PTP 2 Exam 1 Flashcards
(76 cards)
How are providers paid?
- Providers provide services
- Document the nesessary details for payment
- Assign codes to represent services rendered and other pertinent details
- Submit the claim
- Interpret payer’s response
- Prepare post-payment audit
What is the Purpose of ICD-10 Codes?
- They are used to track health care statistics/disease burden, S/S, abnormal findings, social circumstances and external causes of injuries and/or disease, quality outcomes, mortality statistics and billing
ICD-10 was developed by WHO
What is the Purpose of CPT Codes?
Who published and maintains CPT codes?
- CPT codes are used to describe tests, surgeries, evaluations and any other medical procedure performed by a healthcare provider on a patient
- CPT codes tell the insurance payer what procedure the heathcare provider would like to be reimbured for
American Medical Association (AMA)
What are the Characteristics of ICD-10 codes?
- 7 character, alphanurmeric code
- Begins with a letter, followed by 2 numbers
- First 3 characters of ICD-10 represents the “category”, which describes the general type of the injury or disease; the category is followed by a decimal point and the subcategory
What are the characteristics of CPT codes?
- Normally a 5-digit number, which represents a procedure or service provided to the patient
With ICD-10 codes, what 4 things are always needed?
- We need a Medical Dx:
(for example)
1.Z96.641
2.Presence righ artificial hip Joint - Also a Treatmetn Dx:
(for example)
3.R.29.98
4.Abnormality of gait and mobility
What is the difference between Medicaid and Medicare?
- Medicaid: Federal-state program that provides coverage to low income people, pregnant women and people with disabilities
- Medicare: Federally funded
Medicare Coverage Programs
What does Medicare Part A cover?
A, think Acute
- Covers inpatient hospital stays, skilled nursing facilities (SNF) stays, some home health visits and hospice care
- Can return patient to PLOF only
Medicare Coverage Programs
What does Medicare Part B cover?
B, think Best a patient can be
- Covers physicians visits, OP services, preventive services, and some home health visits
- Maximize patient’s function
Medicare Coverage Programs
What does Medicare Part C cover?
C, think children as it relates to therapy services
- Refers to the Medicare Advantage program, through which beneficiaries can enroll in a private health plane, such as a Health Maintenance Organization (HMO) or preferred provider organization (PPO), and receive all Medicare-covered Part A and Part b benefits and typically also Part D benefits
Medicare Coverage Programs
What does Medicare Part D cover?
D, think Drugs
- Covers OP prescription drugs through private plans that contract with Medicare, including stand-alone prescription drug plans (PDPs) and Medicare Advantage plans with prescription drug coverage
What are the different types of Reimbursement Systems?
- Fee-for-Service (FFS): Providers paid for each and every service (more common in Medicare Part B)
- Capitation: Providers are pain in a prospective “cap” or per members per month (PMPM) payment, to provide care for individuals enrolled in managed health plans
- Bundled Payments / Episode-Based Payments: Providers are pain for all service within an episode of care (Think Home Health
With Medicare Part A, what types of Reimbursement is used by setting?
- Hospital: Diagnosis-Related Goups (DRGs)
- Inpatient Rehabilitation Facility (IRF): Patient Assessment Instrument (PAI)
- Skilled Nursing Facility (SNF): Patient Driven Payment Model (PDPM)
- Home Health: Episode of Care
- Hospice: Daily Rate
With Medicare Part A, What is the Diagnosis-Related Groups (DRGs) Reimbursement?
DRGs is a patient classification system that standardizes prospective payment to hospitals and encourages cost containment initiative
- Each DRG has a payment weight assigned to it, based on the average resources used to treat Medicare patients in that DRG
Remember this is mainly for Hospitals
With Medicare Part A, What is the Reimbursement for Inpatient Rehabilitation Facility (IRF)?
The reimursement is paid under the IRF Prospective Payment System (PPS) via the IRF- Patient assessment instrument (IRF-PAI)
Medicare Part A
With the IRF-PAI Section GG, what is the intent of Functional Abilities and Goals?
To provide information about functional abilities and goals. It includes items focused on prior functioning, admission performance, discharge goals and discharge performance
With Medicare Part A, What is Patient Driven Payment Model (PDPM)?
This is a new case-mix calssification system for classifying skilled nursing facility (SNF) patients in a Medicare Part A covers 1 stay into payment groups under the SNF prospective payment system
Case Mix: A measure used by CMS to determine reimbursement rates for medicare and medicade beneficiaries, reflects the diversity, complexity and severity of patient illness treated at a given heathcare facility
With Patient Driven Payment Model, what is the Minimum Data Set (MDS)?
- The patient’s primary diagnosis for the SNF stay
- Each primary diagnosis is mapped to one of 10 PDPM clinical categorize, which is then used as part of the patient’s classification under PT, OT, and SLP
- ICD-10 codes are used to capture additional diagnoses and co-morbidities that the patient has
With the Patient Driven Payment Model, what is the Patient Functional Score?
This is another assessment that goes into the MDS
- The Functional Score for the PT and OT component is calculated based on ten section GG items found to be highly predictive of PT and OT costs per day:
What are Classifiers under PDPM?
There are monetary reimbursements
There are 4 groups:
- Nursing Groups
- PT and OT groups
- SLP groups
- Non-therapy ancillary (NTA)
–The facility is going to place the patient in whichever group is going to reimburse the most for the amount of services that patient is utilizing
With the MDS under the Patient Driven Payment Model (PDPM), how do the Classifiers allow us to place the patient in whichever group is going to reimburse the most for the amount of service he/she is utilizing?
They do this under 3 different scheduled assessments:
- 5 Day assessment
- Interim Payment Assessment (IPA)
- PPS Discharge Assessment
-25% combined limit per discipline for concurrent and group treatment (KNOW THIS)
- Evaluation minutes are not counted on the MDS
With Medicare Part A, what is Episode of Care?
This is traditionally how Home Health Agencies are Reimbursed
- Medicare pays Home Health agencies (HHAs) a predetermined base payment
- Payment is adjusted for the health condition and care needs of the beneficiary
- Payments provided for each 30-day episode of care
- Case-mix adjustment base on patient needs as identifed by Outcome and Assessment Information Set (OASIS) instrument
What is Home Health Reimbursed under?
Consolidating Billing: Means HHA must bill for all home health services, including:
- Nursing
- Therapy services
- Routine and non-routine medical supplies
- Home health aide and medical social services
- Except durable medical equipment (DME) (MUST KNOW)
How is Medicare Part B reimbursed?
This is a Fee-for-Service (FFS)
Reimbursed by Healthcare Common Procedural Coding System (HCPCS), with this there are 2 things we have to pay attention to:
-8-minute rule
-National Correct Coding Initiative (CCI edits)
- This covers reimbursement in our tradional OP facilities andn in Long-Term care inside our SNF
