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OTH Management > Revinue - Week 3 > Flashcards

Revinue - Week 3 Flashcards

1
Q

Modality CPT - Service Codes (not timed)

A

~ doesn’t matter how long or how many body parts

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2
Q

Example of Constant Attendance: requires direct visual, verbal, or manual contact

A

E-stim

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3
Q

When modalities there is what types of CPT codes

A

unattended and attended.

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4
Q

97022 Whirlpool (includes

A

fluidotherapy)

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5
Q

Modality that Medicare stopped paying based on ONE EBP article)

A

97033 Iontophoresis (Medicare stopped paying based on ONE EBP article)

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6
Q

95992 Vestibular Canalith –

A

1 charge per day, began paying in 2009

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7
Q

97150 Group Therapy:

A

2 or more individuals

(1 unit to each patient) if charged one patient, must have charged a second patient

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8
Q

Two patients present in outpatient ortho clinic at same time. You go back & forth working with each, at times giving direction for exercise then working with the other. They chat and encourage each other in a therapeutic way. Both are there 30 min.

Can you charge for Group?
Can you charge each for individual 30 min of exercise?

A

Yes. Each pt gets charges 1 unit of a group. or they each gets charged for 15 minutes of treatment.

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9
Q

Fee for services

A

the insurance says what their charges are worth.

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10
Q

Untimed CPT codes doesn’t matter how long.

A
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11
Q

CPT timed how long

A

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

you have to add 15 minutes in order to move up to next time code.

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12
Q

What is the 8 minute rule?

A

CPT timed codes the min amount of time is 8 minutes

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13
Q

Splints: for purposes of documentation and billing ALWAYS use the word

A

Orthoses

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14
Q

Why can’t you use the word splint?

A

The word “Splint” is associated with fractures and casting: mainly used in MD office

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15
Q

Orthotic Mgmt is $6 more per unit than __________ which many charge to teach exercises in the splint
L-Codes: (100+) charge for a specific type of splint

A

therapeutic exercise

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16
Q

Service Orthosis CodesL Codes: Specific to Orthosis

A

From the Level 2 Code Section of HCPCS Manual
Service Code (un-timed)
Includes orthosis fabrication & supplies
Does NOT include wear schedule, skin care, or exercise instructions

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17
Q

Evaluations require what using CPT

A

the amount of time was spent with pt.

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18
Q

L Codes: Specific to Orthosis require the clinic to have a special

A

DME license.

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19
Q

General orthotic code is

A

timed

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20
Q

specialized orthotic code or L code is

A

not timed

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21
Q

Timed CPT Orthosis Codes

A

97760 Orthotic Management and Training (15 min per unit)

Includes assessment, fitting, and training

Does NOT include supplies

Includes teaching wear, care, skin care, modification of splint, and patient instruction in exercises to be completed while wearing splint

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22
Q

initial orthosis fabrication is _______
Any changes on same splint is _______

A

97760 Orthotic Management and Training (15 min per unit)

97763 Check out Orthotic for established patient

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23
Q

If the patient got a prefab orthosis you would use what code

A

97763 - check out orthotic for established pt.

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24
Q

What to do if the patient receives 8 minutes or 24 minutes of treatment?

A

Look at 8 minute chart.
8 minutes = 1 unit
24 minutes = 2 units

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25
Q

15-minute increments
Can charge 2 or more of same code depending on the time spent

A
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26
Q

8 Minute CPT Code Rule

A
  1. Count service-based codes first
  2. Count timed codes second
  3. Don’t add service codes into your total minutes
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27
Q

Although we usually think of a unit of service as 15 minutes…

A

1 unit can be charged if you have provided a minimum of 8 minutes of service

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28
Q

8 minutes CPT code rule - Applied to time-based CPT Codes only

A

8-22 minutes= 1 unit

23-37 minutes= 2 units

38-52 minutes= 3 units

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29
Q

Always reach the multiple of 15 min, then add 8 min to identify where you will reach and be able to charge at next unit level

A

15 min + 8 min = 23 min or > = 2 units
30 min + 8 min = 38 min or > = 3 units

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30
Q

You saw a patient for 44 minutes of therapeutic exercise. How many units can you charge?

A. 2 units
B. 3 units

A

B. 3

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31
Q

You saw a patient for
total of 44 minutes to
teach them to don their socks for 22 minutes
upper body strengthening for 22 minutes

What will you charge?
A 1 unit of ADL, 1 unit of Exercise
B 2 units of ADL, 1 unit of Exercise
C 1 unit of ADL, 2 units of Exercise

A

C 1 unit of ADL, 2 units of Exercise

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32
Q

97110 Therapeutic Exercise
to develop

A

strength, endurance, ROM, flexibility

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33
Q

97112 Neuromuscular Treatment
Can include things like

A

PNF, NDT, swiss ball, body blade, baps board

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34
Q

Discussion about being sure you are charging for the right thing
Neuromuscular actually pays about

A

$1.25 more
BC/BS of Tennessee does not pay for Neuromuscular: considers it experimental

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35
Q

Patient who lives with girlfriend and is receiving treatment in rehab facility

Had recent paraplegia and she is in a wheelchair

Practicing home-making of making meal in kitchen for 54 minutes

Which code would you choose
97535: Self Care/Home Mgmnt $28
97150 Group Therapy $28
97530 Therapeutic Activities $38
97542 Wheelchair Management $34

A

97535: Self Care/Home Mgmnt $28

36
Q

Therapuetic timed codes
97535 Self Care/Home Management

A

ADL and IADL training

37
Q

Therapuetic timed codes
97542 Wheelchair Management

A

Assessment, fitting, training

38
Q

97530 Therapeutic Activities, direct patient contact, 15 min.

A

Lifting, carrying, pushing, pulling, grasping, overhead activities, may include bed mobility, transfer training, functional activities

39
Q

Consider many of the occupation based activities may fit more closely with therapeutic activities than straight therapeutic exercise which most therapists tend to use. Therapeutic Activities tends to pay

A

$3. more per visit than therapeutic exercise

40
Q

97124 Massage

A

Percussion, stroking compression, effleurage

41
Q

97140 Manual Therapy

A

Soft tissue mob, joint mob, myofascial release, contract-relax, neural glides, lymphedema

42
Q

Patient with flexor tendon repair receives 12 minutes of scar tissue release followed by teaching extension exercises to limits of splint for 8 minutes.

97110 Therapeutic Exercise: $35
97124: Massage $32
97140: Manual Therapy $34
97530 Therapeutic Activities $38
97760 Ortho Mgmnt and Training $41

A

97140 - manual therapy and

97110 - therapeutic exercise

43
Q

Two patients in an orthopedic clinic at same time for rehab from wrist fracture. The therapist goes back and forth between the two patients. At times giving instructions for independent exercises so the therapist can work with the other patient. Patients are present for 60 minutes all together. Each patient received a total of 12 minutes of joint mobilization, soft tissue release, and contract-relax to promote increased ROM and 16 minutes of direct work on prescribed eccentric and concentric exercises using either theraband or therapist hand over hand assist. Could I build an L code? Which codes would you use?

97110 Therapeutic Exercise: $3597124: Massage $3297140: Manual Therapy $34
97150 Group Therapy $28
97530 Therapeutic Activities $38
97760 Ortho Mgmnt and Training $41
L3916 Wrist Orthotic $250

A

No.
Therapeutic activity
group therapy
manual therapy
therapeutic exercise

44
Q

MUE: Modified Unlikely Edits (2007) …it’s a Medicare thing

A
  • Sets maximum units of a specific CPT you can charge in one day
  • Prevent fraud or accidental error in automated system
    You can still make the Charges:
  • Just add MUE to your bill:
45
Q

Examples: of MUE

A

might be charging for two splints (Left and Right)
Charging for electrical stim in OT for thumb and Electric stim in PT on same day for knee

46
Q

Medical Hospital Inpatient Coverage

A

Payment based on Medicare’s Diagnostic Related Group “DRG” system (i.e., hip replacement) is a form of episode-based payment

Hospital receives a “per episode” rate based on admission diagnosis
Adjusted for complicating factors

47
Q

Medicare’s Diagnostic Related Group “DRG” system

A

form of episode-based payment

Hospital receives a “per episode” rate based on admission diagnosis
Adjusted for complicating factors

48
Q

Per Episode DRG rate:

A

based on the level of service an individual hospital typically provides

49
Q

OT still submits CPT code “charges” to help demonstrate level of service provided (tracking productivity)
In reality,

A

OT is an included service in the daily rate, just like nursing and meals

50
Q

Utilization Reviewer or Case Manager:

A

Hospital employed nurse or

Insurance employee (often nurse)

Often BOTH working together

51
Q

Purpose of Utilization reviewer or case manager -

A

identify cost containment
assure services are provided in a timely manner

52
Q

Hospital’s nurse case manager focused on:

A

Making sure processes run efficiently
Reducing delay in care (advocate for patient)

53
Q

Utilization Review (Hospital)

A

Insurance Case Manager/Reviewer focused on:
Evaluating necessity of service
Pre-admission certification
2nd opinion before surgery

54
Q

Clinical Pathways (Hospital

A

Clinical Pathways
Team developed standard process to manage care for similar DRG case admissions

Assure services needed are ordered at the right time and that processes work efficiently for a timely placement at discharge
resulted in increased OT referrals

55
Q

Clinical Pathways Example (Hospital)

A

Admission for Hip Replacement

Clinical Pathway will trigger automatic orders: certain lab work, nursing care, prn pain medication

Rehab ordered in a standard way:
Day 0 (day of surgery) or Day 1: PT bedside for transfers & ambulation
Day 1: OT begin LE dressing & transfer training

56
Q

Episodic Payment Models (EPM)

A

Began in 2017 (67+ Hospitals NOW)

DRG system (i.e., hip replacement) is a form of episode-based payment

One lump sum payment covers ALL Services through to 90 days post-discharge for specific diagnoses

Inpatient hospital coordinates payment/care

Currently Includes:
Surgical Hip/Femur Fracture Treatment
Acute MI (Myocardial Infarction)
CABG (Coronary Artery Bypass Graft)

57
Q

Psychiatric Inpatient Hospitalization

A

DRG Exempt: paid on a per diem rate rather than based on the diagnostic related group (DRG)

This covers all needed services (including OT) based on statistics of each hospital’s costs

58
Q

Hospice Care Services

A

Physician must certify the client is terminally ill

OT may only provide services to control symptoms or maintain ADL and basic functional skills

59
Q

Medicare Part A: Home Health Agency (HHA)

A

Eligibility based on need for skilled nursing, PT, or SLP

OT covered only after qualifying for above skilled service (OT used to be NOT first in home)
COVID-19 Pandemic Emergency Rule

Once receiving OT can continue to do so even if other skilled services no longer needed

60
Q

Home Health Agency is very _________ based

A

function. Need to document patient response

61
Q

PDGM: Home Health Patient Driven Groupings Model (Miller, 2019)

A

Uses 30-day periods as a basis for payment that considers diagnosis, functional impairment level, and co-morbidities

62
Q

Payment for PDGM is a

A

lump sum provided based on single rate for 30-days (recent change from 60), based on prediction of care needs upon completion of screening tool (OASIS)

63
Q

PDPM: Oct 1, 2019

A

Patient Driven Payment Model:

Applies to all Medicare A settings
Value based payment: based on patient performance – improvement in function
More holistic approach to billing. Looks at all services provided and the severity of the patient case.
New case-mix classification for reimbursement in SNF, Rehab, and HH (PDGM)

64
Q

Medicare Part AHome Health Agency

A

OASIS: “Outcome and Assessment Information Set”
Name of Assessment Documentation form

Completed initially by PT or Nursing only
OT will provide input and may complete OASIS once active on case
COVID-19 Pandemic Emergency Rule

OT can now initiate homecare services

65
Q

To be called Rehab facility- need to have a specific mix of

A

conditions admitted.
Generally, payment is for 100 days or less (unless extenuating circumstances)

66
Q

Generally to qualify for rehab, payment is for

A

100 days or less (unless extenuating circumstances)

67
Q

Acute Rehab: meets

A

3-hour therapy/day rule

68
Q

Subacute Rehab: can have

A

less hour of therapy/day

69
Q

Medicare A: Eligible first 100 days only if

A

patient needs skilled Nursing (i.e., decubitus care) PT, OT, or SLP

70
Q

SKilled nursing facility

A

Must receive therapy services at least 5 days/week

71
Q

to qualify for SNF - Must have been hospitalized for a minimum of ______ prior to admission to qualify

A

3 days

72
Q

75% of therapy must be individual therapy (only 25% of treatment can be provided in a group or concurrent format)

A

PDPM: Patient Driven Payment Model

73
Q

CARE Plan “Continuity Assessment Record and Evaluation”

A

Multidisciplinary document used to demonstrate assessment and care (PDPM)

Scored based on first three days of admit and last three days before discharge => improvements drive reimbursement rate

Generally completed by a Nursing Administrator

Expected to have input from other disciplines despite nursing admin completing

Self-Care and Mobility (Section GG) should be completed by OT

AOTA Advocates that OTs use the 6-point scale to provide information to the main care plan document

74
Q

Self-Care Items Scored

A

Eating
Oral Hygiene
Toilet Hygiene
Wash Upper Body
Shower/bathe self
Upper Body dressing
Lower body dressing
Putting on/taking off footwear

75
Q

Section GG 6-Point Rating Scale
Section GG 6-Point Rating Scale

A

Code 06 Independent

Code 05 Setup or Clean-Up Assistance

Code 04 Supervision or touching Assistance
Verbal cues, steadying assistance constant or intermittent

Code 03 Partial Moderate Assistance
Helper does LESS THAN HALF the effort; lifts, holds, supports limbs.
Code 02 Substantial/Maximal Assistance
Helper does MORE THAN HALF the effort; lifts, holds, supports limbs.
Code 01 Dependent
Helper does ALL of the effort. Or assistance of 2 or more to complete

76
Q

GG code if treatment not attempted

A

Code 07 Resident Refused

Code 09 Not applicable
If resident did not perform this activity prior to current illness, exacerbation, or injury

Code 88 Not attempted due to medical condition or safety concerns

77
Q

Outpatient OT Services: cost is based on

A

Current Procedural Terminology (CPT Code) directly
Documentation must reflect service is part of code chosen

Requires a skill performed by an OT

78
Q

Multiple procedure payment reduction (MPPR)

A

They give you less the more codes you charge

79
Q

Outpatient OT and Medicare

A

Requires current MD prescription & Plan of Care approved by physician (i.e., 700 form)

Focus on improved safety or function

Medicare B pays 80%, patient pays 20% or goes to a supplemental insurance policy (i.e., AARP)

Retrospective Review of Services to determine if Medicare will pay

Only pays 85% of charge if COTA treated (CO Modifier)

Multiple procedure payment reduction (MPPR)

80
Q

Medicare Cap~

A

Medicare Cap~
Voted successfully to eliminate and has been repealed

Must use the KX Modifier for a threshold amount of $2150. for OT services (claims over this amount without the KX modifier are denied) at $3000. automatically do a review

Requires therapist to submit documentation that proves:
- Prove: needs are complex & medically necessary
- Prove: Further therapy WILL achieve higher level of function in a reasonable period of time.

81
Q

Outpatient & Medicare Part B:

A

Instead of automatic Medicare Cap…

Center for Medicare & Medicaid Services (CMS) will:

Monitor High Usage of Services and audit

Retrospective review: red flags = review

82
Q

Outpatient and Other Insurances What questions should you ask?

A

Is there a limit to number of visits?
Does your patient have a copay or high deductible?
Is there a yearly cap on number of visits?
Did the patient have therapy somewhere else?
Are you in network?
Is there a case manager?

83
Q

Avg. reimbursement for OT

A

$50-100/visit

84
Q

high copays lead to

A

Decreased Therapy Visits

85
Q

Medicare Changes & AOTA

A

Law requires -> opportunity for public comment prior to implementation

AOTA monitors -> provides assistance in interpreting potential changes

AOTA lobbies for your benefit
=> Be an AOTA member

OTH Management (8 decks)

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