billing and documentation

Question 1

ICD-10 vs CPT

Answer 1

ICD-10: diagnosis code
-OA, hip pain
CPT: procedure
-ther-ex
-eval
-txt

Question 2

ICD - 10 coding how many characters, in what settings, examples

Answer 2

used in all US healthcare settings

3-7 characters

ex: Z86.31

Question 3

your primary diagnosis should be a

Answer 3

PT diagnosis (what you can treat)

Question 4

what are eval codes

Answer 4

elements are body structures and functions, activity limitations and or participation restrictions

Question 5

97161

Answer 5

Low complexity; 20 min face-to- face; no personal factors or comorbidities; stable; addressing 1-2 elements

Question 6

97162

Answer 6

Moderate complexity; 30 min face-to-face; 1-2 personal factors or comorbidities; evolving; addressing 3 or more elements

Question 7

97163:

Answer 7

High complexity; 45 min face-to-face; 3 or more personal factors and/or comorbidities; unstable; addressing 4 or more elements

Question 8

eval codes are currently reimbursed how?

Answer 8

the same! Medicare is collecting data. We need to document and justify medical necessity of these different codes and different payment structure.

Question 9

What is the 8 minute rule?

Answer 9

To help you figure out how much to charge when you don’t do exactly 15 minutes for timed codes

Question 10

who does 8 minute codes?

Answer 10

medicare only!

note: but most payers use same code

Question 11

1 unit

Answer 11

15 minutes

8-22 mins

Question 12

2 units

Answer 12

30 mins

23-37

Question 13

3 units

Answer 13

45 mins

38-52 mins

Question 14

4 units

Answer 14

60 mins
53-67 mins

Question 15

timed codes vs untimed codes

Answer 15

timed:

require direct, one on one pt care
-15 min txt increments
-8 min rule

ex: ther-ex (97710) neuro re-ed, gait, MT

un-timed:

dont require direct one on one
does not matter on how long procedure

ex: hot/cold, mech traction, e-stim, GROUP(97150)

Question 16

how to determine units of biling

Answer 16

1. Count the total number of minutes for timed, skilled treatments

Example: 15 minutes of gait training, 25 minutes of therapeutic exercise

2. Look on 8-minute rule chart to determine how many units can be billed

15 + 25 = 40 minutes = 3 units

3. Decide what code(s) to bill and how
   many of each
   1 unit gait training, 1 unit therapeutic exercise
4. Remainder rule
   Example: 35 minutes of exercise, 20 minutes of balance exercises = 55 minutes = 4 billable units
   2 units of ther-ex (accounts for 30 minutes); 1 unit of neuromuscular reeducation (accounts for 15 minutes)

30 + 15 = 45 minutes 10 billable minutes left

Choose either 1 more unit of ther-ex or 1 more unit of neuromuscular re-education (not both)

5. Count the total number of untimed treatments
6. Bill one unit per untimed treatment
7. Documentation MUST justify units billed and codes used

Question 17

documentation must justify what

Answer 17

units billed and codes used

Question 18

use of modifiers 59 or X

Answer 18

modifiers 59: To identify procedures/services that are not normally reported together but are appropriate under the circumstances.

X

Designed to be more specific than 59, and are preferred when they apply.

Breakdown:

XE = Separate Encounter (procedure done at a different time)

XS = Separate Structure (procedure performed on a different organ/structure)

XP = Separate Practitioner (different provider performed the service)

XU = Unusual Non-Overlapping Service (rare situation where the service does not overlap usual components of the main procedure)

Question 19

Who is the payor?

Answer 19

Medicare → Federal insurance for people 65+ or disabled.

Medicaid → State + federal program for people with low income/limited resources.

Commercial Insurance (e.g., BlueCross BlueShield, Aetna) → Private insurance, usually through employer or bought individually.

Self-Pay → Patient pays out of pocket, no insurance coverage.

Veterans Affairs (VA) → Federal program providing care for military veterans through VA facilities.

TRICARE → Federal insurance for active duty military, retirees, and their families.

Workers’ Compensation → Insurance that covers job-related injuries or illnesses, paid by employer’s plan.

Question 20

Payment systems

Answer 20

value based
prospective
fee for service (FFS)

Question 21

value based

Answer 21

payment based on outcomes
AKA APM (alternative payment model)

aim to
-reduce cost
-improve patient edu
-improve quality of care
-improve health

Payment tied to outcomes instead of just services.

Question 22

prospective

Answer 22

-lump sum payments
-predetermined
-patient classified system
-operating and capital expenses

Predetermined lump sum based on patient classification

Question 23

fee for services

Answer 23

payment based on dollar amt to each service

volume=greater reward

Payment per each service provided.

Question 24

ICD-10 which is diagnostic

Answer 24

G= diagnostic
cerebral palsy, spastic

Z= hip athro

Question 25

ICD-10 sign/symptoms

Answer 25

R gait,diff walking M pain in R hip

Question 26

medicare

Answer 26

Started in 1965 by President Lyndon Johnson * Largest single payer of health care services in the US * Organized and managed by the federal government * Qualifications to receive Medicare * 65 or older * Younger than 65 with a disability * End stage renal disease * Do not have to pay premium unless insured or spouse never paid Medicare taxes through employment * Annual Fee Schedule * “Medicare for all” is currently be proposed as a plan by many as a solution for the healthcare crisis in the US

Question 27

Medicare part A

Answer 27

-covers inpatient/hospital Acute Care * Inpatient Prospective Payment System * (IPPS) *Diagnosis Related Group (DRG) Inpatient rehabilitation facility (IRF) *IPPS Case Mix Index (CMI) Skilled Nursing Facility (SNF) * Patient Drive Payment Model (PDPM) Minimum Data Set (MDS) Functional Scoring Case Mix Index Qualifying hospital stay Up to 100 days of care Home Health (HH) - some Patient must be homebound Outcome and Assessment Information Set (OASIS) Lump sum for episode of care Hospice Care

Question 28

Medicare part B

Answer 28

covers OP/medical services Supplementary optional Beneficiary pays a premium If eligible for Part A, will be eligible for Part B Covers: Outpatient therapy Physician visits DME Home Health - mostly covered here SNF - meds, transportation, MD visits

Question 29

Medicare and Students

Answer 29

Part A: Hospital/SNF Hospitals: No problem with reimbursement or documentation; general supervision SNF: No problem with reimbursement or documentation; Must have line-of-sight supervision. Part B: OP Does not reimburse if services are provided by unlicensed personnel (students). Students can still treat but not bill independently. APTA recommends student does not document directly.

Question 30

Medicare and Value based payments

Answer 30

Functional Limitation Reporting (FLR) -No longer required Quality Payment Program (QPP) 1.Merit based Incentive Payment System (MIPS) Providers scored on quality, cost, improvement activities, and interoperability. Payment tied to scores. Advanced APM Alternative model; providers get 5% bonus and are exempt from MIPS reporting.

Question 31

Medicare and Co treatments part A vs part B

Answer 31

General Rule: Must document medical necessity. note: cannot be more than 2 disciplines treating at once Part A (Inpatient/SNF): Both therapists can bill for the full time. Part B (Outpatient): Therapists must split billing, can’t both bill for full session. A 72 year old male with a traumatic brain injury receives therapy services at an outpatient clinic. The patient has some residual

Question 32

medicare and group therapy part A vs part B

Answer 32

Part A acute: -txt more than one pt at a time -concurrent -splits time and charge IFR/SNF: -doing similar activities -therapist is in constant attendance -2-6 pts , restricted to 25% of total txt time Part B (Outpatient): Must be billed as group therapy (97150) if more than one pt seen at same time Must be skilled, untimed, constant attendance, similar function level.

Question 33

Medicaid

Answer 33

* Public health insurance program for low-income adults, children, pregnant women, elderly adults, and people with disabilities * Administered by states according to federal requirements * Children’s Health Insurance Program (CHIP) * Eligibility and coverage varies geographically * Can be dual eligibility for Medicare and Medicaid * Covers skilled therapy services in a variety of settings

Question 34

Medicaid and students

Answer 34

Considered auxiliary personnel May participate in PT services Must be supervised according to state law/licensure requirements May not bill for services provided solely by auxiliary personnel

Question 35

medicaid and co treatments

Answer 35

Has to be prescribed by physician A primary therapist MUST be designated Only primary therapist can bill Must be medically necessary

Question 36

medicaid and group therapy

Answer 36

Must be prescribed by physician * All patients don’t have to do same activities * If therapist’s 1:1 contact is brief If therapist is giving same instructions to two or more patients Therapist must be in the same room at ALL times (constant attendance) * Billed as group therapy