Medicare A
True or False- Medicare is a federal and state assistance program
FALSE!
What percent does Med B cover and what percent must you pay?
They pay 80%, you pay 20%
What is the purpose of the Rule of 8's?
To receive payment for time-based CPT codes
What is the purpose of PDPM?
Medicare payment rule for SNF's
What is TRICARE?
Coverage for active duty personnel, retired military personnel, and other groups associated with the military
Medicare Part A is considered the "what" part of Medicare.
Hospital insurance
Med B is considered the "what" part of Medicare?
Supplementary medical insurance
True or false: You must treat 15 minutes to bill 1 unit of service
False- you need 8 minutes
What does PDPM stand for?
Patient-Driven Payment Model
What does CPT stand for?
Current Procedural Terminology
What is the typical length of stay for a patient with Med A in the acute care setting?
3-5 days
True or False- Med B covers the cost of some supplies and equipment
What are the beneficiaries involved with Medicaid? (name 2)
People with low income, a disability, mental illness, school-based services, older adults, parents/caregivers, expecting mothers
What was the payment model before PDPM came into effect?
RUG-IV; Resource Utilization Group-version 4
What does HMO stand for and what does it allow/do?
Health Maintenance Organization- policyholders select a PCP and receive treatment/specialists within network provider.
What are the 3 eligibility requirements for Med A?
65 or older, disability, end-stage renal disease
What setting is covered under Med B and is for clients who required 24 hour care
Long Term Care
You saw Susan for 24 minutes for an ADL and 19 minutes for TherEx. How many units should you bill
43 minutes= 3 units
Fill in the blank: With PDPM, we look at the ______ of OT, not the _______ of treatment time.
*Need both responses
Value, volume
Who is constantly working to educate the government and insurance companies about the nature of OT to ensure proper reimbursement?
AOTA
Medicare A covers patients in a SNF under what condition?
What is the typical length of stay and population in an outpatient setting?
(Need both right)
Varies depending on client goal or reason for referral
Diagnoses vary, lives in the community but not home bound
Under what Act allows children to get reimbursement for services through Medicaid?
IDEA- Individuals with Disabilities Education Act
Name 4 of the 6 areas PDPM must be documented under
*Need 4 to get credit
ADL's, IADLS, Behavioral and psychosocial factors, fall prevention, vision, and functional cognition
State 3 reasons OT services can be denied
Authorization was not obtained, incomplete/missing billing code info, therapy not covered under plan, plan coverage limits, insufficient medical necessity, out of network provider