PP: L.3 - Documentation/Billing/Coding

Question 1

Purpose of Documentation

Answer 1

-legal record
-informed consent (usually verbal)
-malpractice and risk management
-patient safety and quality of care
-communication
-clinical problem solving/EBP (outcomes)
-reimbursement
-confidentiality (HIPAA)
-Fraud and abuse

Question 2

Fraud vs. abuse

Answer 2

fraud: billing more than you should bill them (numbers)

abuse: not providing skilled/medically necessary treatment

Question 3

Minimum Documentation Items

Answer 3

-referrals
-initial eval and exam
-plan of care
-each treatment session by PT/PTA
-re-evals
-PT and PTA interactions
-discharge summary

Question 4

7 Essentials of documentation

Answer 4

1. Hx and physical exam
2. Skilled services
3. Pt Response
4. Plan for future care
5. Rationale and need for skilled services
6. Complexity
7. Pertinent Characteristics of pt

Question 5

medical necessity

Answer 5

-authority
-purpose
-scope
-evidence
-value

does it get them back to PLOF, independence, prevent effects of bed rest

Question 6

how to correct error in documentation

Answer 6

one line cross out
initials (SPT)
date

EMR: add addendum

Question 7

Documentation Guidelines

Answer 7

-every visit
-approved abbreviations
-document no shows
-done within 24hrs
-3rd person
-cross out with pen

Question 8

10 Payer Complaints (Denials)

Answer 8

-poor legibility
-incomplete documentation
-abbreviation issues
-no documentation for day of service
-not skilled
-not necessary
-does not demonstrate progress
-interventions not timed

Question 9

Red Flags of Documentation

Answer 9

-ranges of level of assistance min-max
-pt agitated or confused
->3 modalities after 4th visit
-poorly written goals
-testing too often/not reported
-no documentation of exercise or education

Question 10

Discharge Planning

Answer 10

-where to go
-what support is needed
-referrals
-follow up care

Consider:
-prior level of function
-current function and needs
-rehab ability
-safe for home or community

Question 11

Long Term Acute Care Discharge Rec

Answer 11

-high medical needs
-not safe to go home
-might need ventilator
-variable prognosis

Question 12

Skilled Nursing Facility Discharge Rec

Answer 12

-moderate medical needs
-mod to good prognosis
-<3 hours a day of rehab
-not safe to go home
-Mod-high multidisciplinary needs

Question 13

Inpatient Rehab Facility Discharge Rec

Answer 13

-high prior functional level
-mod to stable medical needs
-good prognosis
-3 hours of rehab a day
-High multidisciplinary needs

Question 14

Outpatient Discharge Rec

Answer 14

-high prior function
-stable medical needs
-Good prognosis
-good current function
-safe to go home
-single multidisciplinary needs

Question 15

Home Health Discharge Rec

Answer 15

-stable medical needs
-good functional prognosis
-limited current function <150 feet
-safe to go home
-nursing or PT required
-possibly homebound

Question 16

Nursing Home Discharge Rec

Answer 16

-low pre functional level
-stable medical needs
-limited prognosis
-limited skilled therapy needs

Question 17

ICD-10 Codes - diagnostic codes

Answer 17

-International classification of disease
-international code system for diagnoses
-7 digits
-used in all healthcare

Question 18

CPT Code - procedural codes

Answer 18

-Current Procedural Terminology
-services provided
-PT bill for time and skills (97000)
-can be timed or untimed
-indicate care given by PT

Question 19

your primary diagnosis should be a ____________.

Answer 19

PT diagnosis

Question 20

8 Minute Rule

Answer 20

falls under timed procedural code

1 Unit: 15min: 8-22min
2 Units: 30min: 23-37
3 Units: 45min: 38-52
4 Units: 60min: 53-67

Question 21

Timed Codes

Answer 21

-require direct patient care
-15 min increments

Ex:
-therex
-neuro re-ed
-gait training
-manual

Question 22

Untimed Codes

Answer 22

-does not require direct
-time does not matter

Ex:
-evals
-modalities
-group
-estim

Question 23

Modifiers 59/X

Answer 23

-can bill for certain pairs of codes during one visit

Question 24

Value-Based Payment System

Answer 24

-payment based on outcomes

Question 25

Prospective Payment System

Answer 25

-lump sum payment -predetermined -patient classified system -acute care

Question 26

Fee for Service

Answer 26

-payment based on dollar amount -Volume= greater reward -cash pay

Question 27

Medicare

Answer 27

-65+ or < with disability Part A: -Acute Care -Inpatient rehab -SNF -Home Health -Hospice Care Part B: -optional -must pay a premium -Outpatient, physician, DME, home health, SNF, observation in ER

Question 28

Medicare and Students

Answer 28

Part A: Hopital: general supervision SNF: line of sight Part B: -will not pay for services by students -students shouldn't document directly on chart

Question 29

Medicare and Co-Treatments

Answer 29

-cannot be more than 2 disciplines Part A: -each therapist can bill for whole time Part B: -each therapist cannot bill for entire

Question 30

Medicare and Group Therapy

Answer 30

Part A: -Acute: split time and charge, can do multiple pts -IRF and SNF: doing similar activities, 2-6 pts, 25% of total treatment Part B: -if more than one, must be group -must be skilled -must be similar level of function

Question 31

Medicaid

Answer 31

-public health for low income, children, pregnancy -can have aid and care

Question 32

Medicaid and Students

Answer 32

-may participate -must be supervised -considered auxiliary personnel

Question 33

Medicaid and Co-treatment

Answer 33

-must be prescribed -primary therapist must be there -only primary therapist can bill -must be medically needed

Question 34

Medicaid and Group Therapy

Answer 34

-must be prescribed -pts don't have to do the same activities -therapist mus be in the room at all times