PTP Billing and Coding, Practice Settings Questions and Answers

PTP Billing and Coding, Practice Settings Questions and Answers Acute Hospital Medicare DRG (Diagnostic Related Group) or per diem (a prenegotiated, per-day, flat fee) Inpatient Rehab Hospital PPS (Prospective Payment System) or per diem payment methodology by private or managed care payers Skilled Nursing Facilities (SNFs) Medicare Prospective Payment System Home Care CMS (formerly HCFA), There is a 60-day national episode payment based on information obtained through a patient assessment tool known as OASIS. Outpatient Care Third Party (Medicare, medicaid, public school systems, worker's comp) First Party (pt. pays bill then submit own claim to insurance) OASIS A nurse or therapist from the HHA uses the Outcome and Assessment Information Set (OASIS) instrument to assess the patient's condition. (All HHAs have been using OASIS since July 19, 1999.) OASIS items describing the patient's condition, as well as the expected therapy needs (physical, speech-language pathology, or occupational) are used to determine the case-mix adjustment to the standard payment rate. HCPCS The Healthcare Common Procedure Coding System is a set of health care procedure codes based on the American Medical Association's Current Procedural Terminology (CPT). Coders today use HCPCS codes to represent medical procedures to Medicare, Medicaid, and several other third-party payers. The code set is divided into three levels. Level one is identical to CPT, though technically those codes, when used to bill Medicare or Medicaid, are HCPCS codes. IDEA Individuals with Disabilities Education Act Physical therapy (PT) is one of the related services under Part B of the Individuals with Disabilities Education Act (IDEA) and is provided to support the Individualized Education Program (IEP) for students ages 3-21, who have a disability that interferes with their educational performance Initial Eval. Low Complexity (CPT) Formerly 97001 97161 Initial Eval. Moderate Complexity (CPT) Formerly 97001 97162 Initial Eval. High Complexity (CPT) Formerly 97001 97163 Therapeutic Exercise (CPT) 97110 Hot/Cold Pack (CPT) 97010 Manual Therapy Techniques (CPT) 97140 Electrical Stim (CPT) 97014 Physical Therapy Reevaluation (CPT) 97164 Neuromuscular Re-education (CPT) 97112 Gait Training (CPT) 97116 G-Code Mobility G8978 - current status G8979 - projected goals G8980 - discharge status G-Code Changing & Maintaining Body Positions G8981, G8982, G8983 G Code Carrying, Moving & Handling Objects G8984, G8985, G8986 G Code Self Care G8987, G8988, G8989 Functional Limitation Severity Modifier 0% impaired, limited, or restricted CH At least 1% but less than 20% impaired, limited, or restricted CI At least 20% but less than 40% impaired, limited, or restricted CJ At least 40% but less than 60% impaired, limited, or restricted CK At least 60% but less than 80% impaired, limited, or restricted CL At least 80% but less than 100% impaired, limited, or restricted CM 100% impaired, limited, or restricted CN Functional Limitation Therapy Modifier Code for Physical Therapy GP What is FLR? Functional Limitation Reporting A mechanism for objectively demonstrating the connection between rehab therapy and patient progress. All outpatient therapy providers billing under Medicare Part B must complete FLR in order to receive reimbursement for their services. ICD-10 International Classification of Disease. Originated 1850s, 1st Edition 1893 International List of Causes of Death Coding must include all the components of the diagnoses that lead to the justification of the treatment ICD-10 Code for Sucked Into a Jet Engine V97.33 Acute Care Setting/Facility: A hospital Types of Patients: Short-term due to illness, surgery, accident or recovery from trauma Focus of Treatment: To discharge the patient ASAP, seen 1-2 times a day Length of Stay: 3-5 days Rehabilitation Hospital Setting/Facility: specialized facility in a separate building from an acute care hospital Types of Patients: All ages, most often admitted from an acute care hospital due to extensive neurological or musculoskeletal involvement Focus of Treatment: Provide intense therapy to improve self-care, 3 hrs/day LOS: 1-2 weeks, up to 6 weeks Outpatient Clinic/Private Practice Setting/Facility: Free standing facility or department in a hospital Types of Patients: Short term orthopedic issues, or had orthopedic surgery Focus of Treatment: Restoration or rehabilitation of neuromuscular and/or musculoskeletal problems LOS: shorter periods, several times a week for several weeks Skilled Nursing Facility (SNF) Setting/Facility: nursing home or building associated with acute care hospital Types of Patients: Older patients who require additional therapy that cannot be provided at home Focus of Treatment: restore patients' ability to function independently to care for themselves, 1.5 hrs/day LOS: couple of weeks to a couple of months Extended Care Facility Setting/Facility: nursing home, free standing Types of Patients: elderly patients who have extensive, long term care. They don't have rehab potential to qualify for rehab placement, skilled care or assisted living facilities Focus of Treatment: resolution of recent decline in function LOS: Remainder of their lifespan