Final Study Guide Flashcards

1
Q

Limits the number of visits or limits the payment per visit

A

Health Maintenance Organization (HMO)

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2
Q

Higher copays for out of network providers

A

Point of Service (POS)

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3
Q

These organizations have a preferred network than everyone else; will pay more there than out of network

A

Preferred Provider Organization (PPO)

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4
Q

Case rate payment system; reimbursement is provided by diagnosis; a system of classifying inpatient stay into groups for purposes of payment. You group patients with the same treatment and diagnosis into a price point. Medicare part A. it is a prospective payment system. The hospital is given a certain amount per condition..so they better not get the pt sick or they’ll lose money.

A

Diagnostic Related Groups (DRG)

- if pt is in hospital for pneumonia, insurance will play $x regardless if you’re there for 2 days or 15 days

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5
Q

Reimbursement method in which each health service is paid on an individual basis; Charges may be paid in full by the insurer but in most instances are paid on a percentage basis

A

Fee for service

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6
Q

Based on the minimum data set where a patient is assigned a category based on their clinical presentations and functional ability

A

Resource Utilization Group (RUG)

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7
Q

Group based on diagnosis/condition, motor and cognitive function, age, and comorbidities

A

Case Mix Group (CMG)

-inpatient rehab

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8
Q

Does medicare A or B cover acute care?

A

A

  • pts must be admitted to “inpatient” status
  • if they’re under “observation” status, they are not admitted and medicare B covers it
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9
Q

stand alone hospital or a unit of a hospital where patients receive intense rehabilitation services with the ultimate goal to return home

A

Inpatient rehabilitation facility (IRF)

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10
Q

What are the qualifications for an inpatient read facility stay?

A

mus have one or more of the qualifying diagnosis and be able to participate in 3 hours of therapy per day for 5 days per week

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11
Q

What part of medicare covers and IRF stay?

A

medicare A up to 100 days

- PT provided under Case Mix Group

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12
Q

Medical services are provided in the home of the individual who qualifies based on physician determination of homebound status

A

Home Health care

  • covered under med A up to 60 days
  • PT provided under PPS based on diagnosis
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13
Q

What part of medicare pays for OP services?

A

Medicare B

- Med A will NEVER pay for outpatient

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14
Q

A subsection of pediatric physical therapy services provided within a school-based setting to assist with a child’s ability to participate in their education

A

School-based services

  • PT is a related service
  • related service = child must first qualify for special education services, then the child may qualify for school-based PT
  • PT within the school setting aimed at improving the child’s ability to engage in the educational environment
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15
Q

A residential facility where patients can receive a variety of medical services, including physical, occupational, speech therapy; May also include nutrition and/or dietary services

A

Skilled Nursing Facility

- pt must have a medical need for skilled nursing to qualify; documented by PCP

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16
Q

What part of medicare covers SNF stay?

A
  • Medicare A up to 100 days post hospitalization

- Medicare B and/or medicaid at day 101+

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17
Q

What is PT reimbursement in a SNF determined by?

A

the individuals RUG level

  • high = 720 mins of therapy provided by 2+ disciplines
  • low = 45 mins by 1+ disciplines
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18
Q

individuals stay on a short-term basis to receive rehabilitation services and ultimately discharge to an environment with increased independence and participation

A

Transitional Care Unit (TCU) aka Swing bed

- generally short term, less than 100 days

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19
Q

What part of medicare covers TCU stay?

A

Med A up to 100 days

- PT determined by RUG

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20
Q

How do you decide on a code for reimbursement

A
  • Use the most specific code available (3 digit category codes); 4th digit is subcategory, 5th digit is subclassifications
  • if you are treating 2+ conditions, include all applicable codes and specify which intervention apply to each diagnosis listed
  • code any coexisting conditions that affect the tx of the pt for that visit or procedure as supplementary info
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21
Q

code is specific to health care received following a surgery; shouldn’t be used in isolation

A

Z codes

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22
Q

What level HCPCS are identical to CPT codes?

A

Level I

- procedural codes for medicare pts

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23
Q

What level HCPCS are for clinical supplies and equipment?

A

Level II

- alphabetical character followed by 4 numbers

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24
Q

What level HCPCS are local codes?

A

Level III

- devices like FWW

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25
Q

What codes are untimed codes?

A

Eval, Re-eval, unattended modality

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26
Q

What are the time increments for timed codes?

A
8-22 mins = 1 unit
23-37 mins = 2 units
38-52 mins = 3 units
53-67 mins = 4 units
68-83 mins = 5 units
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27
Q

If the provider is overseeing the therapy of more than one patient during a period of time, he or she must bill the code for _____ since he or she is not furnishing constant attendance to a single patient

A

group therapy

- pts must be doing the same exercises for similar conditions

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28
Q

What is an ABN? when is it used?

A

Advanced Beneficiary Notice
- A provider may ask a patient to sign an ABN in the case that the service being provided will not be covered by Medicare (services outside of therapy cap, experimental service, etc)

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29
Q

Functional limitation reporting; describes impairment limitation restrictions and functional categories

A

G codes

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30
Q

What are the categories for functional G-code categories

A
  1. Mobility: walking and moving around
  2. Changing and maintaining body positioning
  3. Carrying, moving and handling objects
  4. self care
  5. Other PT primary fxn’l limitation
  6. Other PT subsequent fxn’l limitation
    - each of these have different codes for Current status, Projected goal, and Discharge status- end reporting
31
Q

What are the modifiers for impairment limitation reporting with G codes?

A
CH = 0% impaired
CI = 1-19% impaired
CJ = 20-39% impaired
CK = 40-59% impaired
CL = 60-79% impaired
CM = 80-99% impaired
CN = 100% impaired
32
Q

When are Gcodes used?

A
  • Evaluations, reevaluations, and discharge

- when therapy of one functional limitation has ended and another one is started

33
Q

Payment for services vary with resources and costs needed to provide them

A

Resurce Based Relative Value Scale (RBRVS)

34
Q

How is RBRVS determined?

A
  1. Work expense or value: mental effort and judgement, physical effort and technical expertise, and stress associated with risk to the pt
  2. Practice expense
  3. Malpractice expense
35
Q

What are the 3 components of fee schedule payment (payment for each service under RBRVS)?

A
  1. A nationally uniform relative value for the service
  2. a geographic adjustment factor for each physician fee schedule area
  3. a nationally uniform conversion factor for the service
36
Q

What are the guidelines for Worker’s Comp?

A
  • prior authorization is needed
  • 1 initial window period is allowed for a flame that includes all body parts and diagnoses
  • PT and OT have separate window periods
37
Q

What is included in the therapy window for worker’s comp?

A
  1. 10 treatments (including initial eval) or 60 days of care, whichever comes first
  2. post surgical is 10 treatments or 60 days, and must be initiated within 90 days following surgery
  3. limit of 2 modalities per visit
  4. prior auth is required for tx outside of initial therapy window
38
Q

What are the window periods for rehab therapy for BCBS?

A
  1. Window 1 (non-surgical) 10 visits or 60 days
  2. Window 2 (ortho post surgical) 18 visits or 6 months
  3. Extensions available
  4. Peer review - random reviews to make sure the tx was medically necessary
39
Q

What is considered skilled care for medicare according to the Outpatient PT Standards Act?

A
  1. Restorative w/ expectation of sig. improvement in reasonable/predicatble time frame
  2. condition of pt warrants complexity of intervention
  3. related to documented POC
  4. Qualified provider
40
Q

What are the 3 major audit-worthy red flags?

A
  1. Excessive use of the KX modifier
  2. Multiple Therapists using one NPI number
  3. Billing significantly greater-than-average number of codes per date of service
41
Q

What are the conditions that would warrant an audit review to flag for immediate denial?

A
  1. No initial examination and evaluation performed by a PT
  2. No documentation of PT visits or progress notes
  3. Billing of the same supervised modality to multiple body regions on the same visit
42
Q

What are the conditions that would warrant an audit review to flag for further review?

A
  1. An evaluation fee plus an additional specific test fee on the same date of service
  2. Billing separately for “Constant Attendance” modalities to separate body regions
  3. Daily intervention beyond 1 week
  4. Providing and Billing for “Supervised” or “Constant Attendance” modalities through-out the entire course of care
  5. Lack of tapering of frequency of intervention over the course of treatment
  6. Modality codes (Supervised or Constant Attendance) that change and/or repeat continually during the course of treatment
  7. Lack of active, restorative and functionally based treatment
  8. Use of certain CPT codes billed together on same DOS: ultrasound & phonophoresis, ultrasound & iontophoresis, manual therapy techniques & massage, therapuetic ex/NMR/therapeutic activities & aquatic therapy
43
Q

What are the aspects of a good team?

A
  1. Individual Self-Esteem
  2. Appropriate Communication of Needs
  3. Trust and Openness
  4. Utilization of Individual Styles/Abilities
  5. Flexibility
  6. Open-Mindedness
  7. Mutual Commitment Towards a Common Goal
  8. Respect
  9. Sense of Ownership and Responsibility
  10. Sense of Humor
  11. Problem Solving Skills
44
Q

ability to accurately identify and understand one’s own emotional reactions and those of others, ability to identify your feelings and the feelings of others helps to solve conflicts

A

Emotional intelligence

- higher EI = leader

45
Q

communication, conflict management, leadership, collaboration: aspects of…

A

Social skills

46
Q

understanding others, developing others, policital awareness, leveraging diversity, service of orientation

A

empathy

47
Q

achievement drive, commitment, initiative, optimism

A

Self-motivation

48
Q

self-control, conscientiousness, adaptability, trustwrothiness, innovation

A

Self-regulation

49
Q

emotional awareness, accurate self-assessment, self-confidence

A

Self-awareness

50
Q

form of behavior characterized by a confident declaration without need of proof; this affirms the person’s rights or POV without either aggressively threatening the rights of another or submissively permitting another to ignore/deny one’s rights or POV

A

Assertiveness
- Self-expressive, Respectful of rights of others, Honest, Direct and firm, Equalizing (benefits self and relationship), Verbally and nonverbally appropriate, Appropriate for person and situation, Socially responsible, Learned, not inborn

51
Q

What does DESC stand for? DESC helps you be assertive

A

D – Describe the situation
E – Express your feelings “I feel…”; Or I –Indicate the problem the behavior is causing
S – Specify the change you want: “I’d like for you to…”
C – Consequences. Identify the results that will occur. “In that way…”

52
Q

What are the aspects of effective listening?

A
  1. Active Listening – use encouragers
  2. Paraphrase – what I hear you say is….
  3. Check-ins and ask open ended questions – “how can perform this skills more efficiently?”
  4. Make Observational Comments – you seem upset
  5. Summarize - recap what’s happened toward the end of a conversation or begin a conversation by summarizing what you heard the person say
53
Q

Supervison: The PT is NOT required to be on-site for direction and supervision, but must be available at least by telecommunications

A

General supervision

54
Q

Supervision: The PT is physically present and immediately available for direction and supervision; The PT will have direct contact with the patient/client during each visit; Telecommunications does not meet the requirement

A

Direct supervision

55
Q

Supervision: The PT (or PTA) is physically present and immediately available to direct and supervise tasks that are related to pt management; The direction and supervision is continuous throughout the time these tasks are performed.; Telecommunications does not meet the requirement

A

Direct Personal Supervison

56
Q

What are the supervision guidelines for medicare part A?

A

SNF, acute care, inpatient rehab = direct supervision

HHC = refer to state laws

57
Q

What are the supervision guidelines for medicare part B?

A

Direct personal supervision ALWAYS, no matter what setting

- OP is ALWAYS direct personal supervision

58
Q

Services are billable under medicare B if..

A
  1. PT responsible
  2. PT present in room entire session, and is directing service, making skilled judgment, and responsible for assessment and treatment
  3. Direct Personal Supervision
59
Q

Treatment of 2 residents at same time regardless of payer source when in line of sight of treating PT/CI under Med A

A

Concurrent therapy

- Med B pts can’t be treated concurrently but med A can

60
Q

What are the medicare rules on supervision of a PTA in a HHA?

A

requiring the initial direction and periodic inspection of the actual activity; Supervisor need not always be physically present or on the premises when the assistant is performing services

61
Q

What are the medicare rules on supervision of a PTA in a IP, OP?

A

regulations do not specifically delineate the type of direction required, the provider must defer to his or her physical therapy state practice act

62
Q

What are the medicare rules on supervision of a PTA in a Private practice (PT or doctor owned)?

A

direct supervision from PT who must be present in the room at the time the service is performed

63
Q

What are the medicare rules on supervision of a PTA in a SNF?

A

services provided directly or under the general supervision PT (requiring the initial direction and periodic inspection of the actual activity. However, the supervisor need not always be physically present or on the premises when the assistant is performing services.)

64
Q

What part of medicare pays for DME?

A

Part B

-durable medical equipment

65
Q

Amount an individual needs to pay before insurance will kick in

A

deductible

66
Q

Dollar amount that is due at the time of service to solicit health care services

A

copayment

67
Q

What does CMS stand for?

A

Centers for medicaid and medicare services

68
Q

Type of healthcare plan: work by assigning a fixed payment rate to specific treatments. While these rates might change over time because of factors such as inflation, they are not adjusted to accommodate individual patients; a healthcare provider will always receive the same payment for providing the same specific type of treatment.

A

Prospective payment plan

69
Q

pay healthcare providers based on their actual charges; a provider will treat a patient and submit an itemized bill to an insurance company detailing the services rendered. The insurance company, in turn, may approve or deny payment for the treatment or portions thereof, but healthcare providers generally get paid in full for the amounts they bill.

A

Retrospective payment plan

70
Q

_____ occurs when a procedure or service with a unique CPT® or HCPCS code is included as part of a “more extensive” procedure or service provided at the same time. ______ occurs when multiple procedure codes are billed for a group of procedures that are covered by a single comprehensive code.

A

Bundling; Unbundling

71
Q

a CMS program designed to prevent improper payment of procedures that should not be submitted together. is an automated edit system to control specific Current Procedural Terminology (CPT) code pairs that can be reported on the same day. CMS developed to control overpayment of Part B claims

A

Correct coding initiative (1995)

72
Q

Eval complexity: no personal factors and/or comorbidities, addressing 1-2 elements, stable clinical presentation

A

Low-complexity 97161

73
Q

Eval complexity: 1-2 personal factors and/or comorbidities, addressing 3+ elements, evolving clinical presentation

A

Moderate-complexity 97162

74
Q

Eval complexity: 3+ personal factors and/or comorbidities, addressing 4+ elements, unstable clinical presentation

A

High-complexity 97163