QUIZ: 2023 Medicare Part B Coverage, Coding and Billing

If a resident has Medicare Part A, they automatically have Medicare Part B.

Medicare Part B pays the following amount for therapy services provided:

The Medicare Benefit Policy Manuals contain all Medicare regulation. In what Chapter can the rules for Part B in the SNF be found?

When the physician signs the therapy Plan of Care, which of the following is the physician attesting to?

True or False? A MD order for therapy services is not required by Medicare Part B.

Payment is dependent on the certification of the plan of care rather than the order, but the use of an order is prudent to determine that a physician is involved in care and available to certify the plan.

Under Part B, therapy treatment cannot begin until the Plan of Care is established. Medicare defines “established” as “written or dictated.” According to Chapter 15 of the Manual, the only exception to this rule which will allow treatment to begin before the Plan of Care is written is:

The contents of the therapy Plan of Care are dictated by Medicare Part B. The minimum contents include:

The maximum duration for the therapy Plan of Care is 30 days.

The following statements are True:

• Diagnosis or prognosis is NOT a factor in deciding if a service is SKILLED
• Potential for recovery is NOT a deciding factor
• The key is if the SKILL of the therapist was needed—if the service could have been provided by non-skilled personnel (aide, family) it is not skilled

Medicare Part B defines a Clinician as a Therapist or Assistant, and defines a Qualified Professional as only a Therapist, not an Assistant.

Part B defines both Rehabilitative and Maintenance Therapy services. What do they both have in common?

The Medicare Program Integrity Manual used by reviewers to determine medical necessity states that is is possible to provide a level of therapy that exceeds the resident’s need.

The documentation requirements (type of documentation, amount of documentation, who can complete the documentation) are different for Part A and Part B.

In order for reimbursement under Medicare Part B in the SNF, physical therapist assistants and occupational therapy assistants (PTA’s and OTA’s) must be under general supervision of the licensed therapist. General supervision does not require the therapist to be on site.

Part B therapy services are categorized and billed using what type of codes, owned by the American Medical Association?

An example of when Modifier 59 would need to be used is:

We no longer have a “Therapy Cap.” However, continue to have a dollar “threshold.”  The KX Modifier is used on the billing claim next to all therapy charges when the KX $ threshold is reached. This means that when the “limit” of OT services or “limit” of PT and Speech services combined are reached, the KX needs to be included. The definition of the KX Modifier on the claim is:

“Stating that the therapist or therapy provider is confirming that the services are medically necessary as justified by appropriate documentation in the medical record.”

A Manual Medical Review is AUTOMATIC once a therapy threshold of $3000 is reached by OT and/or PT and Speech, and the potential for a denial of services is likely.

How would the following treatment session be billed?

• 24 minutes of neuro-muscular reeducation, code 97112
• 23 minutes of therapeutic exercise, code 97110

New Modifiers were required on Part B billing claims starting 1/1/20 to indicate when an assistant (PTA/OTA)  provided “in whole or in part” of a  therapy “service.” How does CMS define “in whole and in part?”

Which of the following are potential signs of Part B billing negative practice patterns / fraud / abuse?

Medicare Part B treatments are categorized as either “individual” or “group.” A group is defined as 2 or more residents receiving treatment at the same time by the same therapist.

Part B billing allows “concurrent therapy,” which is defined as treatment of 2 residents at the same time.

If you have been identified as being part of a TPE (Targeted Probe and Educate) audit by CMS, CMS has already identified a potential problem with your facility billing patterns.

“Tolerated well” “ Continue Plan of Care” & “Remains Stable” are all acceptable terms when documenting for a resident covered by Medicare Part A and B.