Final Study Guide Flashcards
Limits the number of visits or limits the payment per visit
Health Maintenance Organization (HMO)
Higher copays for out of network providers
Point of Service (POS)
These organizations have a preferred network than everyone else; will pay more there than out of network
Preferred Provider Organization (PPO)
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.
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
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
Fee for service
Based on the minimum data set where a patient is assigned a category based on their clinical presentations and functional ability
Resource Utilization Group (RUG)
Group based on diagnosis/condition, motor and cognitive function, age, and comorbidities
Case Mix Group (CMG)
-inpatient rehab
Does medicare A or B cover acute care?
A
- pts must be admitted to “inpatient” status
- if they’re under “observation” status, they are not admitted and medicare B covers it
stand alone hospital or a unit of a hospital where patients receive intense rehabilitation services with the ultimate goal to return home
Inpatient rehabilitation facility (IRF)
What are the qualifications for an inpatient read facility stay?
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
What part of medicare covers and IRF stay?
medicare A up to 100 days
- PT provided under Case Mix Group
Medical services are provided in the home of the individual who qualifies based on physician determination of homebound status
Home Health care
- covered under med A up to 60 days
- PT provided under PPS based on diagnosis
What part of medicare pays for OP services?
Medicare B
- Med A will NEVER pay for outpatient
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
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
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
Skilled Nursing Facility
- pt must have a medical need for skilled nursing to qualify; documented by PCP
What part of medicare covers SNF stay?
- Medicare A up to 100 days post hospitalization
- Medicare B and/or medicaid at day 101+
What is PT reimbursement in a SNF determined by?
the individuals RUG level
- high = 720 mins of therapy provided by 2+ disciplines
- low = 45 mins by 1+ disciplines
individuals stay on a short-term basis to receive rehabilitation services and ultimately discharge to an environment with increased independence and participation
Transitional Care Unit (TCU) aka Swing bed
- generally short term, less than 100 days
What part of medicare covers TCU stay?
Med A up to 100 days
- PT determined by RUG
How do you decide on a code for reimbursement
- 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
code is specific to health care received following a surgery; shouldn’t be used in isolation
Z codes
What level HCPCS are identical to CPT codes?
Level I
- procedural codes for medicare pts
What level HCPCS are for clinical supplies and equipment?
Level II
- alphabetical character followed by 4 numbers
What level HCPCS are local codes?
Level III
- devices like FWW
What codes are untimed codes?
Eval, Re-eval, unattended modality
What are the time increments for timed codes?
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
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
group therapy
- pts must be doing the same exercises for similar conditions
What is an ABN? when is it used?
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)
Functional limitation reporting; describes impairment limitation restrictions and functional categories
G codes