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CRIP, Section 5-1
Certified Revenue Integrity Professional Recurring OP and Clinical Services
| Question | Answer |
|---|---|
| How should outpatient repetitive services such as OP rehab be billed? | These should bill once per month or at the conclusion of treatment. They also should not be on the same bill as other, non-repetitive services. |
| All OP rehab must have a written plan of care. Who can write this and when? | Plan of care must be established before treatment begins. Can be written by a physician, a PT, an OT or a speech-language pathologist. |
| What must a plan of care contain? | Patient's diagnoses long-term trtmt goals Type of rehab therapy svcs, specified by interventions, procedures and modalities amt of therapy trmt sessions/day # of sessions per wk # of wks or sessions signature & id of person writing the plan |
| Initial Certification or plan of care for OP rehab: | Satisfies the requirements for the duration of the plan of care or 90 calendar days from the date of initial trmt. |
| When is certification of the initial plan of care considered timely? | When the physician's certification is documented, by signature or verbal order, and dated w/i 30 days following teh first day of trmt, including eval. If verbal orders are obtained, must be followed up w/i 14 days with signature and date. |
| When is a recertification necessary? | If continued therapy is needed after the initial 90 days: recertification is needed when the plan of care is modified or every 90 days after initiation of trmt under the plan of care. |
| How is time required to be noted for OP rehab services? | The amt of time for each specific modality provided is not required in the trmt note, but the total number of timed minutes must be documented. |
| List the Revenue Codes and Modifiers for rehab therapies: | 042X (physical therapy rev code) GP modifier 043X (occupational therapy( GO modifier 044X (speech/language pathology) modifier GN |
| What are the 3 required Occurrence Codes for therapy services? | Onset of Symptoms Date plan of care established or last reviewed Date treatment started |
| What is the Occurrence Code for Onset of Symptoms for each therapy? | For PT, OT and Speech-Language Pathology services, the occurrence code is 11. |
| What is the Occurrence Code for the Date the Plan of Care established or last reviewed? | For PT: 29 For OT: 17 For speech/language pathologist: 30 |
| What is the Occurrence Code for the Date Treatment started? | For PT: 35 For OT: 44 For Speech-Language therapy: 45 |
| What does CR stand for and what does CR 11532 update? | Change request the annual per-beneficiary thresholds and related policy for the calendar year. (now called KX modifier thresholds.) |
| What are the KX modifier thresholds for CY 2024? | Prior to 2024: $2,080 for PT and SLP and $2,080 for OT. As of CY 2024: $2,330 for PT and SLP services combined, and $2,330 for OT services When therapies have gone over these limits, claims will deny w/o the KX modifier. |
| What does the KX modifier indicate? | The requirements specified in the medical policy have been met. - to indicate that medical necessity has been met. |
| List the guidelines for number of units billed for therapy services: | billed in 15 min increments. Follow the 7 minute rule: If 7 min or less, don't bill. 8-22 min = 1 unit. 23-37 min = 2 units, etc. If mult svcs are provided for 7 min or less w/ a total of 8 or more min, bill1 unit of the svc performed for most min. |
| What are the different types of wound care? | Surgical Debridement Selective Debridement Non-Selective Debridement Active Wound Care Mngmt Wound Vacuum Therapy Ultrasound Multi Layer Compression or Unna Boots Transcutaneous Oxygen Tension Measurments Hyperbaric Oxygen Therapy |
| Wound care: explain Surgical Debridement: | Includes photos of the work, assessment & cleaning of the wound anethesia, collection of specimens, measurement of the wound, topical ointments, dressing, topic hemostatic agents and discharge instructions |
| Wound care: explain Selective Debridement: | Describes type of trmt, like high pressure water jet (w/ or w/o suction) & debridement using scissors, forceps or scalpel, type of open wound, wound assess, whirlpool and instr for cont care/session. Describes the surface area for 1st 20 squ. cm or less. |
| Wound care: explain Non-Selective Debridement: | Used to remove tissue that is devitalized and to promote the healing of the wound. Used when both healthy tissue and necrotic tissue are removed. Includes wet to moist dressing, wet to dry dressing, abrasions, occlusive dressing and enzymatic chemicals. |
| Wound care: explain Active Wound Care Management: | Used to remove necrotic or devitalized tissue and to promote healing of the wound. |
| Wound care: explain Wound Vacuum Therapy: | Includes topical applications to wound, wound assessment & instr related to ongoing care. Used when phys prescribes a negative pressure wound therapy w/ vacuum assisted drainage to promote healing of non-healing chronic wound such as decubitus ulcer. |
| Wound care: explain Ultrasound (low frequency, no-contact, and non-thermal): | Used to promote wound healing by using acoustic sound energy at the wound bed and the tissue surrounding the site. |
| Wound care: explain Multi Layer Compressions or Unna Boots: | Compression dressing thtat promotes wound healing by providing sustained compression on the wound |
| Wound care: explain Transcutaneous Oxygen Tension Measurements: | The measurement of oxygen that is used to identify if wounds need extra oxygen in order to heal; can be used to help determine if Hyperbaric Oxygen (HBO) therapy may benefit patient. |
| Wound care: explain Hyperbaric Oxygen Therapy: | Body is exposed to O2 under atmospheric pressure, providing add'l oxygen into bloodstream and body fluids; allows O2 to reach tissue/bone not accessible to red blood cells; promotes formation of capillary vessels, can enhance white blood cell functions. |
| In documentation of Wound Care, documents should show: | That the practitioner was involved in wound care trmt. Status of the wounds and if they are healing Svcs performed by hospital staff must have documented physician orders |
| What is required to show documentation of wound healing or improvement? | - Inflammation - Changes in amt of wound drainage - Decrease in amt of swelling - Decrease in amt of pain - Size of wound dimensions - Increase in tissue granulation |
| CMS Classifies wound Debridement as surgical services. Therefore, med recs should include: | Name & acct # for pt Complication (if any) Name & surg proc performed date & time of debr Name of practitioner performing proc pre & post op diagnoses descr of findings, removal of tissue & techniques used size, depth length or width of wound |
| When can E&M Services be billed for Wound Care? | The physician treats a new pt for an initial visit the pt was seen for a f/u visit & no svcs were provided the pt was seen for a f/u visit, a new sign or symptom was identified and the physician made a medical decision on how to treat the new condition |
| When E&M Services NOT be billed for Wound Care? | If a medical or surgical procedure is performed, HBO services were provided or a diagnostic test is performed. |
| What are the CMS recommendations for documentation of Hyperbaric Oxygen Therapy? | SEE PAGE 5-8 AND 5-9 |
| Describe Observation Services | Furnished in hospital setting to evaluate an OP condition to determine the need for admission. Includes assessment, reassessment & short-term trmt. Also includes use of a bed and monitoring by nursing staff. Cvrd when there is a written physician order. |
| How long should/can observation services last? How are the hours determined? | Per CMS, should not exceed 48 hours but MC will cover up to 72 hours if medically necessary. Should be rounded to the nearest hour. 0-30 min is 0 units. 31-60 min is 1 unit. |
| What is MOON and when is it required to be given and to whom? | MC OP Observation Notice any MC or MC Advantage beneficiaries to inform them if they are in observation care as OP and not an IP. Required if 24 hrs of observation care are given and required by hour 36. |
| What are the 2 types of Observation Services and how are they billed? | Direct Admit Patient to Observation - Billed w/ HCPCS G0379 Hospital Observation Per Hour - Billed w/ HCPCS G0378 Both w/ rev code of 762 Not subject to ABN criteria when pd under OPPS due to bundling. Only exception is Critical access hospitals. |
| Who can determine if a patient should be admitted or treated as OP and what is the criteria? | Only a physician can determine that the pt needs to be admitted, based on: pt's current medical needs pt's medical history hospital's admission policy appropriateness of trtmt severity of symptoms / signs of the pt. |
| When are Observation Services appropriate for Post-Op (following a surgical or invasive procedure)? | -pt exhibits a signfiicant adverse reaction to proc or anes - pt's cond requ monitor/trtmt beyond what's normal in post-op period. *phys order must be based on pt's current cond at time of order. *Case Mgmt Team must verify that dox supports |
| Per CMS, what are the requirements (all of which must be met) for a hospital to receive an APC payment for an extended assessment and management assessment? | Observation time documented in record time must match physician orders ends when all clinical or medical interventions are completed # of units reported w/ HCPCS code G0378 (hospital observation services, per hour) equal or exceed 8 hours. |
| The claim for observation services must include one of the following in addition to the reported observation services: | A type A or B emergency dept visit, includes CPT codes 99284 or 99285 or HCPCS codes G0383 or G0384 A clinic visit, CPT code 99205 or 99215 A critical care charge, CPT 99291 Direct referral for observation care, HCPCS code G0379 on same DOS |
| What bill type must be used for visits, critical care and observation services in order to be considered for a composite APC pmt? | TOB 13X |
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Amy17349
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