4 groups:
- Nursing Groups
- PT and OT groups
- SLP groups
- Non-therapy ancillary (NTA)
–The facility is going to place the patient in whichever group is going to reimburse the most for the amount of services that patient is utilizing
With the MDS under the Patient Driven Payment Model (PDPM), how do the Classifiers allow us to place the patient in whichever group is going to reimburse the most for the amount of service he/she is utilizing?
They do this under 3 different scheduled assessments:
- 5 Day assessment
- Interim Payment Assessment (IPA)
- PPS Discharge Assessment
-25% combined limit per discipline for concurrent and group treatment (KNOW THIS)
- Evaluation minutes are not counted on the MDS
With Medicare Part A, what is Episode of Care?
This is traditionally how Home Health Agencies are Reimbursed
- Medicare pays Home Health agencies (HHAs) a predetermined base payment
- Payment is adjusted for the health condition and care needs of the beneficiary
- Payments provided for each 30-day episode of care
- Case-mix adjustment base on patient needs as identifed by Outcome and Assessment Information Set (OASIS) instrument
What is Home Health Reimbursed under?
Consolidating Billing: Means HHA must bill for all home health services, including:
- Nursing
- Therapy services
- Routine and non-routine medical supplies
- Home health aide and medical social services
- Except durable medical equipment (DME) (MUST KNOW)
How is Medicare Part B reimbursed?
This is a Fee-for-Service (FFS)
Reimbursed by Healthcare Common Procedural Coding System (HCPCS), with this there are 2 things we have to pay attention to:
-8-minute rule
-National Correct Coding Initiative (CCI edits)
- This covers reimbursement in our tradional OP facilities andn in Long-Term care inside our SNF
Between PTs and OTs, which discipline can Bill which CPT code?
Which CPT codes should PTs NOT bill?
- Any code in 99000 series - these are for physicians
- Any code in 98000 series - these are for osteopathic and chiropractic manipulations
- 97535 - this is for OT; if PT is working on self-care management, than bill 97530 (Ther. Act)
What is the difference between Coding and Payment Policy?
- Existance of a code does not guarantee payment
- Payment policy is set by the individual payer
- Some payers may limit or restrict payment, or may consider certain codes to be bundled
- Billing a certain code pairs may be prohibited or require use of a modifer to explain why codes should be allowed in a specific situations
What are the 3 components of the CPT Code Values?
- Professional work - Time, technical skill, physical effort required to perform the service or procedure, mental effort and judgement involved, and amount of stress associated with the level of risk to the patient
- Practice Expence - Costs associated with labor, equipement and supplies
- Professional liability insurance relative value - A fixed figure established and updated by CMS
Healthcare Common Procedural Coding System (HCPCS)
What is the Difference between Time-based codes and Event/Serviced-based codes?
- Time-based codes: Are reimbursed based on time
- Event/Service-based codes: Are reimbursments for the service or event. No matter how long they take they are only 1 unit.
What CPT code is 97110?
Therapeutic Exercise (e.g., routine exercise)
What CPT code is 97112?
Neuromuscular Re-education (e.g., balance training)
What CPT code is 97116?
Gait Training (e.g., Ambulation training)
What CPT code is 97530?
Therapeutic Activities (e.g., Bed Mobility Training, Transfer Training)
What CPT code is 97161?
PT Evaluation Low Complexity
This is an event/service-based code
What CPT code is 97162?
PT Evaluation Moderate Complexity
This is an event/service-based code
What CPT code is 97163?
PT Evaluation High Complexity
This is an event/service-based code
What is the CPT code for Gait Training?
97116
What is the CPT code for Therapeutic Exercise?
97110
What is the CPT code for PT Evaluation Moderate Complexity?
97162
What is the CPT code for Therapeutic Activities?
97530
What is the CPT code for PT Evaluation High Complexity?
97163
What is the CPT code for PT Evaluation Low Complexity?
97161
What is the CPT code for Neuromuscular Re-education?
97112
8 Minute Rule
With this rule, how many units do you bill for 8-22 minutes of treatment?
1 unit
8 Minute Rule
With this rule, how many units do you bill for 23-37 minutes of treatment?
2 unit
8 Minute Rule
With this rule, how many units do you bill for 38-52 minutes of treatment?
3 unit
8 Minute Rule
With this rule, how many units do you bill for 53-67 minutes of treatment?
4 unit
8 Minute Rule
With this rule, how many units do you bill for 68-82 minutes of treatment?
5 unit
If you bill 3 units, what was the range of time of the treatment session?
38-52 minutes
If you bill 1 units, what was the range of time of the treatment session?
8-22 minutes
If you bill 4 units, what was the range of time of the treatment session?
53-67 minutes
If you bill 5 units, what was the range of time of the treatment session?
68-82 minutes
If you bill 2 units, what was the range of time of the treatment session?
23-37 minutes
With CPT codes, what are Modifiers?
This further defines the circumstances in which a code was billed, essentially it modifies the original definition of the code:
- 59
- XP
- XE
- CQ
With CPT Codes and Modifiers, what is the National Correct Coding Initiative (CCI) Edits?
Medicare Natoinal Correct Coding Initiative (NCCI) was implemented to promote national correct coding methodologies and to control improper coding leading to inappropriate payment
How do you use the Column 1 and Column 2 Table?
With this we end up using Modifier 59
- Colomn 2 code is considered a component of the more comprehensive Column 1 code
- Without documentation to demonstrate that the two codes were billed distinctly and separately from one another, the column 2 codes will be automatically denied
CCI Edits
With Column 1 and Column 2, what the modifier indicator 0 mean?
Permission: Not allowed
- There are no modifiers associated with NCCI that are allowed to be used with this code pair; there are no circumstances in which both procedures of the code pair should be paid for to the same beneficiary on the same day by the same provider
With Column 1 and Column 2, what does the modifier indicator 1 mean?
Permission: Allowed
- The modifiers associated with NCCI are allowed with this code pair when appropriate. With application of the modifier AND proper documentation, both codes will be reimbursed
Are Modifiers applicable across disciplines?
Yes
-Ex. OT and PT are treating a patient today, OT provides therapeutic activites (97530) and PT is providing community work reintegration. Then PT must apply modifier 59 to the community work reintegration code even if they’re not personally billing therapeutic activities. This is done because all the codes get sent to medicare on the same date of service
With Modifiers, what is XE?
Separate Encounter
- If column 1 and column 2 codes are billed to the same patient in a seperate encounter then use modifier XE
With Modifiers, what is XP?
Separate Practitioner
- If column 1 and column 2 codes are billed to the same patient by seperate practitiones then use modifer XP
With Modifiers, If we are unable to apply modifier XE or XP, what should the PT do if two overlapping codes are provided in the SAME 15 minute interval?
Then the code should not be billed and the coloumn 2 code is billed instead
With Modifiers, If we are unable to apply modifier XE or XP, what should the PT do if two overlapping codes are provided in the different 15 minute interval?
Then use Modifier 59
With Modifiers, what is Modifier CQ?
This is when a PTA has provided more than 10% of a procedure
- This reduces reimbursement by 15%
With Modifiers, what is KX?
Going over the Medicare Part B cap of $2230/year
Billing for more than 1 patient at the same time, what are Supervised Modalities?
One or more supervised modalities may be billed in the same 15-minute time period with any other CPT code, requiring direct one-on-one patient contact
- However, any other actual time the therapist uses to attend one-on-one to a patient receiving a supervised modality cannot be counted for any other service provided by the therapist
Billing for more than 1 patient at the same time, what is Group Treatment?
Simultaneous treatment of 2 or more patients who may or may not be doing the same activites;
- If PT is dividing attention among the patients, providing only brief, intermittent personal contact, or giving the same instructions to 2 or more patients at the same time, it is appropriate to bill each patient one unit of therapy
Billing for more than 1 patient at the same time, what are Team or Co-Treatment?
Two or more therapist working together as a “team” to treat one or more patients for the same or different service provided as the same time to the same patient
- This is forbidden, therapist must divide the time they bill to the patient
Billing for more than 1 patient at the same time, what are Concurrent?
One therapist with 2 patients doing different activities
- Under PDPM, there is a combined limit to concurrent and group therapy of no more than 25% of the therapy received by SNF patients, for each therapy discipline can be delivered in a group or concurrent format
What is the purpose of the Daily Encouter Note?
To create a record of skilled interventions provided to justify the codes on the claim
What information goes in the Documentation by Exception?
- Patient self-report
- Adverse reactions to interventions
- Communication/consultation with other providers
- Equipment provided
- Significant changes in clinical status
-Two level change in one area
or
-One level change in 2 areas
In SOAP notes, what information goes in S?
In SOAP notes, what information goes in O?
In SOAP notes, what information goes in A?
In SOAP notes, what information goes in P?
Why might a Pt discontinue PT services?
- Delines further care
- Unable to progress
- Pt no longer benefits
