Healthcare Systems Exam #2

What is a modifier for coding and billing designed to do?

Is used to identify procedures and/or services that are not normally reported together but are appropriate under the circumstances

Example of Modifier 59

When billing manual therapy and therapeutic activities each for 15 minutes for the same session or date, this concept is only appropriate if the PT performs the two procedures in distinctly different 5 min intervals

*means you cannot report the 2 codes together if you performed them during the same 15 minute time interval

One-on-one code

Requires one on one contact during the application

- visual, verbal and/or manual contact during get time of service

- based on 15 minutes service

Example of one-on-one code

manual therapy

Supervision code

The application of a modality that does NOT require direct (one on one) patient contact

- can be done UNSUPERVISED

- can put person on Tx and go and do something else

Example of supervision code

mechanical traction

electrical stimulation

hot or cold pack

Timed codes

allow for variable billing in 15 minute increments

- use these codes for performing one-on-one services

Example of timed codes

- therapeutic exercise

- therapeutic activities

- manual therapy

- neuromuscular re-education

- gait training

- ultrasound

What is the difference between one-on-one codes and supervision codes?

one-on-one codes require contact with patient for a period of time vs. supervision codes does not require direct contact and is typically an application of a modality

What are the Medicare 8-minute rule bins?

- Direct, face-to-face time with patient considered

- amount of time of session determines treatment units

- first procedure needs to be at minimum 8 minutes

- 15 minutes increments

1 unit for Medicare 8 Minute Rule

8-22 minutes

2 units for Medicare 8 Minute Rule

23-37 minutes

3 units for Medicare 8 Minute Rule

38-52 minutes

4 units for Medicare 8 Minute Rule

53-67 minutes

5 units for Medicare 8 Minute Rule

68-82 minutes

6 units for Medicare 8 Minute Rule

83-98 minutes

Who oversees CPT codes

The AMA

Who oversees ICD-10 and ICD-11 codes?

The WHO

World Health Organization (WHO)

- specialized agency of the UN that was created to improve international public health

- responsible for creating new "diagnoses" codes

Treatment codes

are used by medical professionals, hospitals, clinics and insurance offices to identify medial, rehabilitative, surgical etc. services

- this allows for standardized payment language and reimbursement from health insurance companies

2 types of treatment codes

- Healthcare commons procedure coding system (HCPCS)

- Common procedural terminology codes (CPT)

What does 'at will' employment mean?

means that an employer can fire an employee for any reason (if it's not illegal) or not reason, with no warning and without having to establish just cause

How many U.S. workers are considered at-will employees?

about 74%

Which state doesn't have "at will" employment

Montana doesn't have at-will employment

Which groups are protected from being fired without cause?

- public sector employment

- unionized jobs

- contract basis employment

- a breach of good faith by the employer

- an employer discriminating

- an employee refusing to do something illegal

- an employer retaliating against union members

- tenured faculty members who do nothing wrong

What are categories at risk for discrimination?

for illegal reasons such as race, color, national origin, gender, religion, age, disability, pregnancy, or genetic information

even at-will employees

What is a standardized deduction?

- include the predetermined contract payments with 3rd party payers, fee schedules, and percentages of cost based reimbursement through the government

- different for every clinic

- usually determined by the accounting office or CFO

- can run from 20-45% of total billable revenue depending on the facility type

What does a standardized deduction mean for revenue of companies?

you can charge all you want, but will only get a percentage of that

- recalculated with insurance companies

- set by medicare

How do you calculate a no-show/cancellation rate?

divide the number of missed appointments (no-shows or late cancellations) by the total number of scheduled appointments over a specific period, then multiply by 100 to get the percentage

What does a no-show/cancellation rate typically mean?

Is a good identifier in determining if the patient care provided was worth experiencing from the patient

Why is a no-show/cancellation rate important?

It reflects the quality and value of your care, would you go back if the experience was worthless? patients will not return for care or will cancel a lot if they do not perceive the value of that care

Strategic planning definition

set of decisions that merge and define the future direction of the organization

- your 3-5 year path

-

Vision statement definition

tells people:

- where we want to go

- what we want to become

- what we want to accomplish

- why it is important

mission statement definition

expresses the organization's:

- it is an operationalization of the vision

- how we plan to accomplish the vision

*need to understand values and goals first

You should never accomplish your mission Why?

should always be a step beyond what you aspire to be, always improving

values definition

Acquired beliefs and commitments, derived from culture, about what is good, right, and important to do

- should reflect who you are

What's the best process for strategic planning?

nominal group technique

What is Nominal Group Technique

A structured method for group brainstorming that encourages contributions from all members.

- anchor all strategies to your values and goal (who you really are)

- use mission and vision statements correctly

- focus mostly on what's happening EXTERNALLY, fix what is going on internally

- IMPLEMENT IT*

What are fringe benefits?

ASK about this!

What is internal factor analysis ?

Analysis of where it fits within the rehabilitation market place when developing a strategic and action plan

- what talent you have in your organization

- ~20% of total analysis

What is external factor analysis?

a rehabilitation clinic may identify the following areas when developing a strategic and action plan

- governmental policy changes

- negative changes in reimbursement

- more local competition

- greater supply of standardized and quality driven labor

- 80% of analytical effort

- look outside at what is going on

What is the difference between internal and external factor analysis?

internal factor analysis is what in occurring in your organization vs. external factor analysis is about what is occurring outside of your organization (policy changes, competition, etc.)

Contingency Plan

is a plan devised for an exceptional risk which is impractical or impossible to avoid

- alternative course of action it the plan fails

What is a trigger in contingency planning?

Things that happen that define the moment one should consider the contingency plan

ex) financial situation, losing money

ex) Hurricane Katrina hut, took several days to put a plan into action

CLARIFY THIS

What are motivation theories?

Who espoused the motivation theories?

Productivity measures

- Man hour per stat

- Retention

- Conversions

- Cost per total episode

How do you calculate man hours per stat?

(Total FTE's x Total hours of clinical operation in a given time) / Total visits

Interpretation of man hour per stat

lower the stat the better

1-1.5 is good

Big clinic with more clinicians make it easier to drive down Man hour per stat

How to calculate labor cost per visit

Total labor cost divided by total visits

- generally run about $50 per visit

- some organizations will try to reduce this ratio since labor is the highest expense encountered

How to calculate expense per stat

total expenses divided by total visits

- a good stat should be lower than the revenue per stat

- salary will make up the largest percentage of expense per stat

How to calculate Retention

ratio of your length of stay vs. 12 (appropriate number of visits)

- higher or lower may mean you are keeping your patients too long and getting rid of them too quick

How to calculate Conversions

ratio of (# of referrals divided by evaluations) x 100

- higher percentage is better

- 85% = good #

- every referral, you want to schedule an evaluation

How to calculate Cost per total episode

total expenses divided by the evaluations

- provide with the cost per case scenario

What are the traits of a leader?

develops individuals in order to complete predetermined goals and projects

- develops relationships with their employees by building communication, evoking images of success, and by eliciting loyalty

What are traits of a manager?

directs resources to complete predetermined goals or projects

- considered a failure if they are not able to complete the project or goals with efficiency or when the cost becomes too high

What is an informal leader?

Someone who does not have the official authority to direct a group but these are the individuals who are willing to step up and take action

What is strategic planning based on?

Based on the premise that changes are somewhat predictable and can be extrapolated using historical growth

How much does it generally cost to replace an employee?

It costs a company 6-9 months of an employee's salary to replace him or her

= cost you a lot of money

How many personal factors and/or comorbidities are needed to bull for eval code 97161??

- no comorbidities/personal factors

- Low complexity type

- stable or uncomplicated

How many personal factors are needed for eval code 97162?

- 1-2 personal factors/comorbidities

- moderate complexity type

- evolving or changing characteristics

How many personal factors are needed for eval code 97163?

- 3 or more personal factors or comorbidities

- high complexity type

- unstable and unpredictable characteristics

What are the key components of an effective strategic plan?

- short

- value-based

- involves both administration and workers (informal leaders)

- not "slogan oriented"

- use mission and value statements correctly

- focus on EXTERNAL more

Steps of Strategic Planning

1) Determining one's values and goals

2) Mission and Vision

3) Careful Evaluation of Business Standing

5 Step process to evaluating your strategy

- Analysis

- Creativity

- Judgement

- Framing planning and Contingency planning

- Action Plan

Acute hospital payment system

Prospective (per episode)

SNF payment system type

Prospective (per day)

IRF payment system type

Prospect (per episode)

HHC payment system type

Prospective (per episode)

What is the difference in reimbursement for acute and post-acute care settings?

All but SNF are reimbursed under a prospective per episode compared to prospective per day

How does the acute care hospital's incentive to discharge patients quickly affect profit margins?

primary economic incentive: decrease length of stay

- paid per episode = shorter stay = fewer resources, more money, can have even more patients and make even more money

secondly incentive: decrease readmissions

What facility and patient factors increase vs. decrease Medicare reimbursement for Acute hospitals?

- geographic location (higher median wage in area = higher payments)

- condition/case mix (more complex conditions = higher payment)

- providing medical education (physicians residents; providing education = higher payment)

- disproportionate share and uncompensated care payments (more documented cases of uncompensated care = higher payment)

What facility and patient factors increase vs. decrease Medicare reimbursement for SNF?

- case mix for OT and PT (primary reason for SNF care and functional status (more impaired = higher payment)

What facility and patient factors increase vs. decrease Medicare reimbursement for IRF?

- geographic labor costs

- condition/case mix (CMG; more complex conditions = higher payment)

- functional status (more impaired = higher payment)

- cognitive status (more impaired = higher payment)

- age (older = higher payment)

- comorbidities (more of them = higher payment

- length of stay

- providing medical education (= higher payment)

- disproportionate share and uncompensated care payments (more documented cases of uncompensated care = higher payment)

What facility and patient factors increase vs. decrease Medicare reimbursement for HCC?

- timing or episode relative to prior episodes

- referral from an inpatient setting (yes/no)

- 12 clinical categories (more impaired mobility, cognition = higher payment)

- 3 comorbidity categories (more conditions = higher payment)

- geographic factors

How does per-episode cost of SNF affect post-acute care setting?

- prospective payment is per DAY; not per episode (free until day 20, after that SNF starts getting paid)

- payment is no longer ties to therapy service intensity

- EXPENSIVE

implications:

- ask to keep patients up until that 20 day mark to make more money (reach goals by day 6, depending on facility will create more goals?)

How does per-episode cost of IRF affect post-acute care setting?

- get best patients in to earn more

- 60% rule: >60% of patients must have 1 of 13 diagnoses as primary or secondary

- admissions to IRF must be "medically necessary"

- "case misconduct group" assignment directly affects readmission > CMG assignment infused comorbidities, functional status, etc

- patients must revive 15 hours of therapy per 7-day period

- Expensive!

Implications:

- reimbursement isn't tied to what we really do

- payment id higher the sicker the patient

- we evaluate comorbidities/functional status, worse functional status graded = get paid more

How does per-episode cost of HHC affect post-acute care setting?

- prospective payment is per 30-DAY EPISODE

- payment is no longer ties to therapy service intensity

- less expensive than facilities

Implications:

- 60% of payment in 1st 30 days, try to get to day 31

- incentivized to space out appointments rather than front load

Which post-acute care setting requires that admitted patients begin making daily copayments on day 21?

SNF

- incentive to keep them as long as possible to earn more $