reimbursement of occupational therapy services – Flashcards
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licensee
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It is the responsibility of the -----------, not the facility for which you work, to know and apply accurate and correct coding.
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ICD-(-CM in Rehabilitation read?
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will be in effect this year 1st -report the medical diagnosis for which the patient is being treated 2nd report up to three other relevant codes that indicate why the patient is being seen in therapy (pull data to understand cost of care for specific diagnosis and course of treatment)
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Triple Aim (read)
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Mandates under ACA and released March 21, 2011
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Triple Aim
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Better care Healthy People/Healthy Communities Affordable Care
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Better Care:
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Improve the overall quality, by making health care more patient patient-centered, reliable, accessible and safe"
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Healthy People/Healthy Communities:
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"Improve the health of the US population by supporting proven interventions to address behavioral, social and environmental determinants of health in addition to delivering higher quality care"
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Affordable Care
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Reduce the cost of quality health care for Individuals, families, employers and government government Maryland is a waiver state
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All Payer system
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Maryland is teh only state with a -------- ------ -------- of hospital finance,
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Health Services Cost Review Commission (HSCRC).
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All payer system? (what is it) On January 10, 2014, CMS announced its approval of the proposal to Modernize Maryland's all-payer system.
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Why Document?
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Professional responsibility Professionalism - reflection on practice, communication of skilled practice Communication between professionals Legal record Will your record hold up in a court of law? Risk Management Protection against incidents Basis of payment Reimbursement Regulations Joint Commission Standards (Pain, Education)
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Top Errors in Documentation
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illegible missing documention minimal documention overuse of apprev no indication of medical necesity no indication of skilled care? Improper coding Goals not written as functional outcomes No specific plan
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Per Medicare: Unskilled =
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palliative services that are repetitive or reinforce previously learned skills or maintain function. Services not appropriate to setting or condition or by persons not meeting qualifications.
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Documentation Do's
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Write legibly Minimize abbreviations Write logically Demonstrate progression Demonstrate skill (this can be your clinical thought process) Demonstrate medical necessity Illustrate the treatment provided that accounts for codes billed
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Clinical Decision Making
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-Rehabilitation therapy is based on clinical decision making that promotes functional outcomes -Program design is based on functional goals -Documentation must reflect functional outcomes
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Medical Necessity and Skilled Care
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Requires skill of a qualified provider Safe and effective (proven?) Consistent with diagnosis Consistent with generally accepted (therapy specific) standards Does more than promote general health and wellness Expects functional improvement Remediation of safety risk demonstrates medical necessity
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Documentation of Medical Necessity
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Identifies the service or procedure provided Indicates why the service is medically necessary Medical necessity is clearly defined in the evaluation/plan of care (POC) and does not need to be consistently reaffirmed in daily notes Speak to medical necessity in every progress note/reassessment (q 10 visits or every 30 days)
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Red flags for Non Skilled Services
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Maintenance Repetitive, palliative procedures If repetive put why Procedures that reinforce already learned techniques
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CMS Plan of Care
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CMS requires that a medical provider (familiar with the patient) sign the therapy plan of care every 90 days -Ideally the POC is sent immediately for signature post evaluation
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POC (plan of care)
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must contain diagnosis, specific interventions, goals and time frames
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CMS Certification Period
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Therapist initial plan of care (POC) is good for up to 90 days and every recertification for up to 90 days If you write to certify only 4 weeks of care you must recertify the plan of care after 30 days
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Centers for Medicare and Medicaid Services on reevaluation
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Failure to progress new clinical findings associated or related to condition unanticipated change in patient status discharge reevaluation
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progress note
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CMS requires a ----------- --------every 10 visits or every certification period which ever comes first to include documentation of
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progress not includes:
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impairments (re-measure deficits noted at E or last RE progression toward goals (met or not) and reasons changes in plan of care and udate goals
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impairments changes progression
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progress notes
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Goal example
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Patient (actor) will complete upper body dressing (behavior) sitting at edge of bed (condition) with minimal assistance (degree) with one week (expected time)
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SMART goal writing
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Specific measurable attainable realistic timely
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Gatekeepers to care
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That would be the payer Members choose from a fixed provider list Treatment outside the provider list costs more May need to meet deductible May pay a higher co-pay Providers must gain entry to the "group"
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A,B, C, D E Goal Setting
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A = Actor (who) B = Behavior (what activity/function) C = Condition (what circumstances, essential elements of performance) D = Degree (quantitative &/or qualitative of performance; measurable) E = Expected time (how long)
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Levels of Care
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Acute Acute Rehab Chronic- LTAC ? SNF-skilled nursing facility (no time requirement) payed due to amount of services (rug levels) resource utilization group; highest rug level; lower rug; lower dollar Home-have to be homebound (higher cost of care than outpatient Outpatient-can to home visits
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Major Payers
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Medicare-biggest payer of OT services nationally Medicaid Children's Services Worker's Compensation Managed care Private Payers
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Medicare
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Is for individuals over 65 years of age, those with kidney failure, and some disabled persons (diagnoes like ALS-automaticly qualify and end stage kidney failure) Funded by the federal government There are fiscal intermediaries throughout the country-companies that moditor compliance with medical standards (applying regulations that medicaid is putting out)
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Medicare Coverage and Payment Policies
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-General coverage guidelines apply to all settings -criteria for payment varies from setting to setting -thei variation effects how theapist must provide, document and bill for services -more documentation for outpatient
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Diagnostic Related Groups
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how long patients should be seen general cot of care by diagnoses
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Medicare part A
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OTs are not a qualifying service to open home health cases acute care services are funded under DRGs SNF services are funded using RUGS
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SNF
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Skilled nursing facility
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Variations on the payment policies?
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Hospital Inpatient Prospective Payment Inpatient Rehab PPS rest of states (not maryland;evaluation done at resources needed to care for patient; based on functional independence measure Skilled Nursing Facility PPS (Part A) Home Health Agency PPS (OASIS) (evaluation tool similar to inpatient rehab; looks at quality at approriate cost Outpatient Rehab (Part B)
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MDS
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Minimum Data Set?
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RUG
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Resource Utilization Group
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Resident Assessment Instrument
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RAI
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Medicare BBA of 1997
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Began the wave to redefine rehab Changes initially affected SNFs A per diem for SNFs covers all costs under Part A Medicare (RAI/MDS evaluation tool, RUG's) SNF's went from fee for service model to prospective payment system
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Medicare says...
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Rehab services are covered at a duration and intensity that is appropriate to the severity of the impairment and the beneficiary's respone to treatment
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Covered procedures require
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Medicate reimbursement requirement: A physician's order - Physician certification and re-certification (Part B) - Services performed by a qualified occupational therapist or COTA with proper supervision - Medical Necessity
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Documentation must include:
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-Need -measurement -functional limitations -frequency and duration -functional goals -rehab potential
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Medicare Billing: 8 minute rule
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Applies to direct contact/time based codes (do not count service based codes) The total number of units that can be billed is constrained by the total treatment time. Billing time begins when the therapist is directly working with the patient to deliver treatment services. Treatment preparation minutes are billable if the patient is with you during set up.
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Medicare: Rules of Rounding
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≥ 8 through 22 minutes = 1 unit ≥ 23 through 37 minutes - 2 units ≥ 38 minutes through 52 minutes = 3 units ≥ 53 minutes through 67 minutes = 4 units
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Medicare and Group Therapy
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Simultaneously treating two or more patients who may or not may not be doing the same activity. If the therapist is dividing attention among the patients, providing only brief, intermittent contact, or giving the same instructions to two or more patients at the same time. Under Part B, it is not what the patient is doing that determines if it group therapy or 1:1 treatment- it is what the therapist is doing.
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CHRONIC LEVEL OF CARE
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Recognized by Medicare, MA, MAP This level is appropriate for those patients needing a slower pace of rehab, for a longer length of time 2 therapy sessions of any length Longer length of stay Severely deconditioned with ability to participate in therapy Lower level stroke patients - most stroke patients can benefit from a comprehensive CVA program Patients who were independent prior to hospitalization with primary need being rehab Only in maryland
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Medicare- Outpatient Impact (check in book)
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Occupational therapists can become independent providers Annual financial limitation for outpatient occupational therapy services per year is $1860 (initially $1500 in 1999) at non hospital based outpatient locations Why you need to know this ST and PT services combined is $1860 CCI edits and therapy modifiers (eff.1/1/2006)
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Medicare and Recovery Service Audit (RAC)
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There are 4 major contractors hired by Medicare to audit records and retrieve Medicare payments that they deemed were not justified. Millions of $$$ already paid to health care providers have been collected back thus far in NY, FL, and CA.
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Medicaid
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Founded by state government for low income individuals and families States are increasingly using HMOs to implement programs Limit number of evaluations allowed a year Usually preauthorization is required before an evaluation or any treatment can be performed
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Children Services
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Many states have alternate funding for children services (IDEA) May be based on income below poverty level Poverty levels vary widely by state School Systems
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Worker's Compensation
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Covers work related injuries Funding governed by individual states Case managers approve services and claims for patients You, as the therapist will have close contact with them Get preapprovals for all care and equipment Employers often eager for job restrictions and worksite modifications
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RAI
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Resident Assessment Instrument (RAI) classifies patients into resource utilization groups
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Resident assessment Instrument RAI
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consists of minimum data set MDS a core se of screening, clinical and functional status assessment elements
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Health insurance Portability and Accountability Act
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contains requirements relating to privacy and electronic health care transation and code sets
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Per diem
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an amount paid for a group of services provided in a week
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CPT Code
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Current procedural terminology
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Health care professionals advisory committee HCPAC
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AMA has this commitee that annually advised the CPT editorial panel
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Worker's Compensation
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Covers work related injuries Funding governed by individual states Case managers approve services and claims for patients You, as the therapist will have close contact with them Get preapprovals for all care and equipment Employers often eager for job restrictions and worksite modifications
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Private Payers
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Over 200 private insurance companies throughout the US Are your services covered under each policy? Does the therapist need to become a network provider- (e.g., BC/BS) Are number of visits limited-FYI number progress notes Are there co-payments? Are specific credentials required of occupational therapists? Can be secondary providers which cover co-pays
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Expectations (what is POC)
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Know when preauthorization is necessary Be ready to provide your therapy notes Use proper treatment codes with specific ICD-9 codes Patient must be a good rehab candidate That you understand documentation requirements How often are forms completed? Does the physician approve POC? What is correct terminology?
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Current Regulatory Compliance Wave
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Office of Inspector General (OIG) Uncovering fraud and recouping $$$
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Abuse
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Payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. Examples: - Late physician signatures - Services in excess of what patient requires - Waving co-payment without attempt to collect as with other payer sources.
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Fraud
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Knowingly and willfully executing , or attempting to execute, a scheme or artifice to defraud any healthcare benefit program or to obtain, by means of false or fraudulent pretenses, representation, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program.
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OT Manager Responsibilities
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Build and maintain a culture of compliance Prevent compliance problems Detect compliance problems Respond to compliance problems
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Coding
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CPT codes and HCPC codes Medicare Physician Fee Schedule (MPFS) and Relative Value Scale (RVU's) Time based vs. untimed units ICD-9 Diagnosis Codes G Codes
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Key Risk Areas
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Credentialing Documentation Billing and Coding Use of ancillary personnel
