Overview

Question 1

What is the formula for getting reimbursed?

Answer 1

documentation+ analysis of documentation+ assignment of ICD9 and CPT codes+ codes entered in computer system + bill printed + submission to payer/insurance company = REIMBURSEMENT

Question 2

How long should records be kept after last pt. visit?

Answer 2

7-10 years

Question 3

What is assumed if pt. records are not available?

Answer 3

malpractice

Question 4

What is spoliation?

Answer 4

the destruction of or altering of any medical record for the purpose of changing or concealing its meaning.

Question 5

what are the punishments for altering a pt record?

Answer 5

loss of license, fines, loss of accreditation,

Question 6

does a pt have the right to view their own medical records?

Answer 6

YES! they can view them, make copies from them and request amendments, etc. however, not all records must be disclosed (i.e. psychotherapy notes).

Question 7

What if a clinic dissolves?

Answer 7

the pt must be informed and the provider must notify pt as to who will get their records, all other differences depend on state law.

Question 8

Where would the following info be found in a patient's SOAP note? 
current complaints/conditions
prior level of fxn
social history
employment history
family health hstry
fxnl status
meds
response to tx

Answer 8

Subjective

Question 9

Where would the following info be found in a patient’s SOAP note?
tests and measures
tx provided
chart review

Answer 9

Objective

Question 10

Where would the following info be found in a patient’s SOAP note?
SINSS statement
the PT’s thought processing and clinical reasoning
goals
diagnosis
prognosis
disability level
progress towards goals
justification for further treatment sessions

Answer 10

Assessment

Question 11

Where would the following info be found in a patient’s SOAP note?
frequency and duration of treatment
specific txs the patient will receive or that the PT plans to administer
DC plans
education given to family/pt
referral to other services

Answer 11

Plan

Question 12

How do u document a PT diagnosis?

Answer 12

summary of exam findings
how the pt’s fxnl deficits relate to the physical impairments
assign a diagnostic category to a practice pattern
combine with MD info to create reasonable goals

Question 13

How do u document a PT prognosis?

Answer 13

predict a level of improvement in fxn and the amnt of time needed to reach that level –>pt’s rehab potential (good, fair, poor, guarded)

• ->prediction of a level of improvement
• ->amnt of time needed
• ->potential to meet set goals

Question 14

in writing goals: they should always…

Answer 14

1) have a time frame
2) be measureable
3) be functional

Question 15

PTs should never write what kind of goals?

Answer 15

wt. bearing goals

Question 16

What is a SMART goal?

Answer 16

specific, measureable, attainable, routine/fxn based, time sensitive

Question 17

What are the ABCDs of goal writing?

Answer 17

Audience (who involved)
Behavior (what will be done)
conditions ( what ADs, environment, assistance)
Degree (how well will it be done, # of feet, times performed, min/mod/max assist, ROM, MMT, etc.)

Question 18

What should be addressed in a discharge summary?

Answer 18

address goals
recommendations for continuum of care
recommendations for living arrangement
any referrals
PT codes

Question 19

D/C vs. DC??

Answer 19

D/C= discharge/termination of PT services 
DC = pt sick, some prob, discontinue secondary to medical  hold, plans to resume

Question 20

Should u use layman’s terms when communicating to insurance companies?

Answer 20

NO!

Question 21

What is the primary payment source of home health care?

Answer 21

Medicare

Question 22

What is the qualifying criteria to be eligible for home health care and medicare coverage for it?

Answer 22

MD manage pt for 60 days
home bound
have qualifying discipline at start of care
services are intermittent and necessary

Question 23

What is nose to nose/ real time/point of care documentation?

Answer 23

documenting at time care is given

Question 24

What is unbundling?

Answer 24

using individual codes when an aggregate code exists.

Question 25

upcoding?

Answer 25

deliberately using a higher paying reimbursement code than what what actually provided to pt

Question 26

duplicate billing

Answer 26

billing the same visit twice

Question 27

functional limitation vs. disability?

Answer 27

> functional limitation: limitation in performance on the level of the Whole person–> what activity is not able to be performed well or efficiently or typically or competently for that person anymore. What they could do before pathology and what they can’t do now…
Disability: impact of the disease on a person’s normal behaviors and their typical life…