1. Question of the Day
What did you learn with your experience of taking the pretest?
Did you did better or worse than expected?
What test taking technique did you apply with the pretest that you have not used prior to last weeks lecture? Did it help?
What areas of test taking do you still need to work on?
What is your study plan for the National Exam?

2. Health insurance and billing

3. Terms to know ICD 9/10 CPT Medicare/Medicaid DRG mDS RUGS G-codes
PQRS codes

4. Billing

5. Coding and billing Icd-9 codes Icd-10 codes Medical diagnosis code
Required for billing
Icd-10 codes
Will replace icd-9 codes on October 1, 2015
7 digit code (more detailed)
External causes

6. What are diagnosis you might see?
Hemiplegia
Ankle sprain
lookup.aspx

7. CPT codes (current procedural terminology)
Codes used to describe the services rendered by the pt/pta
Most are in the series
Therapeutic exercise
Therapeutic activity
Gait training
Neuromuscular re-education
Some are time based, others are not time based

8. CPT Codes
CPT (Current Procedural Terminology) codes are numbers assigned to every task and service a medical practitioner may provide to a patient including medical, surgical and diagnostic services.
Codes are used by insurers to determine the amount of reimbursement that a practitioner will receive by an insurer.
Since everyone uses the same codes to mean the same thing, they ensure uniformity.

9. CPT Codes: con’t
CPT codes are developed, maintained and copyrighted by the AMA (American Medical Association.)
As the practice of health care changes, new codes are developed for new services, current codes may be revised, and old, unused codes are discarded.
Examples of CPT Codes:
99214 may be used for a physical
90658 indicates a flu shot
90716 may be used for chicken pox vaccine (varicella)
12002 may be used to stitch up a one-inch cut on a patient's arm

10. What is the difference between ICD and CPT codes?

11. CPT Codes for PT: evaluations
97001 Physical Therapy Evaluation Physical Therapy Re-Evaluation

12. CPT Codes for PT: Therapeutic Procedures
97110 Therapeutic procedure, one or more areas, each 15 minutes therapeutic exercises to develop strength and endurance, range of motion and flexibility Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and or standing activities Gait Training (includes stair climbing)

13. CPT: con’t
97124        Massage, including effleurage, petrissage and/or tapotement (stroking, compression and percussion).
97140       Manual Therapy Techniques (eg. mobilization/ manipulation, manual lymphatic drainage, manual traction, myofascial release), one or more regions, each 15 minutes
Therapeutic Activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance)

14. Which CPT will you bill?
Walking patient post sx to bathroom during treatment.
Performing balance work on dynadisk post ankle fracture.
Performing joint mobilizations for pain

15. Tips: Billing Billing Timed Services such as 97110, 97140 and 97112:
Do not report any service done less than 8 minutes!
8 minutes to 22 minutes is billed as 1 unit
23 minutes to 37 minutes is billed for 2 units
38 minutes to 52 minutes is billed for 3 units
Documentation in the patient’s medical record should reflect billing code
Ex if you bill for massage, must document a massage in the SOAP

16. Tips: Billing: con’t Cannot bill in the same 15-minute time period:
2 CPT codes for therapeutic procedures
2 CPT codes for modalities requiring constant attendance
Evaluation and treatment code
Group therapy vs individual therapy
Team therapy – therapists working as a team may not each bill for therapy  only one therapist can bill
Units should be in 15 minute increments
Cannot bill for supervising a patient (not skilled)
Cannot bill for services provided by an aide

17. S: pt complained of pain while playing video games at home; pt also stated she wanted to avoid surgery if possible; pt stated pain 5/10 NRS
O: Vitals: HR 62 bpm; RR 40 bpm
ROM: 45 degrees of wrist extension
MMT: 3/5 wrist ext
Paraffin: dipped 8 x, wrapped for 10 min
Nerve glides 2 x 10 reps
Wrist flexors stretched with opposite hand assistance in siting 3x 15 secs
Chin retractions for posture 3 x 10 reps
Pt education on posture and HEP (nerve glides and stretches)
A: Pt pain decreased to 2/10 NRS, was able to perform nerve glides, stretches with minimal compression on median nerve. Pt also achieved proper posture for when he returns home to play video games.
P: Have pt continue HEP, work on postural control and return for PT

18. Health insurance

19. Private insurance
Aetna
Bcbs
Cigna
Healthnet
Humana
Etc.

20. Private insurance Often involves a copay or a coinsurance
Each individual plan has its own limitations of coverage
May be limited in number of visits
May be limited in number of calendar days

21. Worker’s compensation
Coverage for medical services to manage injuries sustained when working on the job

22. Tricare and veterans’ affairs
Medical benefits for military personnel

23. Medicaid State and federal funds
Eligibility based on age, disability, and financial resources
Eligibility requirements vary state to state

24. Medicare Medicare is a health insurance program for: Medicare has:
people age 65 or older,
people under age 65 with certain disabilities, and
people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
Medicare has:
Part A
Part B

25. Medicare Part a part b Hospital care Snf care Home health
Nursing home care
Hospice
part b
Outpatient therapy services
Dme
Preventative services

26. CMS Assumptions for Part B
must meet personnel qualifications
Care is skilled and medically necessary
Care is appropriate for pt’s POC
PTA treatment billed through supervising PT
Bill using the timed codes as one-on-one or group care
Supervision: direct for private practice; general supervision for SNF, OP rehab, and home health

27. Prospective payment system (pps)
Medicare payment is made based on a predetermined, fixed amount
The payment amount for a particular service is derived based on the classification system of that service (example, diagnosis-related groups for inpatient hospital services) 
separate PPSs for reimbursement for each separate type of facility

28. Diagnostic related group (DRG)
Diagnosis-related group (DRG) is a system to classify hospital cases into one of approximately 500 groups, also referred to as DRGs, expected to have similar hospital resource use
Each DRG has a payment weight assigned to it, based on the average resources used to treat Medicare patients in that DRG
Example: TKA

29. Utilization review
Evaluation of the medically necessary, appropriate, and efficient use of health care services, procedures, and facilities

30. Medicare part a
Minimum data set (MDS)  resource utilization groups (rugs)
Both used in skilled nursing faciliites

31. Minimum data set (MDS)
provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems.
Where the minutes or treatment are reported
Used to classify the residents into a RUG

32. resource utilization groups (rugs)
Used in skilled nursing facilities
Ultra high rehab (720 minutes/week)
Very high rehab
High rehab
Medium rehab
Low rehab (45 minutes/week)

33. RUGS: Con’t
Resident Assessment Protocols (RAPs) are part of this process, and provide the foundation upon which a resident's individual care plan is formulated.
MDS completed for all residents in certified nursing homes, regardless of source of payment for the individual resident.
participants in the assessment process are licensed health care professionals

34. Medicare part b Covers outpatient physical therapy services
Therapy caps determined on a calendar year basis
2015 limit for PT and SLP services combined is $1940.
2013 limit for OT services is $1940.

35. Functional limitation reporting July 1, 2013
For out patient services billed under medicare part b
Functional limitation data (G-codes)
CMS uses these codes to track information pts function and condition
Claim forms must include g-codes at the start of the episode, at least every 10th visit, and at discharge

36. Common g-code categories for PT
Mobility: walking and moving around
Changing and maintaining body position
Carrying, moving and handling objects
Self care
other

37. Severity modifiers
Therapists must attach a severity modifier to each G-code they report
This modifier indicates the severity and complexity of the patient's primary functional limitation
0% impaired, limited, or restricted
At least 1% but less than 20% impaired, limited, or restricted
20-40%
40-60%
60-80%
80-100%
100%

38. Measuring patient function, activity, and participation
Initial measurement tool determines baseline functional status
Use of the same measure at intervals or at discharge determines outcomes
Standardized performance instruments
Berg balance scale
Six-minute walk test
Tinetti
Patient self report instruments
Oswestry disability index
Quality of life questionnaires

39. Functional Limitation Reporting (FLR) Under Medicare: Tests and Measures for High-Volume Conditions
spx

40. Medicare physician quality reporting system (pqrs)
For outpatient pt services billed in private practice settings
a separate set of G-codes to report on PQRS measures
unrelated to those used for functional limitation reporting

41. Terms to know ICD 9/10 CPT Medicare/Medicaid DRG mDS RUGS G-codes
PQRS codes