Module 6 Payment Calculations in PT

What is the Resource-Based Relative Value Scale (RBRVS)?

Used for setting up payment rates, used by Medicare and many private payers, based on the total resources required to provide a service

True or False: Resource-Based Relative Value Scale (RBRVS) assigns procedures a relative value which is adjusted geographically

True

Under RBRVS, prices are typically determined on three separate factors:

Physician work (51%)

Practice expense (45%)

Malpractice expense (4%)

What are some components of physician work for the RBRVS price factor?

- Time to perform the service

- Technical skill and physical effort

- Mental effort and judgment

- Stress associated with concern of risk to the patient

- Portion of recourses in furnishing the service

What is a common criticism when it comes to RBRVS?

Leads to potential overuse of higher paying codes without consideration of outcomes

What is Multiple Procedure Payment Reduction (MPPR)?

Payer reduces reimbursement when a healthcare provider performs multiple procedures on the same patient on the same day

- The code with highest practice expense value will be reimbursed at 100% while the second and subsequent codes are reduced when multiple services are rendered on the same date of service

What is Diagnosis-Related Groups (DRGS)?

Payment for operating costs of acute care hospital inpatient stay under Medicare Part A

True or False: Under DRG, the hospital is paid a flat rate based on diagnosis groups, no matter how much it cost them to provide the care

True

Under a DRG, how can hospitals even make a profit?

If they can treat for less than the DRG pays, they make profit

What is the SNF Patient-Driven Payment Modeel (PDPM)?

Created to reduce administrative burden. Works by classifying patients into payment groups based on their own unique needs, rather than grouping them up into one single volume-driven group

Under the SNF Patient-Driven Payment Model (PDPM), the residents are classified among 5 components:

Physical Therapy

Occupational Therapy

Speech-Language Pathology

Nursing

Non-Therapy Ancillary

True or False: Under SNF PDPM, only 25% of a residents total therapy minutes can be group therapy

True

What is the main effect PDPM has?

By addressing each individual patients needs independently, PDPM improves payment accuracy and encourages a more patient-driven care model

True or False: Cash-based practices do not need to comply with practice act, state, and federal laws for documentation, supervision or direct access

False

True or False: If a cash-based practice is providing a Medicare-covered service to a Medicare beneficiary, you must bill Medicare

True

If you are setting up electrical stimulation, setting treatment parameters, and leaving the patient to relax or to work with another patient, would this count as Attended E-stim?

NO

If you are setting up electrical simulation in conjunction with active treatment such as cueing for a muscle contraction, would this count as Attended E-Stim?

YES

Difference between EX-59 Modifier and KX Modifier?

EX-59 is used to bill a service as a distinct, separate service than another you billed. Prevents “double dipping”

KX is used to attest that a service is medically necessary when the patent exceeds their therapy threshold