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CRIP Set 7
| Question | Answer |
|---|---|
| Since outpatient rehab is considered a repetitive service, how should this be billed? | Services should not be billed on a per visit basis. Instead, the services should be billed monthly or at the conclusion of the patient's treatment. Services should not be billed with non-repetive services. If the patient has other outpatient visits on the same day, services must not be combined on the same claim. |
| What should be included in a written treatment plan for rehab therapy services? | Patient's diagnosis, long-term treatment goals, type of rehab therapy services, amount of therapy treatment sessions in a day, number of weeks or number of treatment sessions for the patient, frequency or number of treatment sessions per week, signature and ID of person who established the plan of care |
| What will the initial certification or plan of care satisfy? | It will satisfy all of the certification requirements for the duration of the plan of care or 90 calendar days from the date of the patient's initial treatment. Certification of the initial care is considered timely when it is documented, signed, and data within 30 days following the first day of treatment which includes the email. If verbal orders are obtained, the orders must be followed within 14 days by signature and date |
| How often should recertification of rehab therapy occur? | If continued therapy is needed, a recertification should be signed whenever the plan of care is modified or every 90 days after initiation of treatment under the plan of care |
| What type of claim is rehab services billed on | Ub04 |
| The amount of time for each specific modality provided to the patient required to be documented in the treatment note | No, however, the total number of time minutes must be documented |
| What are the revenue codes for therapy and what modifiers may be on the line? | 042X - physical therapy lynns May only contain modifier GP 043X - occupational therapy lines me only contain modifier GP 044X - speech language pathology lines may only contain modifier GN Providers are required to report line item dates of service per revenue code line for all outpatient rehab services |
| What are the required three occurrence codes for therapy? | One set of symptoms/ illness: PT = 11; OT = 11; SLP=11 Date plan of care. Established her last reviewed: PT - 29; OT - 17; SLP - 30 Day treatment started: PT - 35; OT - 44; SLP - 45 |
| What modifier is needed when a patient kx modifier threshold amount has been reached and what are the cy 2020 threshold amounts | Kx $2080 for PT and SLP services combined $2,080 for OT services |
| How is therapy number of units based on time calculated? | Less than 8 minutes. Do not Bill 1 unit- 8 to 22 minutes 2 units- 23 to 37 3- 38 to 52 4 - 53 to 67 5 - 68 to 82 6 - 83 to 97 7 - 98 to 112 8 - 113 to 127 |
| What are the different types of wound care services? | Surgical debrisment, selective debrisment, non-selective debrisment, active wound care management, wound vacuum therapy, ultrasound, multi-layer compressions or Unna boots , transcutaneous auction tension measurements, hyperbaric oxygen therapy |
| Can debrisment and grafting CBT codes be reported with planting, casting, or strapping for the same anatomical site? | No. And they cannot have a modifier appended to bypass per CCI edits |
| What documentation should there be for wound healing or improvement? | Inflammation, changes in the amount of wound drainage, decrease in the amount of swelling, decrease in the amount of pain, size of the wound dimensions, increase in the tissue granulation |
| What should be documented for wound debridements? | Name and account number for patient, complications, surgical procedure performed, date and time of debrisment, physician who performed procedure, pre and post-op diagnosis, description of findings, removal of tissue, techniques used, size, depth, length, or width of the wound? |
| Who must provide documentation of wound care management? | Both the physician and the wound care nurse |
| When can E&m services for wound care be charged? | The physician treats a new patient for an initial visit, patient was seeing for a follow-up visit and no services were provided, patient seemed for a follow-up, a new sign or symptom was identified in the physician made a medical decision on how to treat the new condition. If a medical or surgical procedure was performed and E&m charge cannot be billed |
| What is the proper documentation for hyperbaric oxygen services? | Physician order, progress notes, physician records such as consults assessment, documentation to support a threatened loss of function limb or life, results of any diagnostic test, initial assessment, current treatments and effectiveness, history, prior treatments, HBO treatment plan and record, total compress time and dose of oxygen, pressurization level, effects of treatment, etc |
| Give an overview of observation services | Furnished in a hospital setting to determine the need for inpatient care. Includes assessment , reassessment, short-term treatment. Includes the use of a bed monitoring by nursing and covered under a order |
| How many hours can a patient be in the hospital before it must be inpatient? | Usually observation is 48 hours but Medicare will cover up to 72 hours |
| When is observation not appropriate? | Services exceeding 48 hours, outpatient diagnostic services or chemotherapy, pre-op and routine recovery, services if without a written order |
| When must a MOON be given to Medicare beneficiaries? | When they are receiving outpatient services and not as inpatient services, they must be given after 24 hours of observation and must be given by the 36th hour. They're given to regular Medicare and Medicare advantage plans. |
| What are the two types of observation in the HCPCS and revenue codes? | Direct admit to observation - G0379 Hospital observation per hour- G0378 Revenue Code 0762 |
| should abns be used for observation care? | No, except in the case of critical access hospitals because of the reimbursement methodology |
| How is observation hours calculated? | After the order is written, it begins with the time the observation care begins. For example, when the first initial nursing assessment begins |
| If a patient arrives in the ER at 10:00 a.m. observation is ordered by the physician for the patient at 13:30 and the RN begins providing observation care at 1400. What is the time the charging begins? | 1400 |
| If a procedure is done during observation time and the procedure normally has observation as part of the charge, is it carved out of the other observation hours? | Yes |
| When does observation time end? | Ends when all medically necessary interventions and or related to observation care have been completed. This could be at discharge. |
| How should observation hours units be rounded to? | The nearest hour, for example zero units is 0 to 30 minutes and one unit is 31 to 59 is one unit |
| Is a physician order needed to bill for observation units? | No |
| How do you determine whether it should be inpatient versus outpatient? | Only a physician can determine whether a patient should be admitted as inpatient or treated as outpatient. Provider needs to consider patients. Medical needs, patients, medical history, hospitals emission policy, appropriateness of treatment, severity of symptoms |
| When is observation services following a surgical or invasive procedure allowed? | Only in situations where the patient exhibits a significant adverse reaction to the surgical procedure or anesthesia. Otherwise as part of the normal monitoring |
| When can observation be billed in conjunction with a high-level clinic visit, type A or type B emergency department. Visit, critical Care services, direct referral for extended care and will do get paid separately | Two payments can be made if certain criteria are met. Observation must be documented, observation must equal or exceed 8 hours |
| If billing observation care along with other high-level visit, what must be reported on the claim | In addition to the observation services, one of the following must be on the claim A. Type A or B emergency. Visit, a clinic visit, critical care, direct referral for observation on the same date as observation. |
| If billing for a high-level visit along with observation, what is the type of Bill that must be on the claim to be considered for a composite APC payment | 13X |
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