REIMBURSEMENT

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created 5 years ago by leslieann_benegasi
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1

MEDICARE

Part A: Covers inpatient hospitals, home health agencies (HHA), and skilled nursing facilities (SNFs)
Part B: A voluntary and supplementary benefit
Covers: physician services, outpatient services, and durable medical equipment (DME)

2

MEDICAID

Funds care for low-income individuals in US & territories
Covers more people & generates higher health care expenditures than Medicare
Individual states have flexibility to administer programs, determine other benefits, and process claims
Rates vary from state to state
Services may also vary from state to state; because OT falls under “optional” services, it is up to each state to decide if their Medicaid program will cover OT services or not. How do you find out? Via your state OT membership organization (NCOTA and/or NCBOT)
OT practitioners must follow documentation and reimbursement guidelines for the state where services are provided

3

EARLY INTERVENTION AND SCHOOLS

<3 years old who are experiencing developmental delays (or are at risk for)
Under Part C of Individuals with Disabilities Education Act (IDEA)
States have discretion to define “at risk” and length of services
Law mandates services must be provided in child’s “natural environment”
IDEA Part B: children 3-21 with disability; schools must provide an appropriate free public education in least restrictive environment
Special services such as OT can be provided to increase success in school
Unique documentation requirements for school-based settings

4

BILLING CODES

Used when submitting claims for reimbursement
Patients with Med A benefits (hospitals and SNF) come under prospective payment system & pays pre-determined rate
Med B benefits reimbursed for each individual item according to Medicare Physician Fee Schedule (MPFS)
Healthcare Common Procedure Coding System
Enables physicians & health care providers to use common language and standardized codes
Codes identify and bill health services and medical products, and collect data

5

BILLING CODE RULES

Timed services
Based on 15 minute intervals
Untimed services
Billed at fixed amount (ex: OT evaluation)
Some codes are mutually exclusive and cannot be billed together
Medicare has strict criteria regarding documentation by therapy students: require appropriate supervision
Co-treatment criteria
All timed services are billed in 15 minute units, but are considered by Medicare to be anywhere from 8-22 minutes

6

LEVELS OF SUPERVISION

Close: daily, direct contact at the work site
Routine: Direct contact at least 2x/week at the work site with phone or written contact in addition
General: Direct monthly contact with phone or written contact as needed
Minimal: Provided only on an as-needed basis

7

SUBJECTIVE "S"

information from the client, giving his perspective on his condition or treatment.
information that cannot be verified or measured during the treatment session.
EXAMPLE:Client states his ® shoulder hurts when donning shirt

8

OBJECTIVE "O"

You will record all measurable and observable data obtained during the treatment session, any assessments administered. Documentation of assistance level required.
Present a picture of the intervention session you have provided, *through your professional eyes.
Examples:
Pt. seen 45 min. in OT clinic to address ® side neglect and impaired motor planning in order to maximize independence with self-care activities.

9

What if the client is non-verbal?

Examples:
Client unable to communicate due to aphasia.
Client did not speak without cueing.
Patient communicated using her message board that she wanted to make a scrap book page.
Resident does not clearly verbalize during treatment, but smiles and nods appropriately when asked questions.
Patient happy to greet COTA and appeared eager to begin therapy.