Unit 2- WK5- Payment Across the Health Care Continuum

Question 1

How are visits to the emergency department billed to Medicare Part B ?

Answer 1

Fee for service, CPT codes, physician fee schedule

Question 2

How are ICU, CCU, PCU and Acute Care financed ?

Answer 2

Inpatient Prospective payment system ( IPPS)

Question 3

In acute care a patient’s primary diagnosis determines assignment to a ____________.

Answer 3

MS-DRG

Question 4

Medicare pays for _______ days of hospital care per “spell of illness”, plus an additional lifetime reserve of ______ days.

Answer 4

90, 60

Question 5

Define a single spell of illness

Answer 5

From hospital admittance to discharge from facility and gone 60 days without readmittance.

Question 6

What are the 2023 Hosptial deductible, coinsurance for 61st-90th day, and daily coinsurance for lifetime reserve days, for Medicare Part A beneficiaries

Answer 6

1600
400
800

Question 7

Explain the Hospital Value Based Purchasing Program

Answer 7

incentive payments for providing quality care, following best clinical practices, enhancing patient experience

Question 8

Explain the hospital readmissions reduction program:

Answer 8

charges hospital fees for excessive readmission. 2% reduction in payout

Question 9

Explain the Hospital Acquired Condition Reduction program

Answer 9

charges hospitals for injuries or complications occurring in the hospital 1%/

Question 10

How can PTs have an impact on Acute Care Hospital Quality of Care ?

Answer 10

Reducing readmissions
discharge recs
enhancement of care transitions

minimize patient harm events
improve patient satisfaction; clear expectations

Question 11

How is an LTACH paid and how are patient classified into payment groups ?

Answer 11

long term hospital prospective payment system; one time lump sum based on MS-LTC-DRGs

Question 12

A Medicare beneficiary sspent 10 days in an Acute Care Hospital before being transferred to an LTACH. What is the maximum number of days that this beneficiary will be FULLY covered by Medicare at the LTACH ?

Answer 12

80 days

Question 13

How is an inpatient rehab facility paid and how are patients classified into payment groups ?

Answer 13

IRF prospective payment system

IRF-PAI to classify patients

Question 14

A Medicare beneficiary spent 5 days in an Acute Care Hospital before being transferred to an Inpatient Rehab Facility. What is the maximum number of days that this beneficiary will be fully covered by Medicare at the LTACH ?

Answer 14

85 days

Question 15

What happens on day 61-90 for Medicare beneficiaries staying in an inpatient rehab facility ?

Answer 15

They must pay a coinsurance

Question 16

What is the Medicare 60% compliance rule for IRF?

Answer 16

60% of facilities population must meet one or more specific pathological conditions

Question 17

What is the IRF-PAI used for?

Answer 17

payment determination and quality measure at discharge

Question 18

What happens if an LTACH or IRF fails to submit their quality report annually ?

Answer 18

2% point reduction in annual payment.

Question 19

What system is used to pay a SNF ?

Answer 19

SNF-PPS

Question 20

What is the minimum data set used for in a SNF? (MDS)

Answer 20

What determines classification thus reimbursement. Only for Medicare Part A.

Question 21

The payment classification system in SNFs is called:

Answer 21

patient driven payment model

Question 22

How is Medicare’s payment to the facility adjusted starting on day 21 of a SNF stay ?

Answer 22

2% decrease each week after day 20

Question 23

How many nights must a patient have had a hospital stay to qualify for admittance to a SNF

Answer 23

3 nights

Question 24

Medicare Part A will cover up to _______ days per spell of illness, as long as a patient _________

Answer 24

100 days, shows progress

Question 25

Medicare Part A will fully cover days ________

Answer 25

1-20

Question 26

Starting on day 21, the beneficiary must pay the ____________

Answer 26

daily copay until day 100 $200

Question 27

Define this mode of treatment: Individual

Answer 27

1 patient at a time

Question 28

Define this mode of treatment: Concurrent

Answer 28

2 patients being seen by one therapist: doing different things

Question 29

Define this mode of treatment: Group

Answer 29

2-6 patietns, performing same or similar task

Question 30

Define this mode of treatment: Co-Treatment

Answer 30

2 clinicians with one patient at the same time. Performing different treatments.

Question 31

What percentage of a patient's total PT treatment time can be used for concurrent and group treatment ?

Answer 31

25%

Question 32

If a CI and a student see two different patients at the same time, what mode of treatment can be billed ?

Answer 32

The student is an extension of the therapist they must be individual or concurrent, since there is only "one" therapist

Question 33

Differentiate Medicare Part A and B in terms of Home Health

Answer 33

A: patient from hospital or SNF for 3 days must receive home health services within 14 days cover first 100 days per spell of illness Part B covers after 100 days B: no hospital stay required no deductible, co-insurance, or copayment DME requires 20% coinsurance unlimited coverage of home health visits if meets criteria

Question 34

A home health plan of care is based on a 60 certification period. However, each episode of care last for _________. What is used to determine how much a home Health Agency is paid for each episode of care ?

Answer 34

30 days The case mix adjustment flow chart which assigns a classification and rate.

Question 35

Do medicare beneficiaries have cost sharing for home health care services ?

Answer 35

No, except for DME 20%

Question 36

What is the max number of 30 day episodes of care in the home health setting ?

Answer 36

no limits

Question 37

What services are covered in the 30 day episode of care rate in the home health setting ?

Answer 37

nursing, therapy, non routine medical supplies, home health care aide, medical social services

Question 38

What is the OASIS and what is it used for ?

Answer 38

A patient specific , standardized assessment used to plan care, determine reimbursement and measure quality done every 30 days to give new HHRG which gives a new rate

Question 39

Who pays for DME in home health care ?

Answer 39

20% coinsurance

Question 40

Who pays for palliative care ? Is maintenance therapy covered for patients receiving palliative care ?

Answer 40

home health medicare Part A, Yes

Question 41

What is the difference between routine and continuous care under the Medicare Hospice Benefit Plan ?

Answer 41

Routine: beneficiary has chosen hospice at their place of residence Continuous: care provided between 8-24 hours/day during periods of crisis: keep person comfortable

Question 42

Where are Medicare Part B services provided ?

Answer 42

Outpatient PT clinics Hospital Based Outpatient SNF Home Health

Question 43

How are outpatient PT services billed under Medicare Part B? What system is used ?

Answer 43

Paid via retrospective payment system billed using CPT codes and ICD-10 codes uses physician fee schedule

Question 44

What is the time period for certification of the plan of care by the physician or nonphysician practitioner for outpatient PT ? How often does the plan of care need to be recertified ?

Answer 44

30 days, 90 days

Question 45

Discuss the following in Medicare Part B payment for therapy services: KX modifier

Answer 45

after a patient has spent $2150 on PT and SLP; the modifier must be added to the bill continued therapy is medically necessary

Question 46

Discuss the following in Medicare Part B payment for therapy services: Targeted Medical Review

Answer 46

- Above $3000 CMS review of insurance claim Must submit documentation to medicare

Question 47

Discuss the following in Medicare Part B payment for therapy services: Payment fot PTA services

Answer 47

85% of service cost

Question 48

What is the cost sharing for Medicare B beneficiaries in outpatient PT?

Answer 48

Monthly premium: $164.90 Deductible: $226 Coinsurance: 20%

Question 49

What is MIPS ?

Answer 49

Merit based incentive payment prioritizes quality of care must report if PT qualifies

Question 50

What are Alternative payment models ?

Answer 50

a way to reward clinicians for quality care incentives1

Question 51

Define medical necessity and skilled care. Why is it important ?

Answer 51

Service provided for purpose of preventing, minimizing, or eliminating impairments, activity limitations, and or participation restrictions medicare Part B pays for it

Question 52

What is the ABN form ?

Answer 52

notifies beneficiary that medicare may not cover services and charges may come out of pocket if providing services that PT knows medicare won't cover

Question 53

What is a NEMB ?

Answer 53

states that the patient will be financially liable for services.

Question 54

Can a clinic bill for services provided to Medicare Part B beneficiary that were provided by a student ? What are the requirements ?

Answer 54

Yes, when the CI is responsible in the session

Question 55

Explain Medicare Part B rules/regulations for co-treatment.

Answer 55

2 therapists cannot bill separately must split treatment time

Question 56

Discus Medicare Part B rules and regulations for direct access to PT services in private practice and outpatient hospital settings.

Answer 56

private: patient must have a physician, POC must be certified by physician within 30 days, POC good for 90 days, must re-certify POC if goal changes, 90 days after initial visit, POC has expired outpatient hospital: responsible for patient's care, licensed, within scope of practice, or authorized by hospital, doesn't have to be certified by a physician

Question 57

Discuss payment by private insurance for PT services provided via direct access.

Answer 57

Policy determined by insurer, may need referral, verify coverage

Question 58

What are some different types of cash based practices ?

Answer 58

all cash based hybrid mobile/concierge

Question 59

List the different places a Cash Based Practice can reside:

Answer 59

Mobile In your home within a gym or rented space Within other healthcare facility a stand alone clinic

Question 60

How is payment received in a cash based practice ?

Answer 60

cash, check, credit, debit set your own fees usually purchasing sessions or programs

Question 61

What is a superbill ?

Answer 61

A bill listing ICD-10 codes, CPT codes, and # of units forr code bill includes amount charged for visit all documentation

Question 62

Can Medicare beneficiaries pay cash for PT services covered by Medicare ?

Answer 62

No, must charge medicare

Question 63

Describe the relationships that a cash PT clinic can have with medicare

Answer 63

no relationship Participating provider: enroll in medicare, agree to their payment schedules Non-participating: medicare pays part, patient pays the rest

Question 64

What is a limiting charge ?

Answer 64

25$/unit (4), medicare pays 95$ patient pays 14.25. Medicare can pay 95% of bill then PT can bill 15% more.

Question 65

What is the mandatory claims submission rule ?

Answer 65

a beneficiary must be billed through medicare.

Question 66

How are school based services funded ?

Answer 66

Medicaid, local resources ( set by state) third party funding should not be used

Question 67

How are early intervention services funded ?

Answer 67

state, medicaid, private insurances normally free to parents unless there is an exception in that state.

Question 68

How are early intervention services funded ?

Answer 68

state, medicaid, private insurances normally free to parents unless there is an exception in that state.