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37 Cards in this Set
- Front
- Back
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Persons who are eligible for premium free Part A are
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automatically eligible for Part B Medicare
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What type of package is Part B
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optional.
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Usually when people enroll in Part A, they go ahead and enroll in Part B. If they don't enroll then they may enroll at a later date during__________
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open enrollment period, but the premium will be higher
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THe standard monthly premium for Part B medical is determined by the beneficiary's
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annual income and is usually automatically deducted from the SS checks.
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There is a _________ annual Part B deductible and a ________ co-insurance rate
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135.00 and a 20% co-insurance
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After beneficiary pays the deductible, Medicare will pay _____- of what Medicre considers a reasonable charge for the services, provided they are covered by Medicare and then the beneficiary pays the remaining ______
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80%
20% |
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If the physician accepts Medicare's 80% as full pymt the pt is only responsible for their 20% but if the if the physician doesn't accept the Medicare assignment what is the pt responsible for
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the 20% and whatever is not covered by Medicare
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Prior to the BBA (balance budget act of 97) therapy providers were pd accourding to their typoloty. Since the enactiment of the BBA, therapy proveders are reimbursed according to a
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fee schedule
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What is the fee schedule for Medicare Part B
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1. outpatient hospital programs- lab radiology
2. coprehensive outpatient rehab facility- has to provide these "core" services: physician care, physical therapy, and social services/ other services may be offered 3. Private Practice therapist- reimbursed through a Medicare provider |
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What are examples of outpatient hospital programs
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labs, radiology
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Under provider types and fee schedule for Part B
has to provide these "core" services: physician care, physical therapy, and social servicees |
comprehiensive outpatient rehab facility
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under Provider types part b fee schedule
reimbursed therough a regional carrier. Must maintain an independent office to be eligible to be a Medicare provider |
Pravate practice therapist
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what is a list of procedures with associated payments based on the estimated cost of delivering them
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fee schedule
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How is the list of procedures coded
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current procedural technology (CPT)
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What are the different codes used
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procedure only codes and timed codes ex) if you are doing an eval you get one code (procedural type code) no matter how long it takes
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The fee schedule pymts for each code are determined using a cost-determination method called the
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resource based relative value scale or RBRVS
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The amount thatthe facility or therapist is reimbursed for a procedure is affected by the cost of provinding service in
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the region in which you live/work
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Do Part B provicers have to accept the fees schedule amount as pymt in full
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no. This is called accepting or declining Medicare Assignment.
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What happens if the provider accepts the rembursement amount form Medicare as pymt in full
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he accepts the pymt followin ghe ded and 20% coppay from the beneficiary
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What happens if you decine th eMedicre Assignment
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there is a 5% reduction from the fee schedule. The provider may then charge the beneficiary the full charge for the procedure up to 15% over the fee schedule amount. The difference b/w the fee schedule amount and the provider charge along with theded and co-insurance is the responsibility of the beneficiary
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What is the current limit set at on therapy services and when did Medicare Part B start to set limits
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1780.00 per beneficiary, per year
and they started in 97 |
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What are the limits for PT and ST
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they share a limit of 1780.00
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Where do pts receive therapy services
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outpatient clinics
home SNF |
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The therapist can submit for an exxtension over the cap for therapy that is considered to be
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medically necessary
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How does Medicare Part B define therapy services
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Medicare defines therapy services as OT, PT and ST. other services are not reimbursed therapy services and must be provided by licensed provider not a student. OTA can provide services with gneral supervisions. PTA in private practice needs direct supervision
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Discuss Therapy services are required by the condition of the pt
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the care proviced must be considered "reasonable and necessary" based on the needs and conditions of the beneficiary. Care must be considered a skilled service
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Discuss Beneficiary must be under the care of a physician or non-physician practiononer
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Medicare Will reimburse only with certification from a physician (MD, Podiatrist, Optomitrist)
Dentist adn Chiropractors or nonphysician providers such as physician assistant, nurse practioner or clinical specialist cannot refer. |
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Discuss A plan of Care exists taht was designed by the therapist or the physician or non-physician practiononer
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a written active plan of care must be developed and maintained by Medicare beneficiary. Usually the therapist develops tha plan.
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What must the plan of care include at a minimum
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pt dx
long term treatment goals type, amount, frequency and duration of therapy services |
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Discuss Certification and Part B
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Therapy needs to be certified at no less than 90 day intervals by a physician meeting program requirements
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Discuss Services must be provided on an outpatient basis
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this applies only to the Part B benefit
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The benefit defines 5 groups eligible for Part B therapy
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1. providers to outpt in the pts hoem
2. providers to outpt who come to the outpt clinic 3. providers to inpts of other institutions 4. suppliers to outpts in the pt's homes or in outpt clinics |
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Under documentation for Part B what must you provide to prevent cov being denied or delayed
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an evaluation/reevaluation , progress notes, and treatment notes
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Under documentation what is the need for therapy services and outlines care
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evaluation
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under documentation what is the change in goal or pt nearing discharge
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reevaluation
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What is required for each recertivation in order to continue with treatment on part b documentation
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progress notes[ these are used to justify treatment
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what ar the daily or pre=visit record of the pt's condition, the intervention and the pt's responsiveness to therapy
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treatment notes
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