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Flashcards in PPT - Documentation for Reimbursement Deck (31)
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1
Q

Reimbursement Basics

A

Everything OTs provide must be linked to a code

Codes describe a client’s condition or medical reason for services

Codes depend on the setting

Coding system used in the U.S. is the ICD 10-CM = International Classification of Diseases, 10th Revision, Clinical Modification
updated annually

2
Q

Medicare enacted in ___

A

Medicare enacted in 1965

3
Q

Budget Reconciliation Act

A

1981: Budget Reconciliation Act cut out of the qualifying services for home health care

PT, RN, SLP can evaluate a person in their home, but OTs cannot

4
Q

Tax Equity and Fiscal Responsibility Act (TEFRA)

A

1982: Tax Equity and Fiscal Responsibility Act (TEFRA) allowed OT to work in hospice setting temporarily
- also limited payment of services by capping allowable costs while patient is hospitalized
- 1986: permanently allowed OT to work in hospice setting

5
Q

Effects of payments changing from retrospective to prospective with diagnostic-related group (DRG) system

A

made LOS shorter and patients were being discharged sooner to SNF and rehab units – OT clients are now more medically complicated

6
Q

DRG

A

a code system that categorizes a diagnosis into a payment group. This system allows for a lump sum paid for a specific diagnosis

7
Q

Balanced Budget Act (BBA)

A

1997: Balanced Budget Act (BBA) included a prospective payment plan for Medicare Part A in SNFs
- created to control the growth of Medicare spending and allow Medicare beneficiaries w/ additional choices for care through private health plans
- also placed caps on outpatient therapy

8
Q

Balanced Budget Refinement Act (BBRA)

A

1997-98 Balanced Budget Refinement Act (BBRA) called for the development of a prospective payment system (PPS) in inpatient rehab units/hospitals

9
Q

PPS

A

2002: PPS est. in in inpatient rehab hospitals

- to balance the budget, PPS predetermined the amount of money paid based on a diagnosis/condition.

10
Q

Medicare

A
  • A national insurance program, has national standards for documentation
    Is age-based. A major payer source in the geriatric physical disability setting
  • Eligibility: 65+ yo entitled to disability benefits for those 24+ yo
11
Q

Medicare Part A

A

Part A – Hospital Insurance

100 day benefit periods that can be renewed throughout life. Psychiatric care is 190 for entire lifetime

Can be in hospital, acute SNF, hospice, or home health

12
Q

Medicare Part B – Medical Insurance

A

Voluntary and requires a paid premium (scaled based on income)

Covers out of pocket costs like doctor’s service, ambulance service, preventative services, DME, home health, outpatient OT, PT, SLP

Covers 80% of the cost, patient pays 20% of the cost

13
Q

Medicare Part C – Medicare Advantage Plans (like HMO or PPO)

A

Covers what’s in Parts A and B depending on the plan

Run by contracted private companies, so limited to the providers in the plan

Must be eligible for Parts A and B and NOT have and end-stage renal disease (ESRD)

14
Q

Medicare Part D – Medicare prescriptions drug coverage

A

Run by contracted private companies

Must register 3 months prior to turning 65 yo to qualify

15
Q

Medicare reimbursement requires:

A

Order from a physician

Proof that skilled services are needed and are unique to OT

Document patient limitations and that care is needed

Demonstrates patient significant functional progress

16
Q

Error’s in Physician’s Orders – Beware of:

A

Non-specific: orders, span of duration, treatment plans

17
Q

There are 3 major areas where OT services are provided

A

Inpatient, outpatient, and home health

18
Q

Short Term Acute Hospital (STAH)

A

MD/RN on call 24/7

OT/PT/SLP per physician order. Focus on D/C planning

Flat rate per admission based on diagnosis related group (DRG)
- DRG categorizes a diagnosis into a payment group

19
Q

Inpatient Rehab Facility (IRF)

A

MD/RN on call 24/7

Patient must have 3+ hours of therapy daily, 5 days/week. Must be seen by 2 out of 3 disciplines (OT, PT, SPL)

75% Rule – implemented as 60% rule
- 6/10 patients must fall within the 13 diagnostic categories
1. Fx of Femur (hip)
2. Stroke
3. Spinal cord injury
4. Brain injury
5. Burns
6. Congenital Deformity
7. Amputation
8. Major Multiple Trauma
9. Neurological Disorders (MS, MD, polyneuropathy)
Polyarthritis (including rheumatoid arthritis)
10. Systemic vasculitides w/ joint inflammation
11. Severe/advanced osteoarthritis
12. Hip or knee joint replacement (w/ special circumstances)

20
Q

Payment: Case Mix Group (CMG), flat rate payment/discharge

A

CMG: Prospective Payment System (PPS) places patients into groups requiring similar healthcare resources. CMGs are determined by clinician’s assessments of patients’ functional level upon admission

21
Q

Skilled Nursing Facility (SNF)

A

MD: seen by day 3, once a week for 30 days. Once every 30 days thereafter
- RN per shift

Payment: per diem based on Resource Utilization Group (RUG) level

LOS: up to 100 days
First recorded assessment must be w/in first 5 days (given 3 grace days to complete Minimal Data Set (MDS))

Reassessments on days 14, 30, 60, 90

  • This allows patient to move to a different RUG level
  • RUG levels are assigned to each SNF resident admitted for rehab services. The more therapy the resident receives, the higher the RUG level becomes -> the higher the reimbursement level becomes
    • Business side of SNF will push for higher RUG levels = more money!
22
Q

Outpatient

A

Hospital setting/outpatient clinic

  • Must have medically justified plan of care (updated periodically)
  • Reimbursement is capped
    private outpatient clinic/free standing clinic
    reimbursement is capped. $1960 a year for OT
  • Comprehensive outpatient Rehab Facility (CORF)/Day Treatment programs
    – Hospital based
    – NOT capped
    – Extensive therapy – several hours a day
    – All CORF services are paid under the physician fee schedule (PFS)
23
Q

Home Health

A

OT, PT, SLP, and nurses provide care in client’s homes

OT can do admission visits, but only a qualifying service when there is “continuing need”

Payment: CMG, flat rate/60 days

Can be renewed

Patient must be homebound – patient’s condition keeps them from leaving the home

24
Q

OASIS – Outcome and Assessment Information Set

A

A comprehensive assessment for an adult in home health care

Assesses outcome-based quality monitoring, improvement, and public reporting initiative

Data guides quality and performance improvement efforts

25
Q

Extended Care Facility (ECF) or Long-Term Care (LTC)

A

Patient needs 24 hour care

LOS may be unknown and indefinite
- Functional recovery may not be possible

OT role: direct/consultative

Requires Medicaid or private pay

26
Q

Assisted Living (AL)

A

Housing, personalized support for patients who need ADL help

For people who do NOT need skilled medical care

OT role: enhance habits and routines, safety, ADL assessments, social activities, education to staff

27
Q

Coding and Billing

A

Local Coverage Determination (LCDs) provide guidance that supports submissions of claims for payment

28
Q

CPT

A

CPT: the code used to describe the treatment/procedure provided for that diagnosis

29
Q

Private Insurance

A

Most private insurance follows Medicare guidelines

May be used as a secondary insurance to cover whatever Medicare does not

Examples: HMO, PPO, Anthem, Kaiser, Blue Cross etc

30
Q

OT service must:

A

Be necessary, reasonable – and require the skills of an OT

Either improve, maintain, or prevent/slow further deterioration of the patient’s condition

31
Q

List of Documentation Requirements

A
  • Referral from MD/DO
  • Eval or re-eval
  • Intervention plan (goals, type, frequency etc.)
  • Certification from physicians (as appropriate)
  • Treatment notes
  • Progress reports
  • Discharge summary