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201 exam 1
Medicare, Insurance and Billing
| Question | Answer |
|---|---|
| what brought about the implementation of telehealth? | COVID |
| does Medicare cover telehealth? | yes, most major insurances do |
| how were PT offices supposed to change their caseload due to COVID? | were only supposed to see emergent cases |
| what did AMA implement in response to COVID? | new Current Procedural Terminology (CPT) codes in response to COVID-19. |
| what new CPT code was added in 2021? | 99072, added in 2021 to cover costs of Personal Protection Equipment and clinical staff time to perform safety protocols |
| what other new CPT codes were added in response to COVID? | 86413, used in laboratory testing to measure SARS-CoV-2 antibodies Other CPT codes for individual vaccines: J&J, Pfizer, Moderna, etc. |
| federally or state funded insurances | Medicare, Medicaid, Tricare, state funded worker’s compensation. |
| managed care organization insurances | Health Maintenance Organizations or Preferred Provider Organizations. Contracted with insurances at reduced rates to provide care. Can be a closed market in which providers cannot apply. |
| commercial insurance | Companies that sell medical type of insurance are for-profit corporations, and offer their insurance services through group insurance plans as well as individual or personal plans. |
| insurance types | federally or state funded insurances, managed care organization insurances, commercial insurances |
| Medicare | funded health insurance for people over the age of 65 and for those people with disabilities who qualify for medical care. |
| who sets the standard for all other insurances to follow? | CMS (Centers for Medicare and Medicaid) guidelines are more restrictive |
| ____ does have control as to how Medicare is funded and ultimately how providers will be paid for services. | Congress |
| An effect of the Healthcare Reform, Affordable Care Act (ACA) was the onset of ______& Utilization Management systems | Third Party Administrators |
| utilization management | process of evaluating medical necessity, appropriateness, and efficiency of health care services. |
| goal of utilization management | maintain the quality and efficiency of health care delivery by caring for patients at appropriate level of care, coordinating health care benefits, ensuring the least costly but most effective treatment benefit, and the presence of medical necessity. |
| how does utilization management achieve their goal | by utilizing nationally accepted clinical practice guidelines |
| ____ is a system for reviewing the medical necessity, appropriateness and reasonableness of services proposed or provided to a patient or group of patients | Utilization review (UR) review is conducted on a prospective, concurrent and or retrospective basis to reduce the incidence of unnecessary and or inappropriate provision of services. |
| min visits that private insurances can provide in WA without utilization review | 6 |
| when did min of 6 visits rule go info effect | jan 2019 |
| MIPS | CMS regulated system to replace the physician fee schedule. |
| 3 types of MIPS participation | Mandatory, Opt-in, Voluntary |
| mandatory MIPS 3 criteria | Receive more than $90,000 in Medicare payments Provide care for more than 200 Medicare Part B beneficiaries Bill more than 200 professional services |
| opt in MIPS | participates same as mandatory |
| voluntary MIPS | submits reports, but not subject to payment adjustment |
| criteria for MIPS in based on performance in what 4 categories | Quality Measures Cost Clinical Practice Improvement Activities Promoting Interoperability |
| 4 categories that PT will be required to report under | quality measures: health care processes, outcomes, pt care experiences improvement measures: Gauges participation in activities that improve clinical practice |
| MIPs payment system will score the ____ or ____ | group, individual |
| how does MIPS scoring work | Composite Score compared to performance threshold If score above threshold, will receive positive payment adjustments If score below threshold, will receive negative payment adjustments |
| If MIPS score ____ threshold, will receive positive payment adjustments | above |
| If MIPS score___threshold, will receive negative payment adjustments | below |
| what are outcome measures for PT used for? | Identification of efficacy of intervention. Quantifiable patient progress for referral sources. Guide for physical therapist in regards to continuing education. Data for referral sources and payers on effectiveness of treatment. |
| samples of outcome measures used in PT | Oswestry Disability Index DASH (Disabilities of the Arm, Shoulder, and Hand) Outcome Measure TUG (Timed up and Go) 6 minute walk test |
| electronic medical records (EMR) | computerized medical record documentation via a software that integrates treatment and billing. Procedures are performed for time and dependent upon insurance how each procedure can be billed. |
| diagnosis coding (ICD 10) | Each patient is given a treatment diagnosis and this links the patient to the treatment for insurance billing purposes |
| posting charges (CPT) | The physical therapist completes a charge sheet for each patient treatment in conjunction with documentation. |
| electronic billing | Most insurance companies receive physical therapy charges electronically with the software sending the information. This is done on a daily basis; however, a cycle of patients alphabetically is done each week. |
| posting payments 18 | |
| secondary billing and re-billing 18 | |
| what does explanation of benefits (EOB) include? | procedure physical therapy billed .amount billed for each procedure performed. amount the insurance company will allow for that procedure. patient’s responsibility for each procedure. total amount paid by insurance. Reason for denial or non-payment |
| ICD-10, the Tenth Revision, was accepted in___ by the WHO. ICD-10 mandatory date for implementation was October 2015 | 1990 |
| Diagnosis coding under ICD-10 uses ___ digits instead of 3 to 5 digits used with ICD-9, but the format of the code sets is similar. | 3 to 7 |
| Coding is more ___ and substantially different than ICD-9 and will assist with transition to episodic payment model in the future. | specific |
| what does IDC 10 allow for greater detail of? | Laterality (right or left) Traumatic versus non-traumatic injury Single condition or multiple conditions Cause of traumatic injury Initial encounter versus subsequent encounter versus sequela |
| 7th character is primarily used for___ and certain consequences of ___ ____. | injuries, external causes |
| Rare for physical therapists to utilize 7th character, unless___ __state where patient is evaluated by physical therapist prior to any other medical intervention. | direct access |
| 7th character “A” will need to be changed after initial evaluation to “D” for ___ ___ | subsequent treatment |
| CPT | current procedural terminology |
| what are CPT codes | terms and identifying codes for reporting medical services and procedures. The purpose is to provide a uniform language that will accurately describe services and provide an effective means for reliable communication nationwide among the profession.¹ |
| Evaluation code descriptors stratify evaluations by complexity—___ (97161),___ (97162), ___ (97163). | low, moderate, and high *codes take into consideration co-morbidities, personal factors, standardized tests and measures, and clinical presentation. |
| Codes are ___ however, guidelines for time performed for each code is listed: 97161 – guideline__ minutes 97162 – guideline ___minutes 97163 – guideline ___minutes | non-timed 20 30 40 |
| modalities | Any physical agent applied to produce therapeutic changes to biologic tissue; includes, but not limited to, thermal, acoustic, light, mechanical, or electric energy. ¹ |
| supervised modality | application of a modality that does not require direct (one-on-one) patient contact by the provider |
| unattended modality | electrical stimulation. ¹ Constant Attendance US |
| therapeutic procedures | A manner of effecting change through the application of clinical skills and/or services that attempt to improve function. Therapist required to have direct (one-on-one) patient contact¹. |
| CPT code for therapeutic procedures | 97110: therapeutic exercises to develop strength and endurance, range of motion and flexibility, each 15 minutes. ¹ |
| CPT code for NM re-ed | 97112: Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception for sitting and/or standing activities, each 15 minutes. ¹ |
| CPT code for manual therapy | 97140Mobilization/manipulation, manual lymphatic drainage, manual traction, each 15 minutes. ¹ |
| therapeutic activities CPT code | 97350: use of dynamic activities to improve functional performance, each 15 minutes. 1 |
| self care/home management CPT code | 97535: Activities of daily living and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment, each 15 minutes. |
| Codes may be bundled with other codes if they are performed for __ or less | 8 minutes |
| Codes are billed in number of units, generally ____timeframe. A maximum of ___ units can be used per day. | 15 minute, 4 |
| 8 minute rule is governed by___ | CMS (Medicare) |
| Current Procedural Terminology indicates that one on one direct treatment procedures are ___minutes in length | 15 |
| One on one direct treatment procedure needs to be performed a minimum of ___ minutes in order to bill for procedure. | 8 |
| In order to bill for 2 units , a minimum of ___ minutes needs to be performed | 23 |
| 3 units billed requires a minimum of ___ minutes to be performed | 38 |
| 4 units billed requires a minimum of ___ minutes to be performed. | 53 |
| Prior to 8 Minute Rule, most insurances including Medicare allowed the____ billing. | Substantial Portion Methodology(SPM) |
| Some insurances continue to allow SPM that indicates that each unique procedure done for___minutes or more can be billed for a ___minute unit. | 8, 15 |
| With the SPM, one procedure performed for ___ minutes or greater can be billed twice. | 25 |
| SPM billing can potentially have 4 units billed for a ___minute treatment. | 45 |
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