Payment for Services/Documentation Guidelines/Related Federal Legislation

  1. Persons eligible for Medicare medical coverage for health care services:
    • persons 65 or older
    • individuals of all ages w/ end stage renal disease/permanent kidney failure that may require dialysis tx or a kidney transplant
    • persons w/ a long-term disability who have received government-funded disability benefits for 24 months may be eligible
    • retired railroad workers
  2. Medicare Part A
    • inpatient hospitals
    • SNF
    • home health
    • rehab
    • hospice
  3. Medicare Part B
    hospital outpatient physician and other professional services including OT provided by independent practitioners
  4. Medicare criteria for coverage of OT services:
    • prescribed by a physician or furnished according to a physician-approved plan of care
    • performed by a qualified OT or OTA under the general supervision of an OT
    • service is reasonable and necessary for tx of individual's injury or illness
    • diagnosis can by physical, psychiatric, or both. There are no diagnostic restrictions
    • OT must result in significant, practical improvement in the person's level of functioning w/in a reasonable period of time
  5. SNF Medicare reimbursement is based upon:
    resource utilization groups (RUGs)
  6. SNF Medicare reimbursement is typically not provided for:
    • therapist to carry out the maintenance plan
    • or if services can be performed safely and effectively by unskilled personnel
  7. The restorative potential of a person was determined to:
    • NOT be the sole payment criteria for skilled services
    • services to prevent or slow deterioration and maintain a person at the highest functional level possible must be recognized as skilled and covered if these services are reasonable and necessary
  8. PHP
    partial hospitalization
  9. Do psychosocial programs that provide structured diversional, social, and or recreational, services or vocational rehabilitation meet the criteria for active tx in a PHP?
    no, therefore, they are not reimbursable under Medicare
  10. When are rental or purchase expenses for DME covered by Medicare?
    • if DME is used in beneficiary's home and if necessary and reasonable to treat an illness or injury or to improve functioning
    • physician's prescription is needed and must include diagnosis, prognosis, and reason for DME need
  11. Are self-help items (bathtub grab bars and raised toilet seats) reimbursable?
    no, because other people can use them and they are not considered medically necessary
  12. Medicaid
    for persons who have an income that is below an established threshold and/or have a disability
  13. Workers' compensation primary focus:
    rehab and disability management to return the person to gainful employment
  14. Structure of goal statement
    • patient will... or family/caregiver/teacher will...
    • desired functional behavior to increase
    • underlying factors that must be remediated to achieve
    • circumstances under which behavior must be performed or the conditions (independent, cues, assist)
    • degree to which behavior is exhibited (3 out of 4, etc)
  15. SMART goals
    • Specific
    • measurable
    • attainable
    • relevant
    • time-limited
  16. RUMBA goals
    • realistic/relevant
    • understandable
    • measureable
    • behavioral
    • attainable/achievable
  17. reasons for discharge
    • goals attained
    • client no longer making functional gains
    • client refuses or is noncompliant w/ intervention
    • client moves to another location
    • setting not appropriate to individual's needs
  18. Problem Oriented Medical Record (POMR):
    a system of providing structure for progress not writing that is based on a list of problems based on assessments
  19. What setting must report functional data on their claims in the form of new G-codes?
    outpatient occupational therapy services
  20. Some documentation of improvement must be made at least on a weekly basis, otherwise, tx will be
    considered maintenance
  21. Does Medicare reimburse for OT practitioners to implement maintenance tx?
    no, considered unskilled service
  22. When does transitional planning in the IEP begin?
    age 14
  23. When do transitional services begin in the IEP?
    age 16
Card Set
Payment for Services/Documentation Guidelines/Related Federal Legislation
Ch. 4