- A physical therapist working in outpatient Medicare Part B treats a patient for 45 minutes of therapeutic exercise and 15 minutes of manual therapy.
Which billing rule applies?
A. AMA unit rule only
B. Medicare 8-minute rule
C. Capitation rule
D. Per diem rule
Answer: B
Medicare Part B requires use of the Medicare 8-minute rule for timed codes.
- Define fee-for-service reimbursement.
A. Payment per episode of care
B. Payment per patient per year
C. Payment based on price per unit of service
D. Flat rate per visit regardless of units
Answer: C
Fee-for-service reimburses based on price per unit of service (CPT code × units).
- A clinic receives $3,000 per patient with low back pain regardless of number of visits.
This model is:
A. Per diem
B. Fee schedule
C. Per case
D. Capitation
Answer: C
Per case reimbursement pays a fixed amount per episode of care.
- Under capitation, payment is:
A. Based on CPT units
B. Based on patient diagnosis only
C. Set amount per enrolled person per period of time
D. Paid per visit
Answer: C
Capitation pays a set amount per enrolled person per period of time whether care is used or not.
- A PT in an acute care hospital is reimbursed under which Medicare system?
A. Part B Fee Schedule
B. IPPS using DRGs
C. PDPM
D. PDGM
Answer: B
Acute care facilities are reimbursed under IPPS using Diagnosis Related Groups (DRGs).
- Define deductible.
A. Fixed visit charge
B. Percentage after deductible
C. Amount patient pays before insurance starts paying
D. Monthly premium
Answer: C
A deductible is the amount paid before insurance begins coverage.
- A SNF replaced RUG with which current payment model?
A. PDGM
B. DRG
C. PDPM
D. CMG
Answer: C
Skilled Nursing Facilities use PDPM (Patient-Driven Payment Model).
- PDPM PT classification is based on:
A. Minutes of therapy only
B. Diagnosis only
C. Clinical category and functional score (Section GG)
D. Age and sex only
Answer: C
PDPM PT component is based on clinical category and functional score (Section GG).
- In home health under PDGM, reimbursement is driven primarily by:
A. Volume of therapy visits
B. Patient characteristics
C. CPT codes
D. Minutes billed
Answer: B
PDGM reimburses based on patient characteristics, not volume of therapy.
- Define coinsurance.
A. Fixed dollar amount
B. Percentage of cost paid after deductible
C. Monthly payment
D. Annual cap
Answer: B
Coinsurance is a percentage of cost paid after deductible is met.
- A PT bills 97110 for 22 minutes under Medicare.
How many units may be billed?
A. 1 unit
B. 2 units
C. 3 units
D. None
Answer: A
Under the 8-minute rule, 8–22 minutes = 1 unit.
- AMA billing allows:
A. Strict 8-minute rounding only
B. 1 unit for any portion up to 15 minutes
C. No timed codes
D. Only Medicare patients
Answer: B
AMA guidelines allow 1 unit for 0–15 minutes.
- In IRF PPS, classification is based on:
A. CPT units
B. DRGs
C. IRF PAI data and case mix groups
D. Capitation
Answer: C
IRF PPS uses IRF PAI and classifies into case mix groups.
- Which setting uses PDGM?
A. Acute care hospital
B. Skilled nursing facility
C. Home health agency
D. Outpatient clinic
Answer: C
Home Health Agencies use PDGM.
- Define premium.
A. Percentage of cost
B. Monthly amount paid for insurance coverage
C. Deductible amount
D. Out-of-pocket max
Answer: B
Premium is the monthly payment for health insurance coverage.
- A patient in outpatient Medicare has met deductible. Medicare pays what percentage of PT services?
A. 100%
B. 90%
C. 80%
D. 50%
Answer: C
Medicare Part B pays 80%; patient responsible for 20% coinsurance.
- DRG payment weight is based on:
A. CPT time units
B. Average resources used for that DRG
C. Patient income
D. Premium amount
Answer: B
DRG payment weight reflects average resources used for patients in that DRG.
- Which CPT codes are considered service-based?
A. 97110
B. 97140
C. 97161–97163
D. 97116
Answer: C
Evaluation codes (97161–97163) are service-based.
- A PT performs reevaluation but makes no change to plan of care.
Can 97164 be billed?
A. Yes always
B. No, must include change to POC
C. Only in acute care
D. Only for Medicare
Answer: B
Reevaluation requires a documented change to the plan of care.
- Define allowed amount.
A. Hospital charge master price
B. Maximum amount insurance will cover for service
C. Patient copay
D. Premium total
Answer: B
Allowed amount is the maximum amount an insurance plan will cover.
- Under per diem reimbursement, payment is:
A. Per CPT code
B. Flat rate per visit regardless of units
C. Per diagnosis
D. Per patient per year
Answer: B
Per diem pays a flat rate per visit regardless of units performed.
- SNF PDPM includes which five components?
A. PT, OT, SLP, Nursing, NTA
B. DRG, CMG, CPT, ICD, VPD
C. Part A, Part B, HMO, PPO, POS
D. Rehab, Acute, IRF, HHA, SNF
Answer: A
PDPM includes PT, OT, SLP, Nursing, and Non-Therapy Ancillary components.
- A PT treating under capitation should be most mindful of:
A. Maximizing units
B. Visit frequency relative to fixed payment
C. CPT complexity only
D. Coinsurance rates
Answer: B
Under capitation, payment is fixed, so resource utilization must be managed carefully.
- In outpatient billing, charge master prices represent:
A. Actual reimbursement
B. Negotiated insurance rate
C. Organization-set price for service
D. Medicare allowable
Answer: C
Charge master is the organization-set price, not necessarily reimbursement.
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