Reimbur$ement: Reimbur$ement: Show Me the Show Me the Money! Money! Carolyn A. Dobson, MT-BC Carolyn A. Dobson, MT-BC AMTA Reimbursement Committee AMTA Reimbursement Committee Representative Representative WRAMTA Conference - Long Beach, CA WRAMTA Conference - Long Beach, CA April 1, 2011 April 1, 2011
Reimbur$ement: Show Me the Money!. Carolyn A. Dobson, MT-BC AMTA Reimbursement Committee Representative WRAMTA Conference - Long Beach, CA April 1, 2011. Reimbursement Sources. Medicare Partial Hospitalization (PHP) Healthcare Common Procedure Coding System (HCPCS) - PowerPoint PPT Presentation
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Reimbur$ement: Reimbur$ement:
Show Me the Show Me the
Money!Money!
Carolyn A. Dobson, MT-BCCarolyn A. Dobson, MT-BCAMTA Reimbursement Committee AMTA Reimbursement Committee RepresentativeRepresentative
WRAMTA Conference - Long Beach, CAWRAMTA Conference - Long Beach, CA
Section O: Special Treatments,Section O: Special Treatments,
Programs, And Programs, And Procedures Procedures
O0400: TherapiesO0400: Therapies
MDS 3.0 Section OMDS 3.0 Section OImportance of OImportance of O
0400104001
Item Rationale Item Rationale – Health-related Quality of Life Health-related Quality of Life
Maintaining as much independence as possible in activities of daily Maintaining as much independence as possible in activities of daily living, mobility, and communication is critically important to most living, mobility, and communication is critically important to most people. Functional decline can lead to depression, withdrawal, people. Functional decline can lead to depression, withdrawal, social isolation, breathing problems, and complications of social isolation, breathing problems, and complications of immobility, such as incontinence and pressure ulcers, which immobility, such as incontinence and pressure ulcers, which contribute to diminished quality of life. The qualified therapist, in contribute to diminished quality of life. The qualified therapist, in conjunction with the physician and nursing administration, is conjunction with the physician and nursing administration, is responsible for determining the necessity for, and the frequency responsible for determining the necessity for, and the frequency and duration of, the therapy services provided to residents. and duration of, the therapy services provided to residents.
Rehabilitation (i.e., via Speech-Language Pathology Services and Rehabilitation (i.e., via Speech-Language Pathology Services and Occupational and Physical Therapies) and respiratory, Occupational and Physical Therapies) and respiratory, psychological, and recreational therapy can help residents to psychological, and recreational therapy can help residents to attain or maintain their highest level of well-being and improve attain or maintain their highest level of well-being and improve their quality of life. their quality of life.
MDS 3.0 Section OMDS 3.0 Section OCriteria for Applicable Treatments, Criteria for Applicable Treatments,
Procedures, & Programs Procedures, & Programs
Applicable treatments/ procedures include: Applicable treatments/ procedures include: Services provided by or under the direction of a qualified Services provided by or under the direction of a qualified
occupational or physical therapistoccupational or physical therapist Skilled therapy services onlySkilled therapy services only Respiratory, psychological, and recreational therapy that Respiratory, psychological, and recreational therapy that
meet specific criteria onlymeet specific criteria only
Applicable treatments/ procedures do not include: Applicable treatments/ procedures do not include: Services provided solely in conjunction with surgical services Services provided solely in conjunction with surgical services
and diagnostic servicesand diagnostic services Non-skilled servicesNon-skilled services
Minimum Data Set (MDS) 3.0 Section O August 2010 Minimum Data Set (MDS) 3.0 Section O August 2010
Purpose of O0400 TherapiesPurpose of O0400 TherapiesConduct the AssessmentConduct the Assessment
Purpose of O0400 TherapiesPurpose of O0400 TherapiesConduct the AssessmentConduct the Assessment
Determine :Determine : Therapy(ies) the resident receivedTherapy(ies) the resident received Mode for each therapy receivedMode for each therapy received How many minutes the resident spent in each mode of therapy How many minutes the resident spent in each mode of therapy
during the look-back periodduring the look-back period Number of days of therapy during the look-back periodNumber of days of therapy during the look-back period Document the start and end date of each therapy.Document the start and end date of each therapy.
Review the resident’s medical record. Review the resident’s medical record. Rehabilitation therapy evaluationRehabilitation therapy evaluation Treatment recordsTreatment records Recreation therapy notesRecreation therapy notes Mental health professional progress notes Mental health professional progress notes Consult with each of the qualified care providers.Consult with each of the qualified care providers.
The RAI Version 3.0 Manual states that Recreation Therapy is NOT a skilled The RAI Version 3.0 Manual states that Recreation Therapy is NOT a skilled service according to the Security Act however, for purposes of the MDS, service according to the Security Act however, for purposes of the MDS, providers should record services for recreational therapy when the providers should record services for recreational therapy when the conditions for the provision of recreation therapy are as follows: conditions for the provision of recreation therapy are as follows:
The physician orders Recreation Therapy that provides therapeutic The physician orders Recreation Therapy that provides therapeutic stimulation beyond the general activity program; stimulation beyond the general activity program;
The physicians order must include a statement of frequency, duration, The physicians order must include a statement of frequency, duration, and scope of treatment; and scope of treatment;
The services must be directly and specifically related to an active written The services must be directly and specifically related to an active written treatment plan that is based on an initial evaluation performed by a treatment plan that is based on an initial evaluation performed by a therapeutic recreation specialist; therapeutic recreation specialist;
The services are required and provided by a state licensed or nationally The services are required and provided by a state licensed or nationally certified therapeutic recreation specialist or therapeutic recreation certified therapeutic recreation specialist or therapeutic recreation assistant who is under the direct supervision of a therapeutic recreation assistant who is under the direct supervision of a therapeutic recreation specialist; and specialist; and
The services must be reasonable and necessary for the resident’s The services must be reasonable and necessary for the resident’s condition. condition.
Special Treatments and Special Treatments and Therapies: Therapies: Section OSection O
Special Treatments and Special Treatments and Therapies: Therapies: Section OSection O
Remember……… Remember……… Remember……… Remember………
The assessor records the number of days and the The assessor records the number of days and the minutes that recreation therapy was administered over minutes that recreation therapy was administered over the 7 day look back period. Sessions must be at least the 7 day look back period. Sessions must be at least 15 minutes in length. The RAI Version 3.0 Manual states 15 minutes in length. The RAI Version 3.0 Manual states that therapy logs are not a MDS requirement but is that therapy logs are not a MDS requirement but is standard of good clinical practice by all therapy standard of good clinical practice by all therapy professionals. professionals.
It’s also important to note that when two clinicians work It’s also important to note that when two clinicians work together, which may be common with a recreational together, which may be common with a recreational therapist and an occupational therapist, the clinicians therapist and an occupational therapist, the clinicians must split the time between the two disciplines. must split the time between the two disciplines.
Music Therapy is included under Recreational Music Therapy is included under Recreational Therapy as well. Therapy as well.
– Music Therapy DefinitionMusic Therapy Definition
– Supportive ResearchSupportive Research
– Health Care Industry RecognitionHealth Care Industry Recognition
– QualificationsQualifications
Reimbursement Reimbursement ProcessProcess
Step Six: Contact Primary Care Step Six: Contact Primary Care
Physician Physician – Provide MT information Provide MT information – Seek Written Referral Seek Written Referral – Request Diagnostic CodesRequest Diagnostic Codes
International Classification of International Classification of
Reimbursement Reimbursement ProcessProcess Step Twelve: Follow-up with PayerStep Twelve: Follow-up with Payer
– Appealing an Adverse DecisionAppealing an Adverse Decision What was the reason for denial?What was the reason for denial? Who made the initial decision?Who made the initial decision? What is the appeals process?What is the appeals process? What additional information is needed What additional information is needed
to to review the appealed case?review the appealed case? Involve the referring physicianInvolve the referring physician Involve the patient/familyInvolve the patient/family
Reimbursement TipsReimbursement Tips
– Don’t Stop at “NO”Don’t Stop at “NO”
– Develop Relationships with Insurance Develop Relationships with Insurance
Company Case ManagersCompany Case Managers
– Present Clear and Accurate InformationPresent Clear and Accurate Information
– Respond to All Communication in a Respond to All Communication in a
Timely and Professional MannerTimely and Professional Manner