The Health Record
This type of health record is shared across different healthcare organizations involved in a client's care, unlike an EMR which stays within a single practice.
What is an Electronic Health Record (EHR)?
In a SOAP note, client quotes, subjective complaints, or personal goals belong under this specific section.
What is the "S" (Subjective) section?
This educational law outlines student privacy rights regarding education records (including school OT documentation) and requires parent consent to release records.
What is FERPA (Family Educational Rights and Privacy Act)?
Maintained by the WHO, this coding system is used internationally to classify health conditions, diseases, and injuries.
What is ICD-10 (or ICD-11)?
This Medicare part covers inpatient hospital stays, inpatient rehabilitation, limited SNF care, hospice, and home health services.
What is Medicare Part A?
Under HIPAA's Privacy Rule, this standard mandates that providers request or disclose only the minimum amount of PHI necessary to perform the intended purpose.
What is the Minimum Necessary Standard?
Currently in its 4th edition, this foundational document embodies the heart and focus of occupational therapy practice and professional terminology.
What is the OTPF-4 (Occupational Therapy Practice Framework: Domain and Process)?
Part C of this federal law mandates early intervention services for children under age 3 in their natural environment.
What is IDEA (Individuals with Disabilities Education Act)?
Under Medicare Part B's 15-minute rule, how many units can be billed for a timed session lasting 30 minutes?
What is 2 units? (Range for 2 units is 23–37 minutes)
Intentionally and knowingly making false representations of facts to obtain payment from Medicare is defined as what?
What is Fraud?
Formed to oversee health records, this professional association offers useful resources regarding health information management.
What is AHIMA (American Health Information Management Association)?
This type of documentation entry is completed every single time an OT intervention or client contact occurs.
What is a Contact Note (or Treatment Note)?
Passed in 2010, this reform law aimed to increase health insurance access, lower costs, and establish new consumer protections.
What is the Patient Protection and Affordable Care Act (ACA)?
This modifier must be appended to CPT codes when outpatient OT services are provided in whole or part (>10%) by an OTA.
What is the CO modifier?
This written notice must be given to a Medicare Part B beneficiary before delivering services that Medicare is expected to deny for lack of medical necessity.
What is an ABN (Advance Beneficiary Notice of Noncoverage)?
In this system of health record organization, all discipline records are filed together in strict chronological order.
What is an Integrated Medical Record?
The SOAP note format was originally adapted from the Problem-Oriented Medical Record (POMR) advocated in the 1960s by this physician.
Who is Dr. Lawrence Weed?
This 2014 law requires post-acute care facilities (SNFs, IRFs, Home Health) to report standardized client assessment data and quality measures.
What is the IMPACT Act (Improving Medicare Post-Acute Care Transformation Act)?
This modifier must be attached to outpatient claims exceeding the annual Medicare monetary threshold to confirm medical necessity.
What is the KX modifier?
This Medicare Part A payment model implemented in SNFs shifts reimbursement away from therapy minute volume to patient clinical characteristics.
What is PDPM (Patient-Driven Payment Model)?
According to documentation mechanics, if you make an error on a paper record, you must never use white-out or erase. What type of ink must be used for paper entries
What is black waterproof and nonerasable ink?
True or False: An OTA may contribute to progress notes and evaluations under supervision, but overall responsibility for modified plans of care remains with the OT.
What is True?
This 2015 legislation established the Quality Payment Program (QPP), shifting Medicare rewards from volume to value through MIPS and APMs.
What is MACRA (Medicare Access and CHIP Reauthorization Act)?
An OT comprehensive evaluation is considered an untimed procedure. How many units should be billed on a claim regardless of time spent?
What is 1 unit?
Name 2 of the 4 CMS criteria required for equipment to qualify as Durable Medical Equipment (DME).
What are any two of: 1) Can withstand repeated use, 2) Primarily used to serve a medical purpose, 3) Generally not useful in the absence of illness/injury, or 4) Appropriate for home use?