billing, insurance, and documentation

entity who is paying the bill

third party payer

state funded program, for beneficiaries with low income

medicaid

health insurance for 65 and older

medicare

medicare part A =

inpatient

medicare part B =

outpatient care, in home, assisted living, long term care

medicare part C =

medicare replacement plans

medicare part D =

pharmacy

the percentage of cost the patient pays after having met the deductible

co-insurance

hospital payment model - diagnostic related group: assigns a ____ amount for a particular condition or treatment sequence

set amount

home health payment model - patient driven groupings model: groups pts into categories and determines _____

payment

Skilled nursing home payment model - patient-driven payment model: classifies pt based on ______, ______, therapy, and non-therapy ancillary components and determines payment from that

diagnosis, characteristics

outpatient therapy payment model: bills _____ codes

CPT

modifier for therapy services provided via Telehealth by qualified PTs

95

modifier for therapist verifying that they did not bill 2 codes for the same amount of time

59

modifier for therapist verifying that a pt still requires skilled care beyond a certain threshold

KX

modifier for a service not related to the hospice patients terminal condition

GW

modifier for PT performed the billing services (multidisciplinary practice)

GP

modifier indicates that a required advance beneficiary notice of non-coverage is on file for a service not considered medically necessary

GA

modifier to denote outpatient therapy services furnished in whole or in part by a PTA

CQ

low complexity PT eval CPT code =

97161

low complexity eval

• history with no _____ that impact POC

• exam using _____ tests and measures

• _____ clinical presentation

• clinical decision making that is _____

comorbidities/personal factors, 1-2, stable, low complexity

moderate complexity PT eval CPT code =

97162

moderate complexity eval

• history with _____ that impact POC

• exam using _____ tests and measures

• _____ clinical presentation

• clinical decision making that is _____

1-2 comorbidities/personal factors, 3 or more, evolving, moderate complexity

high complexity PT eval CPT code =

97163

high complexity eval

• history with _____ that impact POC

• exam using _____ tests and measures

• _____ clinical presentation

• clinical decision making that is ____

3 or more personal factors/comorbidities, 4 or more, unstable, high complexity

if do not meet all criteria for mod or high complexity eval, it is categorized as the level ____ it

below

if 3 or more comorbidies/personal factors but condition is stable = ____ complexity eval

low

CPT code for re-evalutation

97164

when to use a re-eval code

• pt develops new but ____ problem

• pt has _____ for the same problem during the time covered by your POC

• pt has change in _____

• pt not responding to initial POC and _____ to plan is indicated

related, surgery, status, notable change

CPT code for therapeutic activities

97530

CPT code for neuromuscualr re-ed

97112

CPT code for self-care/ADL training

97535

CPT code for therapeutic exercise

97110

CPT code for gait training

97116

CPT code for manual therapy

97140

CPT code for group therapy

97150

american medical association counts minutes by _____

CPT codes billed

Medicare (CMS) counts minutes by _____

total time

1 billable unit = ____-___ min

8-22

2 billable units = ____-___ min

23-37

3 billable units = ____-___ min

38-52

4 billable units = ____-___ min

53-67

co-treatment and concurrent

• ____ with part A

• ____ with part B

yes, no

billing concurrent part A

• treating ___ residents who ____ performing same or similar activities

• both in line of sight of treating _____

2, are not, PT or PTA

billing group for part A

• _____ people

• same or similar _____

• supervised by ____ or _____ who is not supervising any other individual

• the ____ time can be counted

2-6, activities, PT, PTA, full

billing group for part B

• ____ people

• ____ or ____ activities

• therapist provides _____ attention with intermittent ____ contact or ____ instructions to ____ pts at the same time

• bill 1 unit of ____, untimed code

2 or more, same, different, divided, personal, same, 2 or more, 97150

billing students part A

• students ____ have to be under direct supervision of PT

do not

billing students part B

• supervising therapist must be present for _____, directing the ____, making ____ judgement, and Is responsible for ____ and ____

• when student treating _____ patient, supervising PT may not be treating another pt

all treatment, service, skilled, assessment, treatment, medicare