Orthotics Billing and Documentation Quiz

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Questions and Answers

What is a necessary prerequisite before billing for custom-fabricated AFOs or KAFOs?

Availability of prefabricated options

Prior authorization must be obtained (correct)

Submission of a final invoice

Predetermined patient fee schedule

Which situation qualifies for the coverage of custom-fabricated AFOs or KAFOs?

A patient who prefers custom fittings

A beneficiary unable to use prefabricated AFOs (correct)

A patient without any documented conditions

A patient with a temporary injury expected to heal within 3 months

What modifier might be used on claims to indicate the side of limb where a device is applied?

N for not applicable

C for coverage

RT for right or LT for left (correct)

S for significant

What documentation should be included when submitting a treatment plan for orthotic devices?

Details of all patient interactions Signup and view all the answers

Which condition does NOT warrant custom fabrication of an orthotic device?

A recently diagnosed temporary sprain Signup and view all the answers

What is the primary purpose of the ICD-10 coding system?

To classify and code all diagnoses and symptoms Signup and view all the answers

Which coding system is specifically used for Durable Medical Equipment?

Healthcare Common Procedure Coding System (HCPCS) Level 2 Signup and view all the answers

Which of the following best describes a base code?

A code representing every device in a healthcare setting Signup and view all the answers

What would be an example of patient financial responsibility?

The co-pay amount due at the time of service Signup and view all the answers

What is the role of an Explanation of Benefits (EOB)?

To provide a summary of services covered by the insurance Signup and view all the answers

Which code indicates an acquired absence of the left leg above the knee?

Z89.612 Signup and view all the answers

What does HCPCS Level 1 primarily include?

CPT codes for medical services and procedures Signup and view all the answers

Which of the following best describes contracted service rates?

Agreed-upon payment rates between insurers and healthcare providers Signup and view all the answers

If a patient has a deductible of $500 and has already met $450, how much more does the patient need to meet the deductible?

$50 Signup and view all the answers

What is the patient's financial responsibility if the charge for the orthotic device is $1,000 and the patient has met a deductible of $450 out of $500 with a coinsurance of 20%?

$100 Signup and view all the answers

What does the term 'coinsurance' refer to in patient financial responsibilities?

A percentage of the total amount billed that the patient must pay Signup and view all the answers

Which of the following L-codes refers to a prefabricated ankle foot orthosis that includes fitting and adjustment?

L1930 Signup and view all the answers

How is the term 'EOB' most accurately defined in a healthcare context?

Explanation of benefits detailing charges and payments Signup and view all the answers

What is the total allowable amount for code L1904, a custom-fabricated ankle orthosis?

$517.63 Signup and view all the answers

If the patient has already met a deductible, what percentage does the patient owe for the next $1,000 billed amount considering a 20% coinsurance?

$200 Signup and view all the answers

What is the main focus of 'Improper Payment Reduction' initiatives in healthcare?

To minimize errors in billed claims for services Signup and view all the answers

Which of the following is a characteristic of a contracted service rate?

It is typically negotiated between the insurance company and the provider Signup and view all the answers

What type of L-code would you use to bill for an elastic ankle orthosis that is prefabricated and includes fitting and adjustment?

L1902 Signup and view all the answers

Match the following conditions with the criteria for custom-fabricated AFOs or KAFOs:

Beneficiary could not be fit with a prefabricated AFO = Criterion #1 Need to control knee, ankle or foot in more than one plane = Criterion #3 Condition expected to be permanent or longstanding = Criterion #2 Documented neurological, circulatory, or orthopedic status = Criterion #4 Signup and view all the answers

Match the following modifiers with their meanings in billing:

RT = Right side application LT = Left side application -S = Significant procedural service -F = Reduced service on the fault side Signup and view all the answers

Match the following terms with their descriptions:

Prior Authorization = Requirement before treatment approval Documentation = Record of all interactions Addition Code = Special modifications to the base code Payer = Entity responsible for coverage and payment Signup and view all the answers

Match the following components of treatment plans with their requirements:

Must have authorization = Prior to billing Document ALL interactions = Date, name, reference number Submission of coding = After evaluation Considering policies = What are the coverage criteria? Signup and view all the answers

Match the following claims processes with their requirements:

Submit treatment plan = After evaluation and documentation Authorization must be obtained = Prior to billing Information conveyed by modifiers = Billing or clinical details Matching of conditions to coverage = Analysis of specific beneficiary needs Signup and view all the answers

Match the following diagnosis codes with their corresponding descriptions:

Z89.612 = Acquired absence of left leg above knee Q67.3 = Plagiocephaly W61.43XA = Pecked by a turkey, initial encounter Z56.4 = Discord with boss or workmates Signup and view all the answers

Match the following features with their respective coding systems:

ICD-10 = Classifies and codes diagnoses, symptoms, procedures CPT = 5 numeric digits for medical services/procedures HCPCS Level 1 = Includes medical services not covered by CPT HCPCS Level 2 = Codes for products and supplies not included in CPT Signup and view all the answers

Match the following CPT codes with their descriptions:

99204 = New patient office visit, 45-59 minutes 95851 = Range of motion measurements and report L1960 = Ankle foot orthosis, custom fabricated L5301 = Below knee, molded socket, endoskeletal system Signup and view all the answers

Match the following terms related to reimbursement with their definitions:

Deductible = Amount a patient pays before insurance covers costs Coinsurance = Percentage paid by the patient after deductible Base code = Primary code representing a medical device EOB = Document explaining benefits paid or denied by insurance Signup and view all the answers

Match the following statements with the coding system they pertain to:

CPT = Used primarily for medical procedures and services HCPCS Level 1 = Manages codes for professional services ICD-10 = Codes for health conditions and injuries HCPCS Level 2 = Used for billing supplies and durable medical equipment Signup and view all the answers

Match these components of patient assessment with their billing relevance:

Patient assessment = Determines necessary coding Coding = Standardizes diagnosis for billing Billing = Final process of claiming insurance reimbursement Reimbursement = Compensation received for services rendered Signup and view all the answers

Match the following codes with their coding levels:

CPT = Level 1 HCPCS L-codes = Level 2 HCPCS ICD-10 = Diagnosis coding system HCPCS = Healthcare procedure and product coding system Signup and view all the answers

Match the following medical billing terms with their related functions:

Pre-authorization = Approval for services before they are provided Claim = Request for payment from an insurance company Patient responsibility = Amount patient owes after insurance pays Write-off = Reduction in billed amount accepted by provider Signup and view all the answers

Match the following terms with their definitions related to billing terminology:

Deductible = Amount patient pays FIRST before health insurance begins to pay Coinsurance = Patient share of costs after meeting deductible Copay = Fixed amount paid for service (generally doctor visits, urgent care, ER) Allowable = Contracted rate for service between provider and health insurance Signup and view all the answers

Match the following improper payment terms with their descriptions:

CERT = Comprehensive Error Rate Testing RAC = Recovery Audit Contractors Improperly coded items = Claims with incorrect coding that lead to payment issues Insufficient documentation = Lack of necessary supporting documents for claims Signup and view all the answers

Match the payment responsibilities with their examples:

Deductible = $1,000 amount patient must pay before insurance starts Coinsurance = 20% patient pays after meeting deductible Copay = $30 fixed amount paid for a doctor visit Allowable = Varying amounts for the same service with different insurances Signup and view all the answers

Match the following payment types with their characteristics:

Deductible = Amount patient is required to reach before coverage starts Coinsurance = Percentage of costs patient shares after deductible Copay = Set fee for medical services regardless of total charge EOB = Document explaining benefits and patient financial responsibility Signup and view all the answers

Match the different roles in billing with their corresponding actions:

Patient = Responsible for paying the copay and shared costs Provider = Submits claims to insurance for reimbursement Insurance = Processes claims and determines allowed amounts RAC = Audits claims to identify and reduce overpayments Signup and view all the answers

Match the following billing components with their examples:

Billed vs. Allowed = Total charged vs. approved amount by insurance Improper payments = Payments made incorrectly due to coding or documentation errors Comprehensive Error Rate Testing = Used to evaluate the rate of improper payments Custom vs. off-the-shelf = Types of device classifications for billing purposes Signup and view all the answers

Match the financial responsibilities with their definitions:

Deductible = Amount that must be met before any insurance payment applies Coinsurance = Percentage of a medical bill paid by the patient Copay = Fixed fee paid at the time of service Allowable = Maximum amount insurance will reimburse for a procedure Signup and view all the answers

Match the following payment-related terms with their implications:

RAC auditing = Finds and collects overpayments from improper claims CERT = Monitoring for errors in claims processing Insufficient documentation = Leads to claims being denied or underpaid Improper payment rates = Calculated from a sub-sample of claims reviewed Signup and view all the answers

Match the following residency components with their descriptions:

Residency Mentor = Teach, supervise, and assess resident progress Resident Awards = Financial awards for travel/meeting attendance Feedback mechanism = Neutral 3rd party assessment for residents Regional Residency Liaison Network = CPOs volunteering to assist with NCOPE Signup and view all the answers

Match the types of residency considerations with their categories:

Clinical vs Research = Type of residency Pediatric vs Adult vs Geriatric = Exposure to patient types On-site fabrication = Work setting Specialty populations = Pathologies and device type Signup and view all the answers

Match the questions to ask residency sites with their relevance:

What are your expectations for a resident? = Understanding role definitions Does the residency have a formal structure? = Assessing organization Will I see all the items on the competency forms? = Evaluation readiness How much supervision vs autonomy will I have? = Determining operational dynamics Signup and view all the answers

Match the types of funding options for Resident Awards with their purpose:

Financial awards for travel = Support meeting attendance Research project presentation = Develop presentation skills Funding for additional training = Enhance professional development Grants for clinical practice = Support applied healthcare experience Signup and view all the answers

Match the categories of exposure in residency with their descriptions:

Pathologies = Conditions addressed during residency Patient Types = Demographics encountered Work Setting = Environment of clinical practice Device Type = Orthotic and prosthetic technologies used Signup and view all the answers

Match the following financial responsibilities to their respective patient scenarios:

$200 = Patient has met $500 deductible with 10% coinsurance $450 = Patient has met $500 deductible with 20% coinsurance $500 = Patient has met $1000 deductible with 50% coinsurance $100 = Patient has met $1000 deductible with 0% coinsurance Signup and view all the answers

Match the residency type with its characteristics:

Clinical track = More commonly chosen Research & Development track = Directed study (research project) Not offered by all sites = Research & Development track Quarterly activities = Clinical track Signup and view all the answers

Match the roles of NCOPE with their descriptions:

Accrediting education programs = Responsible for residency standards Creating guidelines = Standards for residency sites Registration of residents = Tracking resident progress Utilizing website = For updated residency information Signup and view all the answers

Match the definitions with the corresponding terms in Orthotic and Prosthetic education:

Residency = Second half of an individual's education NCOPE = National Commission on Orthotic and Prosthetic Education Clinical care = Independent autonomous delivery Board exams = Required for certification Signup and view all the answers

Match the educational requirements with their descriptions:

Combined prosthetics and orthotics master’s degree = Current educational requirement ABC exams = Transition to dual-discipline format Residency standards = Reflecting the full scope of practice NCOPE residency program = Lists accredited residency programs Signup and view all the answers

Match the financial responsibility calculations to their outcomes:

$500 deductible, $100 met = $900 owed with 50% coinsurance $500 deductible, $200 met = $300 owed with 10% coinsurance $1000 deductible, $450 met = $550 owed with 20% coinsurance $1000 deductible, $0 met = $1000 owed with 50% coinsurance Signup and view all the answers

Match the resource with its purpose in residency information:

NCOPE website = Up-to-date residency information Residency Program Directory = Lists accredited programs Dual-credential pathway = Transition information ABC FAQs = Common questions about exams Signup and view all the answers

Match the components of financial responsibility to their implications:

Deductible = Set amount patient pays before insurance Coinsurance = Percentage of costs after deductible Out-of-pocket maximum = Total cap on patient expense Premium = Monthly cost for insurance plan Signup and view all the answers

Match the factors affecting financial responsibility to their descriptions:

Coinsurance rate = Percentage owed for services received Deductible amount = How much needs to be met annually Patient responsibility = Costs after insurance has paid Network status = Impact on out-of-pocket costs Signup and view all the answers

Match the HCPCS codes with their corresponding descriptions:

L1902 = Ankle orthosis, prefabricated, off-the-shelf L1904 = Ankle orthosis, custom fabricated L1940 = Ankle foot orthosis, custom fabricated L2200 = Addition to lower extremity, limited ankle motion, each joint Signup and view all the answers

Match the following financial terms with their definitions:

Deductible = Amount a patient pays before insurance kicks in Coinsurance = Percentage of costs a patient pays after deductible Allowable = Maximum amount insurance will pay for a service Out-of-pocket = Total amount the patient pays for healthcare services Signup and view all the answers

Match the patient financial responsibility items with their amounts:

$450 = Amount met of the $500 deductible $100 = Remaining deductible amount 20% = Coinsurance rate applicable $1,000 = Charge for orthotic device Signup and view all the answers

Match the L-codes with their foot orthosis types:

L1930 = Plastic foot orthosis, prefabricated, includes fitting L1950 = Spiral AFO, custom fabricated L1970 = Plastic AFO with ankle joint, custom fabricated L1945 = Plastic AFO, custom fabricated, floor reaction type Signup and view all the answers

Match the following HCPCS codes with their allowable amounts:

L1902 = $85.60 L1940 = $558.47 L2210 = $72.08 L2280 = $647.40 Signup and view all the answers

Match the types of additional lower extremity orthotic assists with their purposes:

L2210 = Dorsiflexion assist L2220 = Dorsiflexion and plantar flexion assist/resist L2270 = Varus/valgus correction strap L2820 = Soft interface for molded plastic, below knee section Signup and view all the answers

Match the L-codes to their fabrication types:

L1904 = Custom fabricated L1902 = Prefabricated, off-the-shelf L1960 = Custom fabricated, posterior solid ankle L1951 = Prefabricated, plastic with fitting Signup and view all the answers

Match the description with their respective additional codes:

L2275 = Varus/valgus modification L1932 = Rigid AFO, total carbon fiber L2200 = Limited ankle motion assist L1945 = Floor reaction AFO, custom fabricated Signup and view all the answers

Match the patient responsibility scenarios with their calculations:

$100 = Amount owed after $450 deductible met and $1,000 charge $450 = Total deductible met before threshold $400 = Remaining patient responsibility after first step of coinsurance $500 = Total deductible before coinsurance applies Signup and view all the answers

What is the primary reason gloves should be donned last when wearing them in combination with other PPE?

To minimize the risk of contamination during removal. Signup and view all the answers

What is an important step to take after removing gloves?

Perform hand hygiene. Signup and view all the answers

Why are isolation gowns typically removed before leaving a patient room?

To prevent contamination of the exterior surfaces. Signup and view all the answers

What can masks protect against in a healthcare setting?

Direct contact with respiratory secretions. Signup and view all the answers

In which situation would additional transmission precautions be necessary?

When a patient is confirmed to have an infectious disease. Signup and view all the answers

What type of protective equipment is intended to cover the body from neck to mid-thigh?

Gowns. Signup and view all the answers

What common misconception about PPE use might increase contamination risk?

It is unnecessary to perform hand hygiene after PPE removal. Signup and view all the answers

Which type of PPE is primarily used to protect the mucous membranes from infectious agents?

Masks and eye protection. Signup and view all the answers

What is the role of gloves in preventing the transmission of infectious agents?

They act as a barrier during contact with contaminated surfaces. Signup and view all the answers

Which of the following is NOT a category of transmission precautions used in healthcare?

Thermal Precautions. Signup and view all the answers

What is the primary purpose of performing hand hygiene?

To reduce the spread of infection Signup and view all the answers

When should hand hygiene be performed?

Before and after contact with patients Signup and view all the answers

Which of the following personal protective equipment (PPE) is considered essential when caring for patients?

Gloves, masks, and gowns Signup and view all the answers

What is the recommended duration for rubbing hands with soap and water to ensure effectiveness?

15-20 seconds Signup and view all the answers

What should be done before putting on gloves according to proper hand hygiene protocols?

Perform hand hygiene Signup and view all the answers

Which of the following surfaces is known to harbor bacteria for days, necessitating regular cleaning?

Bed rails Signup and view all the answers

What is the recommended method of hand hygiene when hands are not visibly soiled?

Using alcohol-based hand rubs Signup and view all the answers

After removing gloves, what is the next step that should be taken?

Perform hand hygiene Signup and view all the answers

Which precaution is essential for preventing the transmission of infectious agents that are spread by respiratory droplets?

Wearing a mask and eye protection Signup and view all the answers

What should be done to ensure proper hand hygiene in a healthcare setting?

Perform hand washing before and after patient contact Signup and view all the answers

Which is NOT a recommended practice for Personal Protective Equipment (PPE) in a hospital setting?

Simply wearing gloves when handling patients Signup and view all the answers

Which type of infection control guideline is required when dealing with airborne-transmitted infections like tuberculosis?

Airborne infection isolation room (AIIR) Signup and view all the answers

What is the primary role of gloves in infection control?

To minimize direct contact with infectious materials Signup and view all the answers

In what scenario is the use of a respirator required?

For airborne infections like chickenpox Signup and view all the answers

Which practice is crucial to prevent contamination in a healthcare environment?

Maintaining proper hand hygiene practices Signup and view all the answers

Which of the following is a requirement for providers when taking care of patients with contact precautions, such as with norovirus?

Using dedicated or disposable equipment when possible Signup and view all the answers

What is a significant part of the protocol when an inpatient is receiving care in the operating room?

Scrubbing in and wearing appropriate PPE Signup and view all the answers

When providing care in inpatient settings, what should be confirmed with patient interaction?

Patient identification and their family's relationship Signup and view all the answers

Study Notes

Week 12: Billing & Reimbursement, Residency & Board Exams

This week's topic covers billing and reimbursement procedures, residency information, and board exams.
Learning objectives include defining the relationship between patient assessment, coding, and billing, defining reimbursement terms, and calculating sample patient financial responsibility.
Key elements for understanding billing and reimbursement include allowable charges, deductibles, coinsurance, and copayments. Different insurance plans have varying billing policies.
Diagnosis codes, such as ICD-10, are crucial for accurate billing and reimbursement. Examples of ICD-10 codes include Z89.612, Q67.3, W61.43XA, and Z56.4.
Healthcare Common Procedure Coding System (HCPCS) codes are standardized codes for medical procedures and products. HCPCS is managed by the Centers for Medicare and Medicaid Services (CMS).
HCPCS codes are categorized into Level 1 (CPT codes for medical services/procedures) and Level 2 (DMEPOS codes for durable medical equipment).
The HCPCS codes for Orthopedic and Prosthetics (O&P) can have specific base and addition codes.
Understanding payer considerations is vital. Learn about the policies and coverage criteria for different payers, and when prior authorization is required.
Documentation of all interactions, including dates, names, and reference numbers, is essential.
Coverage criteria for specific treatments, such as custom-fabricated AFOs and KAFOs, may vary based on patient and/or insurance criteria.
Improper payment issues such as incorrect coding and insufficient documentation can lead to overpayments or recovery audits.

Diagnosis Codes

ICD-10 is the International Classification of Diseases, 10th Revision.
It is used to classify and code diagnoses, symptoms, and procedures.
Examples of ICD-10 codes are provided in the material.

Alphabet Soup

HCPCS is a standardized coding system for medical procedures and products.
Part 1 of HCPCS is for medical services and procedures.
Part 2 is for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS).
Level 1 codes use 5 numerical digits (medical services/procedures).
Level 2 codes combine a letter with 4 numerical digits (products/supplies).

O&P HCPCS Codes

Base codes specify the device type.
Addition codes describe specific features or modifications.
Modifiers offer additional information for billing or clinic purposes.

Payer Considerations

Understanding payer policies is essential.
The payer must be indicated and coverage criteria clarified before service is provided.
Prior authorization may be needed.
Document all interactions (dates, names, reference numbers) for billing purposes.

Coverage Criteria Example

Rules govern coverage for customized devices.
Factors like prefabrication, duration of condition, need for control in multiple planes, or injury prevention influence coverage.
Pre-existing conditions (neurological, circulatory, or orthopedic) might necessitate custom fabrication.

Improper Payments

Errors in coding or documentation can result in improper payments.
Organizations that conduct audits (e.g. CERT, RAC) help prevent overpayment.

Billing Terminology

Allowable: Agreed-upon rate between insurance company and service provider.
Deductible: Patient's portion of costs before healthcare insurance begins to pay.
Coinsurance: Patient's portion of costs after meeting the deductible.
Copay: Fixed fee for services (doctor’s visits, urgent care, or ER)

EOB (Explanation of Benefits)

Shows billing amounts, allowed amounts, and patient responsibilities for payment.
It shows allowances, deductibles, and coinsurance details, as well as payer and patient responsibilities.

Activity

Review the codes and descriptions for the orthopedic or prosthetic supplies/devices.
Determining patient financial responsibility for the device.
Identifying Medicare allowable, deductible, and coinsurance.

Residency

Residency is the second half of an individual's O&P education.
Clinical Track is the most common residency path.
NCOPE is responsible for accrediting orthotic, prosthetic, and pedorthic residency programs, and provides current guidelines/standards for programs.
Various residency options (e.g. clinical track, research & development, directed study) exist.

Residency Site Questions

Asking the appropriate questions helps evaluate a residency program.
Assess the residency site, what they expect, how much autonomy/supervision is involved, and if appropriate support is provided.

Residency Advice

Professional skills that are essential in the O&P field are described.
Important skills include excellent patient communication, psychomotor skills, clinical problem-solving, adaptability, enthusiasm, and the ability to learn from errors.

Board Exams

Eligibility for ABC board exams (e.g., Master's, clinical residency) is based on criteria.
Three major parts (Combined O&P Written Exam, Simulation Exam, and Clinical Patient Management (CPM) Exam) to become a CPO.

Domains of Practice

Board exams cover 5 main practice areas: Patient Assessment, Formulation of Treatment Plan, Implementation of Treatment Plan, Follow-up Treatment Plan, and Practice Management.
Online resources provide outlines, references, reading lists, and practice questions.

Combined O&P Written Exam

Covers general knowledge of patient management, including anatomy, physiology, biomechanics, kinesiology, disease processes, prescription criteria, material science, and professionalism.
Format is computer-based with multiple-choice questions.

Combined O&P Written Sample Questions

Sample questions illustrate content covered by the exam.

Simulation Exam

The simulation exam assesses real-world practice scenarios.
Questions focus on problem-solving, implementation of practice, and obtaining information about the patient

The topics of the Simulation Examination are separated broadly into orthoses and prosthetics.

The proportion of time allotted to each topic, as well as time allotted in specific divisions of that discipline.
The exam is 3-hour, computer-based with 7 scenarios.

Clinical Patient Management (CPM) Exam

Assessment occurs through hands on, practical applications and models.
The exam includes interaction with patient models, assessment of patient interaction skills, completing assigned clinical tasks, and answering oral questions.
It is taken at designated testing centers in Tampa, Florida.

CPM Exam Topics

Questions about orthotic and prosthetic management, evaluation, and recommendations are frequent and form the core of the exam.

Exam Fees and Dates

Fees and dates for each exam are provided.
Necessary steps to be taken such as application, registration, and appropriate markings for NCOPE are outlined.

Other Notes

Additional notes, considerations, and questions to help the student with the content.

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Description

Test your knowledge on the billing and documentation requirements for custom-fabricated AFOs and KAFOs. This quiz covers necessary prerequisites, coverage situations, modifiers for claims, and essential documentation for treatment plans. Determine your understanding of conditions related to custom fabrication in orthotics.