ORPR580 Week 12 Billing & Reimbursement, Residency & Board Exams PDF

Week 12: Billing & Reimbursement, Residency & Board Exams Darren Bolger, CPO, MSPO Billing & Reimbursement   Define relationship of patient assessment, coding Learning and billing Objectives  Define common terms related to reimbursement  Calculate sample patient...

Week 12: Billing & Reimbursement, Residency & Board Exams Darren Bolger, CPO, MSPO Billing & Reimbursement   Define relationship of patient assessment, coding Learning and billing Objectives  Define common terms related to reimbursement  Calculate sample patient financial responsibility   ICD-10  International Classification of Diseases  Classify and code all diagnoses, symptoms, procedures Diagnosis Codes  Examples  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   Healthcare Common Procedure Coding System (HCPCS)  Produced and managed by CMS (Centers for Medicare & Medicaid Services)  Standardized codes for medical procedures/products  Divided into two subsystems (Level 1 and 2) Alphabet  Level 1  Medical services/procedures (physician, PT, etc.) Soup  Current Procedural Terminology (CPT) codes  5 numeric digits  Examples  99204: New patient office or other outpatient visit, 45-59 minutes  95851: Range of motion measurements and report; each extremity (excluding hand) or trunk section (spine)   Level 2  Products, supplies, services not included in CPT  Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Alphabet  1 letter followed by 4 numeric digits  O&P: Most commonly L or A codes Soup  Example:  L1960: Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated  L5301: Below knee, molded socket, shin, sach foot, endoskeletal system   Base code  Every device has a base code  L1960: Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated  Look for:  Device level  Custom vs. prefabricated O&P HCPCS  Materials  Addition code(s) Codes  May or may not have addition code(s)  “Addition to…”  L2280: Addition to lower extremity, molded inner boot  Modifiers  Conveys information (billing or clinical)  RT or LT   Who is the payer?  What are the policies and coverage criteria? Payer  Do I need a prior authorization?  Submit treatment plan (documentation and consideratio coding) after evaluation ns  Must have authorization prior to billing  Document ALL interactions  Date, name, reference number  AFOs and KAFOs that are custom-fabricated are covered for ambulatory beneficiaries when the basic coverage criteria listed above and one of the following criteria are met: 1.The beneficiary could not be fit with a prefabricated AFO; or, Coverage 2.The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6 Criteria months); or, 3.There is a need to control the knee, ankle or foot in more Example than one plane; or, 4.The beneficiary has a documented neurological, circulatory, or orthopedic status that requires custom fabricating over a model to prevent tissue injury; or, 5.The beneficiary has a healing fracture which lacks normal anatomical integrity or anthropometric proportions.   May include:  Items that are deemed “not medically necessary”  Incorrectly coded items  Insufficient documentation (notes, Rx, delivery receipt) Improper  Comprehensive Error Rate Testing (CERT) Payments  Improper payment rates using sub-sample of claims  Recovery Audit Contractors (RAC)  Reduce improper payment through detection and collection of overpayments  Incentivized to find technical deficiencies in your claim   Allowable:  Contracted rate for service between provider and health insurance  Same service may have different allowable for different insurance  Deductible:  Amount patient pays FIRST before health Billing insurance begins to pay Terminology  Coinsurance:  Patient share of costs after meeting deductible  Copay:  Fixed amount paid for service (generally doctor visits, urgent care, ER)  O&P providers DO NOT receive a copay for patient visits  Deductible $1000 Coinsurance 20% HCPC Billed vs. S Allowed Example EOB (Explanation of Benefits) Who sends the EOB? Who does the patient pay?   Part 1  Code the device pictured  Base code descriptions  Custom vs. off-the-shelf  Materials  Addition codes? Activity  Part 2  What is patient financial responsibility for this device?  Medicare allowable  Deductible and how much met  Coinsurance  HCPC Allowa S ble Long Description Ankle orthosis, ankle gauntlet or similar, with or without joints, L1902 85.60 prefabricated, off-the-shelf Ankle orthosis, ankle gauntlet or similar, with or without joints, L1904 517.63 custom fabricated Ankle orthosis, supramalleolar with straps, with or without L1907 645.32 interface/pads, custom fabricated Ankle foot orthosis, plastic or other material, prefabricated, L1930 288.91 includes fitting and adjustment L1932 1023.33 Afo, rigid anterior tibial section, total carbon fiber or equal Base Codes material, prefabricated, includes fitting and adjustment L1940 558.47 Ankle foot orthosis, plastic or other material, custom fabricated Ankle foot orthosis, plastic, rigid anterior tibial section (floor L1945 1287.27 reaction), custom fabricated Ankle foot orthosis, spiral, (institute of rehabilitative medicine L1950 881.96 type), plastic, custom fabricated Ankle foot orthosis, spiral, (institute of rehabilitative medicine L1951 963.09 type), plastic or other material, prefabricated, includes fitting and adjustment L1960 710.88 Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated L1970 793.74 Ankle foot orthosis, plastic with ankle joint, custom fabricated L1971 537.58 Ankle foot orthosis, plastic or other material with ankle joint, prefabricated, includes fitting and adjustment  HCPC Allowab S le Long Description L2200 57.62 Addition to lower extremity, limited ankle motion, each joint Addition to lower extremity, dorsiflexion assist (plantar flexion L2210 72.08 resist), each joint Addition to lower extremity, dorsiflexion and plantar flexion Addition L2220 92.79 assist/resist, each joint Addition to lower extremity, varus/valgus correction ('t') strap, Codes L2270 70.69 padded/lined or malleolus pad Addition to lower extremity, varus/valgus correction, plastic L2275 149.48 modification, padded/lined L2280 647.40 Addition to lower extremity, molded inner boot Addition to lower extremity orthosis, soft interface for molded L2820 93.12 plastic, below knee section   L-codes(s): Row 1  Financial responsibility:  Patient has met $450 of $500 deductible  Coinsurance: 20%  What does patient owe?   L-codes(s): Row 2  Financial responsibility:  Patient has met $200 of $500 deductible  Coinsurance: 10%  What does patient owe?   L-codes(s): Row 3  Financial responsibility:  Patient has met $100 of $1000 deductible  Coinsurance: 50%  What does patient owe? Residency & Board Exams   Discuss options to consider when choosing Learning residency sites Objectives  Review websites and resources for residents  Describe various board exams required for certification   Second half of an individual's education and advancement towards becoming an O&P professional  The goal of residency is to develop a competent orthotist/prosthetist capable of delivering independent autonomous clinical care What is  Options: Residency?  Clinical track  More commonly chosen  Quarterly activities (CAT, journal club, case presentation, etc.)  Research & Development track  Not offered by all sites  “Directed study” (research project)   Responsible for accrediting orthotic, prosthetic and pedorthic education programs including clinical residency  Roles: NCOPE  Creating guidelines/standards for residency sites National Commission on Orthotic and Prosthetic  Registration of residents Education  Tracking of resident progress/completion https://ncope.org/  Utilize website for most up-to-date residency information   Current educational requirement is a combined prosthetics and orthotics master’s degree  Next step to advance residency standards to Time of reflect the full scope of orthotic and prosthetic Transition practice  After the adoption of revised residency (NCOPE and standards, the ABC exams will transition to a ABC) dual-discipline format https://ncope.org/index.php/hom e-page-v2/residency-program-ser vices/dual-credential-pathway-fa q/# https://abcop.org/faqs/orthotist-p rosthetist-faqs   NCOPE Residency Program Directory  https://ncope.org/index.php/home-page-v2/reside ncy-and-professional-experiences/residency-progr am-directory/ How do I  Lists all “accredited” residency programs find a  May or may not be hiring residents at a given time Residency?  OPRESCAS  Application system  Connects prospective residents and residency sites to facilitate placement  Used by all residency sites except Hanger   No shared timeline/decision making  Interviews  Generally fall through early winter General  Consider for next year: Timing  Letters of Recommendation  Updating resume  Offers/Decisions  Beginning in February   Get registered with NCOPE  Complete registration form at least 2 weeks before residency  Submit paperwork (transcripts, etc.)  Submit registration fee Starting  Single discipline: $1890  Dual discipline: $3780 your  Often (not always) covered by the residency site Residency  Are you working in a state (15 currently) with licensure?  Resident’s responsibility to become familiar with state requirements  May be additional steps (or fees) required to start residency  Example: Florida and NJ you must be a licensed Resident before beginning your residency   Arguments for licensure:  Licensure benefits the patient  Requiring O&P services to be provided only by professionals who meet specific education and experience criteria  Licensure is in the best interests of the profession  Provide official status to the practice of the profession Licensure  Establish a recognized scope of  Provide recognition by other healthcare practitioners  Generally managed by state medical board  Some large private healthcare insurers require O&P facility accreditation by ABC or similar as condition of participation in their network https://www.oandp.org/page/position-statement-on-licensure   NCOPE Tracker  Case log – tracks patient encounters (observe, assist, perform) During your  Quarterly forms Residency   Evaluation of resident Quarterly activities (clinical track or R&D track)  Competency forms  Evaluation of mentor/program  Orthotics Prosthetics  Custom Foot Orthosis  Custom AFO  Transtibial Prosthesis Resident  Knee Orthosis  Transfemoral Prosthesis Clinical  Custom KAFO  Upper Limb Prosthesis Competenci  Custom TLSO  Partial Foot or Symes es  Custom Scoliosis  Post Operative Care  Upper Limb Orthosis  Technical Skills & Safety Competency  Technical Skills & Safety Competency   Residency Director  Responsible for managing program, coordinating the schedule, guiding progress, etc.  Residency Mentor  Teach, supervise, and assess resident progress  Regional Residency Liaison Network (RRL) Residency  CPOs volunteering to assist with NCOPE Resources  Feedback mechanism for residents (neutral 3rd party)  Assist with resident questions  Resident Awards  Financial awards for travel/meeting attendance  Generally awarded for research project presentation   What to think about:  Type of residency  Clinical vs. Research  Hospital vs. Private Practice vs. VA Considerati  Exposure to patient types  Pediatric vs. adult vs. geriatric ons for  Pathologies and device type Residency  Specialty populations (athlete, upper limb)  Work setting  Size of clinic  On-site fabrication  Opportunity to work with variety of clinicians   Questions to ask residency sites:  What are your expectations for a resident? Residency  Does the residency have a formal structure?  How much supervision vs autonomy will I have? Site  What associated fees are paid by the company? Questions  What kind of support do you offer for the ABC exams?  Will I see all the items on the competency forms?   Skills to work on:  Patient communication  Psychomotor skills  Clinical problem solving Residency  Other characteristics Advice   Initiative Adaptability  Self-aware  Enthusiasm  Not afraid to make mistakes and learn from them Board Exams   Eligibility for ABC Board Exams  Master’s degree in O&P  Eligible for Combined O&P Written exam after graduation  Completion of clinical residency American  Three Parts Board for  Combined O&P Written Exam  Simulation Exam Certification  Clinical Patient Management (CPM) Exam (ABC)  To Become a CPO (now): https://abcop.org/individual-c  5 total exams ertification/get-certified/orth otist-prosthetist/overview  Combined O&P Written  2 Simulation – 1O, 1P  2 CPM – 1O, 1P  Future – 3 exams   Board Exams will assess on all 5 domains of practice:  Patient Assessment  Formulation of the Treatment Plan Domains of   Implementation of the Treatment Plan Follow-up Treatment Plan Practice  Practice Management  ABC website provides “content outline” for each exam  Also: reference/reading list, sample questions   Assesses general knowledge of patient management:  Anatomy and physiology  Biomechanics, kinesiology  Combined  Disease process and pathologies Prescription criteria O&P Written  Material science  Exam Ethics and professionalism  Computer Based Testing (testing center)  3 ½ hour exam, 200 multiple choice questions  May be taken after graduation (prior to completing residency)   When designing a thermoplastic solid-ankle AFO, trimming the footplate proximal to the metatarsal heads will MOSTLY effect: 1. The third rocker 2. The second rocker Combined 3. 4. The first rocker Midstance O&P Written Sample  Infection control practices used to prevent transmission of diseases that can be acquired by Questions contact with blood, body fluids, non-intact skin and mucous membranes are referred to as: 1. Contact Isolation 2. Standard Precautions 3. Sterile Technique 4. Biohazardous Waste Program   Interactive problem-solving format (case scenario)  Concentrates on implementation of practice rather than just information recall  Obtain information about patient  Determine device recommendation (components, fitting criteria)  Follow-up assessment and adjustments Simulation  Examples: Exam  "What would be the appropriate steps or assessments to make?"  "What would be the most appropriate device recommendation?"  Computer Based Testing (testing center)  3-hour exam, 7 case scenarios  1 scenario is a pilot problem and not included in final scoring  Orthotics Prosthetics  Lower Extremity – 50%  Transtibial – 50%  Spinal (non-scoliosis) –  Transfemoral/Knee 17% Simulation  Scoliosis – 17% Disarticulation – 33%  Partial Foot/Symes OR Exam  Upper Extremity OR Upper Extremity – Cranial – 17% 17%   Hands-on practical assessment (“day at the office”)  Interact with patient models Clinical  Examiner to observe and assess Patient  Patient interaction skills Manageme  Completion of assigned tasks  Oral questions nt (CPM)  Taken at the ABC Testing Center in Tampa Florida Exam  Offered 3 times per year  4 ½ hours at testing site  Three 1-hour long modules  Orthotics  Transtibial ProstheticsPatient Management  AFO Management  Evaluation and  Casting recommendation  Rx recommendation  Alignment assessment  Lower Extremity  Gait deviations CPM Exam Management  MMT/ROM  Transfemoral Patient  Biomechanical rationale Management  Evaluation and  Assess fit recommendation  Spinal Orthotic  Biomechanical application Management  Initial alignment  Log roll  Fitting criteria  Prosthetic Troubleshooting  X-ray evaluation  Identify problems from patient feedback  Solutions   Be aware of application deadline AND residency deadline  NCOPE must have residency marked as “complete” Exam Fees  Fees:  Combined O&P written : $300 + $250 and Dates (application)  Simulation Exams: $300 (each)  CPM Exams: $775 (each)  Check ABC website for information and exam resources  https://abcop.org/individual-certification/get-certified/orthotist-prostheti st/fees-dates Questions