Documentation/Billing/Coding Flashcards
Purpose of Documentation
-legal record
-communication
-clinical problem solving
-reimbursement
-confidentiality
-Fraud and abuse
Minimum Documentation Items
-referrals
-evals and exam
-plan of care
-each treatment session
-re-evals
-PT and PTA interactions
-discharge summary
7 Essentials of Evaluation
- Hx and physical exam
- Skilled services
- Pt Response
- Plan for future care
- Rationale and need for skilled services
- Complexity
- Pertinent Characteristics of pt
Documentation Guidelines
-every visit
-approved abbreviations
-document no shows
-done within 24hrs
-3rd person
-cross out with pen
10 Payer Complaints
-poor legibility
-incomplete documentation
-abbreviation issues
-no documentation for day of service
-not skilled
-not necessary
-does not demonstrate progress
-interventions not timed
Red Flags of Documentation
-ranges of level of assistance min-max
-pt agitated or confused
->3 modalities after 4th visit
-poorly written goals
-testing too often
Discharge Planning
-where to go
-what support is needed
-referrals
-follow up care
Consider:
-prior level of function
-current function and needs
-rehab ability
-safe for home or community
Long Term Acute Care Discharge Rec
-high medical needs
-not safe to go home
-might need ventilator
-variable prognosis
Skilled Nursing Facility Discharge Rec
-moderate medical needs
-mod to good prognosis
-<3 hours a day of rehab
-not safe to go home
-Mod-high multidisciplinary needs
Inpatient Rehab Facility Discharge Rec
-high prior functional level
-mod to stable medical needs
-good prognosis
-3 hours of rehab a day
-High multidisciplinary needs
Outpatient Discharge Rec
-high prior function
-stable medical needs
-Good prognosis
-good current function
-safe to go home
-single multidisciplinary needs
Home Health Discharge Rec
-stable medical needs
-good functional prognosis
-limited current function <150 feet
-safe to go home
-nursing or PT required
-possibly homebound
Nursing Home Discharge Rec
-low pre functional level
-stable medical needs
-limited prognosis
-limited skilled therapy needs
ICD-10 Codes
-internaional classificaion of dissease
-international code system for diagnoses
-7 digits
-used in all healthcare
CPT Code
-Current Procedural Terminology
-PT bill for time and skills (97000)
-can be timed or untimed
-indicate care given by PT
8 Minute Rule
1 Unit: 15min: 8-22min
2 Units: 30min: 23-37
3 Units: 45min: 38-52
4 Units: 60min: 53-67
Timed Codes
-require direct patient care
-15 min incements
Ex:
-therex
-neuro re-ed
-gait training
-manual
Untimed Codes
-does not require direct
-time does not matter
Ex:
-modalities
-group
-estim
Modifiers 59/X
-can bill for certain pairs of codes during one visit
Value-Based Payment System
-payment based on outcomes
Prospective Payment System
-lump sum payment
-predetermined
-patient classified system
Fee for Service
-payment based on dollar amount
-Volume= greater reward
Medicare
-65+ or < with disability
Part A:
-Acute Care
-Inpatient rehab
-SNF
-Home Health
-Hospice Care
Part B:
-optional
-must pay a premium
-Outpatient, physician, DME, home health, SNF
Medicare and Students
Part A:
Hopital: general supervision
SNF: line of sight
Part B:
-will not pay for services by students
-students shouldn’t document directly on chart
