Billing Codes (exam 2 - finished editing)

what is the 8-minute rounding rule?

method to bill for OP therapy for Medicare Part B

8 - 22 minutes of therapy

1 unit of CPT charged

23-37 minutes

2 units

38-52 minutes

3 units

53-67 minutes

4 units

68-82 minutes

5 units

83 minutes

6 units

OT Evaluation Codes

- 97165 OT Evaluation: Low Complexity

- 97166 OT Evaluation: Moderate Complexity

- 97167 OT Evaluation: High Complexity

97165 OT Evaluation: Low Complexity Definition

30 Minutes face to face with the patient and/or family

example of service billed under 97165 OT Evaluation: Low Complexity

ROM, grip strength

97166 OT Evaluation: Moderate Complexity Definition

45 Minutes face to face with the patient and/or family

example of service billed under 97166 OT Evaluation: Moderate Complexity

tendon repair initial evaluation moderate severity

97167 OT Evaluation: High Complexity Definition

60 Minutes face to face with the patient and/or family

example of service billed under 97167 OT Evaluation: High Complexity

- neurocognitive disorder with ADLs, mobility, cognition, safety (+ ROM, tone, balance)

- Peds with long standard assessments

- brain injuries with behavior complications

are OT evaluation codes times?

no

97168 OT Re-Evaluation

30 minutes face-to-face with the patient and/or family

criteria for 97168 OT Re-Evaluation code:

- revised POC

- updated occupational profile (pt info)

- done within the same period of the POC without readmission

Cognitive Interventions codes

- 97129 Direct 1:1 First 15 minutes

- 97130 Add on Code (each 15 mins after initial 15 mins)

For a 45-min cognitive intervention session, how many units are billed?

1 unit of 97129 Direct + 2 units of 97130 Add on Code

are cognitive intervention codes timed?

yes

caregiver training codes: client present

- 97535 ADL Training

- 97110 Therapeutic Exercises

- 97129/97130 Cognitive

caregiver training codes without the client present are used during:

caregiver training in strategies and techniques to facilitate patients functional performance in the home or community

caregiver training codes: client NOT present

- 97550 Initial 30 Minutes Caregiver Training

- 97551 Each additional 15 minutes Caregiver Training

- 97552 Group Untimed Caregiver Training

what is the criteria required to bill for caregiver training?

- established clinical need

- training is provided to informal, UNPAID caregivers

- training focuses on caregiver skills that enhance patient, NOT caregiver, outcomes

Medicare Fraud

Intentionally, knowingly, willfully making false statements

what is an example of medicare fraud?

- documenting things that did not happen

- billing for services that were not rendered

- soliciting/offering kickbacks (engaging in financial rewards or gifts)

what is the Stark Law and Anti kickback Statue?

prevents engaging in financial rewards or gifts

Medicare Abuse

Providing services that were not medically necessary or extended, and result in unnecessary costs (intentional or unintentional)

Upcoding

billing for a more expensive service or procedure than was actually provided to receive higher reimbursement.

unbundling

separating services that should be billed together into multiple codes to increase total reimbursement.

if upcoding or unbundling is done intentionally then what is that considered?

fraud

1 multiple choice option

if upcoding or unbundling is done UNintentionally then what is that considered?

abuse

1 multiple choice option

An OT documents in a patient’s record that the patient received 45 minutes of upper-extremity therapeutic exercises, but the patient was actually seen for only 20 minutes. This documentation is used to bill Medicare for a full session.

What type of violation does this scenario represent?

A) Abuse – services were unnecessary

B) Fraud – intentionally billing for services not rendered

C) Abuse – overutilization

D) Compliance – proper billing

B) Fraud - intentionally billing for services not rendered

3 multiple choice options

An OT treats a patient with mild difficulty dressing but bills the session as “severe functional limitation requiring intensive therapeutic intervention” to receive higher reimbursement.

What is this an example of?

A) providing extended services

B) proper documentation

C) unbundling abuse

D) upcoding abuse

D) upcoding abuse

3 multiple choice options

An OT continues providing daily therapy sessions to a patient with a fully recovered wrist, even though no further improvement is expected, and bills Medicare for each session.

This scenario is best described as:

A) Abuse – medically unnecessary services leading to unwarranted costs

B) Fraud – intentional false documentation

C) Abuse – soliciting kickbacks

D) Fraud – unbundling services

A) Abuse - medically unnecessary services leading to unwarranted costs

3 multiple choice options

An OT performs a standardized hand therapy session that includes range-of-motion exercises, strengthening, and functional task practice. Instead of billing Medicare using the single comprehensive code for the session, the therapist intentionally bills each component separately to increase reimbursement.

This practice is an example of:

A) providing unnecessary services

B) Abuse – overutilization

C) Fraud – unbundling

D) Compliance – correct billing

C) Fraud - unbundling

3 multiple choice options