Billing and Coding Flashcards
(25 cards)
CMS
Medicare version
Focuses on total time
Accepts mixed remainders
AMA
Private payer system
Does not allow mixed remainders
<8 minutes not billable
Low Complexity evaluation
No personal factors/comorbidities
1-2 elements of Body structure, Activity lim, participation lim
Stable/uncomplicated clinical presentation
Moderate Complexity Evaluation
1-2 personal factors/co-morbidities
3 or more elements of mid ICF
Evolving clinical presentation with changing features
High Complexity Evaluation
3 or more personal factors/comorbidities
4 or more mid ICF
Unstable and unpredictable clinical presentation
Re-Evaluation
Revised plan of care using a standardized patient assessment
Not following 15 minute rule
Progress Report
Evaluation of progress towards goals
Objective measurement
Professional judgement about continued care
Any changes to goals
Cannot be generated by a PTA
4 Components of Medical Necessity
Authority (medical necessity, skilled)
Purpose (medical condition, functional ability, reasonable expectation of progress)
Scope (Does not exceed appropriate supply or level of service)
Evidence based
POC recertification
must be recerted in 90 days max
If care goes beyond 90 or there is a substantial change to the POC the therapist must have the new POC certified
Targeted medical review
$3000 threshold for combined PT and SLP services
Only reviewed if high claims denial, pattern established
Part of a group with above factors
CPT vs ICD-10 codes
Current Procedural Terminology - treatment codes
Diagnosis codes
Therapeutic exercise description and duration
Using exercise to develop strength, endurance, ROM, and flexibility - 15 mins
NM re-ed description and time
Re-ed of movement (pattern), balance, coordination, kinesthetic sense, posture, and/or prooprioception for sitting and/or standing activities - 15 mins
Where does PROM belong when coding/billing?
Ther ex
What is the “ing” code?
Therapeutic activities
T/F Medicare pays for concurrent 1:1 care as long as a PTA is assisting
False - Medicare doesn’t reimburse this. Have to charge Group Ther Procedures
Jimmio Vs Sebelius Case
Allowed for skilled therapy services to be covered by Medicaid for maintenance of function in the case of a degenerative condition (as long as justification is presented for SKILLED services)
KX modifier threshold?
Used to support continued medical necessity
$2230 for PT and SLP combined
$2230 for OT
*specifically document rationale for continuing therapy above threshold
CQ modifier
Medicare reimburses 85% for PTA services
Original POC can be written for a max of?
90 days
The POC must include? (5)
Medical treatment and diagnoses
Long term functional goals
Type of services or interventions planned
Frequency of treatment (no ranges)
Duration of treatment (no ranges)
4 components of medical necessity
Authority
Purpose
Scope
Evidence
Reimbursement in order from most to least
Ther act
NM re-ed
Self-care/home management training
Ther ex
Manual therapy
What modality is timed unlike most?
Ultrasound
