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Understanding Medicare MDS 3.0 for the Rehabilitation Professional Billing, Documentation and Ethics

Profession: Physical Therapists/Assistants,Occupational Therapists/Assistants
Topic: Clinical,Business Administration
CEU: 1.1 unit
Contact Hours: 11 hours

States Approved:
- Physical Therapists/Assistants : California, Hawaii, Indiana, Maine, Massachusetts, Michigan, New York, Rhode Island, South Dakota, Utah, Vermont, Wyoming
- Occupational Therapists/Assistants : Ohio

Skill Level: Beginner
 

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Course Objectives Table of Contents Needs Assessment AuthorTermsAccreditation Printable

Course Description:

On August 8, 2011, the Centers for Medicare & Medicaid Services released the final ruling and commentary for the new implementation of the MDS changes set to take effect on Oct. 1, 2011. The Reimbursable Therapy Minutes will be the deciding factor in determining whether a Change of Therapy (COT) OMRA (Other Medicare Required Assessment) will be required, if at all. Most of our skilled nursing facilities are using some type of tracking tool for managing the prospective payment system minutes. Some are computerized, while others are still using paper forms. The Change of Therapy (COT) observation week must be scheduled exactly seven days following the previous MDS or observation week. If there has been a change in RUG category, then a Change of Therapy (COT) OMRA must be done and the reimbursement will drop or increase to the new RUG until another change occurs. CMS decided to assume all SNFs should offer seven-day rehab options, so facilities that traditionally offered Monday through Friday services will face immense challenges with the new Change of Therapy (COT) OMRAs. This book has been updated to discuss the new MDS assessment schedule, the allocation of group therapy minutes, the revised student supervision provisions, the End of Therapy (EOT) Other Medicare Required Assessment (OMRA) and new resumption items, and the new PPS assessment- Change of Therapy (COT) OMRA (Other Medicare Required Assessment). The long term care industry has anticipated the new MDS 3.0. RUG IV coding requires the therapist to specifically account for the time captured during the look back period. This book could help occupational therapists, physical therapists and speech therapists understand Medicare standards for subacute care programs to be compliant with Medicare MDS 3.0 standards and state regulations. Documenting and billing strategies are also discussed in this book to attain maximum reimbursement. A list of commonly used ICD-9 codes is also provided. Appropriate billing and documentation should be present in the medical record. Medicare is increasingly reviewing therapy claims to ensure that the therapy provided required the skills of a therapist. The Mandated program, Recovery Audit Contractions, recovered 1 billion dollars during their 3 year demonstration project. This book covers establishing medical necessity, refusing to care for a resident, restraints, safety, creating incident reports, supervising assistive personnel and resident privacy. Coding and billing for subacute and long term care settings are also encompassed in this book, along with denial and appeal management, regulatory guidelines for insurers and improving cash flow with denial management strategies. Proper coding and documentation ensures that facilities will keep their money upon a post payment medical record audit.

Course Objectives:

  1. Learn the most current and accurate documentation procedures to support skilled therapy services.
  2. Improve your skills in MDS completion
  3. Understand the basic concepts of long term care administration and ethics such as supervising assistive personnel, restraints and resident privacy
  4. Maximize treatment and rehabilitation services rendered to the skilled nursing home resident using the most specific RUG IV group
  5. Utilize the most specific ICD-9 diagnosis code to maximize Medicare reimbursement and support medical necessity

Needs Assessment (From the AOTA manual)

RehabSurge, Inc. is NOT an accredited AOTA continuing education provider.

Category 3: PROFESSIONAL ISSUES

  • Administration & Management
  • Accreditation
  • Budgeting
  • Funding approaches/issues
  • Productivity
  • Promotion/public relations/marketing
  • Recruitment/retention
  • Legal, Legislative, Regulatory, & Reimbursement Issues
  • Documentation issues
  • Supervision
  • Communication
  • Competence
  • Cultural issues
  • Role delineation

Target Audience:

  • Physical Therapists
  • Physical Therapy Assistants
  • Occupational Therapists
  • Occupational Therapy Assistants

About the Author

Caroline Joy Co, PT, DPT, CHT, CSFA, is a licensed physical therapist and certified hand therapist whose clinical experience includes acute, subacute, home health and outpatient settings. Her background includes Community Based Therapy designed to assist people with disabilities access therapy in their communities using predominantly local resources. She is the President and CEO of PTSponsor.com, an online resource for U.S. hospitals and clinics that seek to sponsor and hire foreign-trained physical therapists. She specializes in hand therapy through an integrated approach that includes education, counsel and exercise. She is also certified in functional assessment for work hardening and work conditioning.

She is also the President of Rehabsurge, Inc. Rehabsurge, Inc. is a continuing education company and a contracting agency. Her past affiliations include Long Beach Medical Center, Horizon Health and Subacute Center, and Grandell Therapy and Nursing Center. She was a professional speaker for Summit Professional Education, Cross Country Education and Dogwood Institute for Hand therapy courses; myofascial release and nerve mobilization courses; and coding, billing, documentation and ethics. She received her transitional doctorate from A.T. Still University and her BS in Physical Therapy from University of the Philippines- College of Allied Medical Professions. She is licensed in California, Nevada and New York.

Terms

Rehabsurge, Inc.’s mission is to support health care and education professionals to continue their educational and professional development. Rehabsurge is committed to identifying, promoting, and implementing innovative continuing education activity which can increase and impart professional knowledge and skills through books, audiobooks or digital e-books based on sound scientific and clinically derived research. The first Rehabsurge continuing education book was published in July 2009. As a sponsor of Continuing Education (CE) seminars and workshops we enable professionals to enhance their skills, pursue professional interests and redefine their specialties within their respective disciplines while earning CEUs, CE credits or Contact Hours. Offerings include CE books, audiobooks and digital e-books focused on the latest treatment and assessment approaches, as well as discussions of alternative and state-of-the art therapies.

Rehabsurge, Inc. exists to provide the latest treatment and assessment approaches to the practicing clinician. The basic proposition of our business is simple, solid, and timeless. When we bring the latest knowledge and skill to our clients, then we successfully nurture and protect our brand- Rehabsurge, Inc. That is the key to fulfilling our ultimate obligation to provide consistently attractive books, audiobooks and digital e-books.

DISABILITY POLICY:

Rehabsurge, Inc. seeks to ensure that all students have access to its activities. To that end, it is committed to providing support services and assistance required for equal access for learners with disabilities. Rehabsurge, Inc. has a firm commitment to meeting the guidelines of the Americans with Disabilities Act and Section 504 of the Rehabilitation Act of 1973. Rehabsurge, Inc. will provide support services and assistance for students with disabilities, including reasonable accommodations, modifications, and appropriate services to all learners with documented disabilities.

Full Disclosure

To comply with professional boards/associations standards, all planners, speakers and reviewers involved in the development of continuing education content are required to disclose their relevant financial relationships. An individual has a relevant financial relationship if he or she has a financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in their presentation content over which the individual has control. Relevant financial relationships must be disclosed to the audience.

As part of its accreditation with boards/associations, Rehabsurge, Inc. is required to resolve any reported conflicts of interest prior to the educational activity. The presentation will be scientifically balanced and free of commercial bias or influence.

To comply with professional boards/associations standards:

I declare that I or my family do not have any financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in my presentation. Additionally, all Planners involved do not have any financial relationship.

Caroline Joy Co, PT, DPT, CHT, CSFA

Accreditation

Physical Therapists/Assistants : Arkansas, California, Colorado, Hawaii, Indiana, Maine, Massachusetts, Michigan, New York, Rhode Island, South Dakota, Utah, Vermont, Wyoming

Occupational Therapists/Assistants: Ohio

Doctors of Chiropractic: Iowa, Nebraska, New Jersey

Understanding Medicare MDS 3.0 for the Rehabilitation Professional
Billing, Documentation and Ethics for Subacute Rehabilitation and Skilled Nursing Home Facilities

Course Description:

The long term care industry has anticipated the new MDS 3.0. RUG IV coding requires the therapist to specifically account for the time captured during the look back period. This book could help occupational therapists, physical therapists and speech therapists understand Medicare standards for subacute care programs to be compliant with Medicare MDS 3.0 standards and state regulations. Documenting and billing strategies are also discussed in this book to attain maximum reimbursement. A list of commonly used ICD-9 codes is also provided.

Appropriate billing and documentation should be present in the medical record. Medicare is increasingly reviewing therapy claims to ensure that the therapy provided required the skills of a therapist. The Mandated program, Recovery Audit Contractions, recovered 1 billion dollars during their 3 year demonstration project. This book covers establishing medical necessity, refusing to care for a resident, restraints, safety, creating incident reports, supervising assistive personnel and resident privacy.

Coding and billing for subacute and long term care settings are also encompassed in this book, along with denial and appeal management, regulatory guidelines for insurers and improving cash flow with denial management strategies. Proper coding and documentation ensures that facilities will keep their money upon a post payment medical record audit.

Course Objectives:

  1. Learn the most current and accurate documentation procedures to support skilled therapy services.
  2. Improve your skills in MDS completion
  3. Understand the basic concepts of long term care administration and ethics such as supervising assistive personnel, restraints and resident privacy
  4. Maximize treatment and rehabilitation services rendered to the skilled nursing home resident using the most specific RUG IV group
  5. Utilize the most specific ICD-9 diagnosis code to maximize Medicare reimbursement and support medical necessity

Table of Contents

Introduction 1
Definition of Terms 3
Chapter 1: Medicare and Reimbursements 5
Medicare Part A 5
Medicare Part B 6
Medicaid 7
Chapter 2: Medical Necessity 8
Medicare Skilled Guidelines 10
Medical Necessity 10
Expressing Medical Necessity and Skilled Care 11
Chapter 3: Recovery Audit Contractor 12
Fighting Recovery Audit Contractors Audit Denials and Overpayment Determinations 12
Program Safeguard Contractor Audits 14
Medicare Administrative Contractors 15
Chapter 4: Health Information Management 16
Effective Documentation 19
Guidelines for Making Corrections 22
Documentation Requirements 23
MDS 3.0 Section G Functional Status Guidelines 25
CPT Codes 31
Therapy Certifications 46
Reasons for Denial 46
Coding Guidelines 47
Major RUG IV Categories 47
Relationship between the Assessment and the Claim 49
Medicare Short Stay Assessment 51
Calculation of Total Rehabilitation Therapy Minutes 52
Delay in Requiring and Receiving Skilled Services 54
Medical Appropriateness Exception 54
Resident Discharged from Part A and Returns to SNF Part A 55
ARD Outside the Medicare Part A Benefit 55
Chapter 5: Coding and Billing 58
Using ICD-9 codes 58
Basic Guidelines in using ICD-9 Codes 58
Steps in Coding 59
Common Billing Errors and How to Avoid them 72
Chapter 6: Administration and Ethics 76
Staffing 76
Restorative Nursing Program 76
Restraints and Safety 76
Elder Abuse 77
Incident Report 77
Refusing to Care for a Resident 82
Unanticipated Outcome 84
Non-compliant Resident 85
Bending the Rules 86
Supervising Assistive Personnel 87
Infection Control 89
Resident Privacy 89
Chapter 7: Group vs Concurrent Therapy 92
Group Therapy 92
Concurrent Therapy 95
Chapter 8: Conclusion and Final Words 98
References 99
Appendix 104
Examination 104
Survey 111

Needs Assessment (From the AOTA manual)

RehabSurge, Inc. is NOT an accredited AOTA continuing education provider.

Category 3: PROFESSIONAL ISSUES

  • Administration & Management
  • Accreditation
  • Budgeting
  • Funding approaches/issues
  • Productivity
  • Promotion/public relations/marketing
  • Recruitment/retention
  • Legal, Legislative, Regulatory, & Reimbursement Issues
  • Documentation issues
  • Supervision
  • Communication
  • Competence
  • Cultural issues
  • Role delineation

Target Audience:

  • Physical Therapists
  • Physical Therapy Assistants
  • Occupational Therapists
  • Occupational Therapy Assistants

About the Author

Caroline Joy Co, PT, DPT, CHT, CSFA, is a licensed physical therapist and certified hand therapist whose clinical experience includes acute, subacute, home health and outpatient settings. Her background includes Community Based Therapy designed to assist people with disabilities access therapy in their communities using predominantly local resources. She is the President and CEO of PTSponsor.com, an online resource for U.S. hospitals and clinics that seek to sponsor and hire foreign-trained physical therapists. She specializes in hand therapy through an integrated approach that includes education, counsel and exercise. She is also certified in functional assessment for work hardening and work conditioning.

She is also the President of Rehabsurge, Inc. Rehabsurge, Inc. is a continuing education company and a contracting agency. Her past affiliations include Long Beach Medical Center, Horizon Health and Subacute Center, and Grandell Therapy and Nursing Center. She was a professional speaker for Summit Professional Education, Cross Country Education and Dogwood Institute for Hand therapy courses; myofascial release and nerve mobilization courses; and coding, billing, documentation and ethics. She received her transitional doctorate from A.T. Still University and her BS in Physical Therapy from University of the Philippines- College of Allied Medical Professions. She is licensed in California, Nevada and New York.

Terms

Rehabsurge, Inc.’s mission is to support health care and education professionals to continue their educational and professional development. Rehabsurge is committed to identifying, promoting, and implementing innovative continuing education activity which can increase and impart professional knowledge and skills through books, audiobooks or digital e-books based on sound scientific and clinically derived research. The first Rehabsurge continuing education book was published in July 2009. As a sponsor of Continuing Education (CE) seminars and workshops we enable professionals to enhance their skills, pursue professional interests and redefine their specialties within their respective disciplines while earning CEUs, CE credits or Contact Hours. Offerings include CE books, audiobooks and digital e-books focused on the latest treatment and assessment approaches, as well as discussions of alternative and state-of-the art therapies.

Rehabsurge, Inc. exists to provide the latest treatment and assessment approaches to the practicing clinician. The basic proposition of our business is simple, solid, and timeless. When we bring the latest knowledge and skill to our clients, then we successfully nurture and protect our brand- Rehabsurge, Inc. That is the key to fulfilling our ultimate obligation to provide consistently attractive books, audiobooks and digital e-books.

DISABILITY POLICY:

Rehabsurge, Inc. seeks to ensure that all students have access to its activities. To that end, it is committed to providing support services and assistance required for equal access for learners with disabilities. Rehabsurge, Inc. has a firm commitment to meeting the guidelines of the Americans with Disabilities Act and Section 504 of the Rehabilitation Act of 1973. Rehabsurge, Inc. will provide support services and assistance for students with disabilities, including reasonable accommodations, modifications, and appropriate services to all learners with documented disabilities.

Full Disclosure

To comply with professional boards/associations standards, all planners, speakers and reviewers involved in the development of continuing education content are required to disclose their relevant financial relationships. An individual has a relevant financial relationship if he or she has a financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in their presentation content over which the individual has control. Relevant financial relationships must be disclosed to the audience.

As part of its accreditation with boards/associations, Rehabsurge, Inc. is required to resolve any reported conflicts of interest prior to the educational activity. The presentation will be scientifically balanced and free of commercial bias or influence.

To comply with professional boards/associations standards:

I declare that I or my family do not have any financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in my presentation. Additionally, all Planners involved do not have any financial relationship.

Caroline Joy Co, PT, DPT, CHT, CSFA

Accreditation

Physical Therapists/Assistants : Arkansas, California, Colorado, Hawaii, Indiana, Maine, Massachusetts, Michigan, New York, Rhode Island, South Dakota, Utah, Vermont, Wyoming

Occupational Therapists/Assistants: Ohio

Doctors of Chiropractic: Iowa, Nebraska, New Jersey