Hospice Elements And Device Models Manual Lymphatic Drainage

Instrument examines functional activities likely to be encountered by most adults in daily routines (some items drawn from existing tools, others are new) -Developed from a sample of 1041 pts -Chosen by CMS as an assessment tool for G-codes -Endorsed by NQF -3-functional areas: basic mobility, daily activity, applied cognitive -Computer Adaptive Testing: algorithm pre-selects the items that will be administered to a specific pt based on responses to previous items -Report: general information, severity, body part.impairment group, payment sources, condition, AM-PAC avg score for each domain. Both parties research relevant facts to be presented to the court -Oral depositions - testimony under oath in the presence of a court reporter -Written depositions - interrogatories -Requests for records - medical records, office calendars, diaries, correspondence, personal notes -Your counsel - be frank, open, answer all questions, give details; he/she is your ally -Opposing counsel - answer questions, be honest, but be concise and brief, only answer what is asked, do not offer information -Maintain emotional composure. Obesity -Diabetes -Mental Illness -Fibromyalgia -Smoker (can be really bad for the joints) -Severe Injury -Previous Compensable -Bad reasons: disgruntled, taking more time to recover than the injury warrants, change doctors after having been released to wor, hx of filing claims with dubious objective findings, develop symptoms in other areas not initially reported, participate in activities beyond your restrictions, habitually miss medical appointments, request narcotic medication more often than prescribed, didn't report the injury in a timely manner. Claim accepted: paid based on Medicare Fee Guidelines ---Relative Value Unit (RVU): a value for a certain treatment ---Geographical Practice Cost Index (GPCI) ---Conversion Factor (CF) = $$ = $52.35 (2010-11) ---[(Work RVU Work GPCI) + (PE RVU PE GPCI) + (MP RVU MP GPCI)] Conversion Factor (CF) -Claim denied. ---In litigation: (1) bill another insurer (Health, Auto), if possible, (2) bill the Patient, if other insurance is unavailable, (3) don't bill, wait for outcome ---If the patient is taken off WC and you are still owed money you need to become an 'intervener' and join their lawsuit (submit 'intervenor' forms, copy of your tx notes, copy of billing statement, send someone from facility to appear in person at the hearing). Dynamic process, PT makes clinical judgments -Includes history, systems review, tests and measures -PT will evaluate examination findings, establish a PT dx, determine the prognosis, and develop a POC that includes anticipated goals and expected outcomes, interventions to be used, and anticipated discharge plans -Evaluation should include: ---The reason for referral (what affects patient's function) ---Diagnosis ---Past level of function ---Current level of function (with objective measurements) ---Potential for return to function ---Plan of care that impacts function. Application of a modality to one or more areas, each 15 minutes -The IontoPatch is typically billed out as ONE unit (only) of iontophoresis to account for the service time in application of electrodes.

(Manual lymph drainage [MLD], compres- sion bandaging/compression garment. [CB/CG], exercise, skin. Elements or abridged protocols of CDT for the intensive phase of treatment. Only a few articles looked. Compression device therapy in six women with unilateral BCRL and three healthy controls. To determine whether an advanced pneumatic compression device. Pneumatic compression with manual lymphatic. Lymphatic drainage.

It is otherwise considered a home use device. -If 2 IontoPatches are applied to 2 different body parts, only ONE unit of iontophoresis is allowed regardless of the number of body parts treated, unless the total time to apply the electrodes and provide patient instruction exceeds 15 minutes. -Electrodes are very expensive, can be re-used -Now the Hybresis product is being used and the same guidelines above apply. E.g, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instruction in use of assistive technology devices/adaptive equipment) -The clinician instructs and trains the patients in self-care and home management activities (e.g., ADLs, use of adaptive equipment in the kitchen, bath and/or car) -Examples: ---Wound care/dressing changes ---Swelling control ---Positioning for sleep/comfort ---Use of a home TENS unit, traction paraffin, contrast bath (except for Medicare ---Signs of infection ---Things to avoid at home (like falls prevention).

Selective Debridement: removal of devitalized tissue from wound(s), without anesthesia ---Surface area less than or equal to 20 square centimeters. (97598 for each additional 20 square cm) ---High RVU (2.30) -Non-selective Debridement: removal of devitalized tissue from wound(s), non-selective, without anesthesia ---Medicare considers this code a bundled service, or otherwise included in other services.

-Negative Pressure Wound Therapy (NPWT): (eg. Vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) ---Surface area 50 cm) ---Medicare bundles these codes into selective debridement. Including assessment and fitting when NOT OTHERWISE reported, -This does NOT include fabrication time, if appropriate, or cost of materials. -Management: assessing and thinking part -Training: in the use of the orthotic (taking care of it, exercises in the orthotic, donning and doffing) -Checkout for orthotic/prosthetic use: established patient, each 15 minutes, the provider evaluates the effectiveness of an existing orthotic or prosthetic device and makes recommendations for changes, as appropriate. Normal code is used for biofeedback training for other than pelvic floor, with the use of surface electrodes. ---It is an untimed code.

---Single and dual channel biofeedback training done to facilitate muscle contraction post-surgically (i.e. Knee scopes) or to illustrate ongoing tension in resting muscles (i.e.

It is also used for tension disorders. ---'Training' means that the exercise is bundled with it (could just code as therex or neuro re-ed -90911 - Biofeedback training - Perineal/anal/urethralincluding EMG and/or manometry: this code applies to biofeedback training that includes the monitoring of the anus and/or rectum - including electromyography (measures muscle contractions) and manometry (measures pressure).

---This code is not timed. ---Very large RVU! ---This is only for electronic devices, not a mirror ---'Training' = exercise bundled with it.

Not an entitlement program (like Medicaid). This is people who buy insurance, but its subsidized by the state (the working poor) -2% tax on ANY revenue that comes into a health care business (MN Provider Tax (health care access bill)) -Not constitutionally protected, may be used for things other than health care -Every year there is a movement to remove this bill, but there is nothing to replace it -Hopefully, by 2015 the MN Provider Tax will be gone (belief is that Obama Care will subsidize this). A tax deferred account that either an employer or an individual, or both, may pre-fund to cover the individual's out of pocket medical costs, now or in the future (essentially lowers your taxable income) -Must be used in conjunction with a high deductible health insurance policy that takes over after the deductible is met (catastrophic coverage) -Money can be rolled over to the next year if not used (not use it or loose it) -Very attractive to young, healthy people (great risk pool. That's why it can be cheaper). Cover medical costs associated with motor vehicle accidents, up to $20,000 (so no one is waiting to get paid) -'No fault' in Minnesota (this is for medical, providers had been waiting until trials were over) - Required by law to have auto insurance -'Usual and customary' charge (after the $20,000 its paid for by the person's insurance) (this is annoying because some people (chiro) will use up the $20,000) -EXAMPLES IN MINNESOTA: (large, for-profit companies) ---State Farm ---American Family ---Allstate ---Geicho ---Progressive.

Out of Pocket Expenses shift cost to the patient -Fee schedule inflation shifts cost to some payers -Out of Pocket Expenses (purpose: if pt has skin in the game, they will use health care more wisely) ---Deductible - a defined amount that is paid up front before the insurance plan covers anything (increasing price) ---Co-insurance - a given percentage of the total bill (i.e. 20%) ---Co-payment - a flat amount, regardless of the total bill (not based on a percentage) (not always cheaper, but sometimes!) (a real problem for those who need prolonged care). (new idea, don't know how it will work yet) -Under the ACA, Accountable Care Organizations (ACO) for Medicare ---ACO: primary care doctor, may or may not work with a hospital, need to be big (manage a whole population for a whole year (5,000), compare the costs to the costs of the year before- if you save money, you get to keep part of those savings) -Obviously not just MDs giving the care.

How do the PTs get part of these savings -Shared Risk; Shared Savings -Each service or intervention has a fee attached to it -Provider's Fee schedule (what we charge) is determined by what the market will bear -The patient may have to pay a portion -Each service is described by a CPT code. Growth in number of users (1.3 Billion spent in 1999 → 5.7 Billion spent in 2011) -≈75% of therapy (PT, OT, Speech) is PT (obviously go after us more than the other rehab specialties) -Therapy utilization is growing at a rate of 8.5% -Growing twice as fast as the rate of general healthcare growth (4.5%) -Growing twice as fast as the rate of GDP growth -2 Primary settings involved (SNF & PTPP) (PTPP: PT private practice, PT or physician owned) (75% in these 2) -Cost per Visit is increasing -More procedures than modalities -Moving from 3.0 units toward 3.5 units/visit ('code creep'). If more than one (timed) CPT code is billed during a calendar day, then the total number of units that can be billed is constrained by the total treatment time -Sum up the total minutes of time spent on services reported as timed codes -Document timed code minutes AND total treatment time -Untimed codes are included in the total treatment time (this is medicare's way of limiting how much we can do, payment for utilization is being contained) * 1 unit: 8-22* * 2 units: 23-37* * 3 units: 38-52* * 4 units: 53-68*. SGR: formula by which payment for providers under the 'Physician's Fee Schedule' is determined -On an annual basis, the fee schedule is updated and is tied to the US economy (intended to moderate healthcare costs) -The formula is FLAWED, annual Congressional activity designed to prevent recurring reductions in the fee schedule (the 'Doc fix') -For 2013 there was a 0% update over the 2012 fee schedule but the SGR would have resulted in a negative 26.9% update.

(congress knows that this isn't ok, the doctors would opt out, WE COULDN'T OPT OUT because we are 'suppliers' not 'providers') (also, we COULD NOT treat the pt for cash if its something covered by medicare) -APTA is joining other health care provider organizations to lobby for repealing the SGR. CMS pays for the procedure that has the highest value in full -CMS then reduces the PRACTICE EXPENSE value of the remaining codes by 50%, results in a reduced overall payment for remaining codes -Based on flawed notion that practice expense is the same no matter how many codes are reported, and that it shouldn't be reimbursed more than once in a treatment session.

That reduction ALREADY occurred! -APTA is lobbying to eliminate MPPR in lieu of its development of an alternative payment system (APS) (basically results in a 6 or 7% decrease in reimbursement, basically paying for 3 codes when we did 3.5) (message to congresss: if you want programs that help, you need to pay for them! If this type of policy persists, we will stop doing certain tx). From 1999 Balanced Budget Act (Medicare Part B) -Several times Congress has placed a moratorium on the cap and more recently directed CMS to develop an exceptions process -For 2013, the therapy cap is $1900/year for OT, and a separate $1900/year shared by PT and Speech. -This cap is arbitrary, is the only service capped under Medicare B, and hurts those who are most in need.

-In 2013, hospitals (except critical access) must participate for the first time. -Ever since this was put into act, congress has known that this is a bad law, they just worry about keeping costs down → then there is an exception (complexity codes) → a different exception process still exists -There will be a therapy cap until there is another system (its CMS's job (they aren't doing much about this), APTA is working with other professions to develop this). (has to do with the cap exception process) -GAO report shows that in 2011 80% of the 4.9 million Medicare beneficiaries who used OT and PT/SLP did NOT exceed the $1900 cap. -20% (980,000 individuals) of Medicare B therapy patients spent an average of $3000 on outpatient therapy. -As part of the Therapy Cap Exceptions process, CMS requires that documentation be reviewed manually for services that exceed $3700.

-In 11 states, pre-payment review occurs (naughty states, high utilization and red flags) (have to WAIT to get paid!) -In other states, post-payment reviews are being done (MN included) (treat, bill, get paid, get a letter asking for documentation, checked, may owe money) -Problems have occurred with turnaround time and with tracking (this means that a PERSON is actually looking at the charts of people who have gone over the cap). Hospital Readmissions Reduction Program (penalized for exceeding a number or readmissions (infection and FALLS! Us!)) -Bundling -Medical (health care) Homes (paying for coordination of care) -Linking Payment to Quality -Program Integrity (provider enrollment, background checks, finger printing) (more surveillance and scrutiny) -Self-referral scrutiny (GAO has released reports on imaging and pathology, should have a PT report soon) (if dr owns the hospital they get the surgical and hospital fees (ortho, cardiovasulcar, cancer)). All providers/payers in Minnesota, exception: Medicare and the Medicare Advantage (replacement) Plans -Includes MA, Work Comp, Auto, and all other general health insurance plans (everything but Medicare/Medicaid) -In the case of time as part of the code definition, more than half the time must be spent performing the service in order to report that code. -Follow general rounding rules for reporting more than the code's time value. Eyetoy Usb Camera Namtai Driver Windows 7 Free Download here. -If the time spent results in more than one and one half times the defined value of the code and no additional time increment code exists, round up to the next whole number.

-Do NOT combine codes to determine total time units. -CPT is developed with this method in mind!!! All providers/payers in Minnesota, exception: Medicare and the Medicare Advantage (replacement) Plans -Includes MA, Work Comp, Auto, and all other general health insurance plans (everything but Medicare/Medicaid) -In the case of time as part of the code definition, more than half the time must be spent performing the service in order to report that code.

Pack Dicos Special Crack Freebox Wpa Posters on this page. -Follow general rounding rules for reporting more than the code's time value. -If the time spent results in more than one and one half times the defined value of the code and no additional time increment code exists, round up to the next whole number.

-Do NOT combine codes to determine total time units. -CPT is developed with this method in mind!!! When billing for physical therapy services (using CPT codes), it is necessary to specify the diagnosis that is being treated (ICD-9 codes) -'Condition' (as identified through an ICD-9 code) can equate with the concept of 'medical necessity' for support for services provided -'Diagnosis' may defined in traditional medical model framework or impairment model ---Traditional = traditional ---Impairment = describes the condition, disability, or dysfunction for which a patient is being seen (we are heading more toward this model) (what we treat is impairments).

Federally mandated transition to newer version by October 1, 2013 (soft date. Not sure if this will happen, may just go to ICD-11) -Process has been going on for several years. -3000 public comments were received in the development process - agreed for the need of update but concerned about cost (cost of training, software, and productivity loss) -Benefits. ---Fewer rejected claims ---Fewer improper claims ---Better understanding of new procedures ---Improved disease management (est @ 1%) ---Better understanding of health care conditions and outcomes ---Harmonization of disease monitoring and reporting world-wide.

1987 Federal Nursing Home Reform Act (no restraint unless you are with them and its for safety in that moment) -Included Omnibus Budget Reconciliation Act (OBRA) -Each resident 'attain and maintain his/her highest practicable physical, mental, and psycho-social well being' in order for the facility to receive Medicare/Medicaid funding -Some of the speaking points include. ---Emphasis on resident's quality of life/quality of care ---New expectations that each resident's ability to walk, bathe, and perform other ADL's will be maintained or improved barring medical reasons ---The right to safely maintain or bank personal funds with the nursing home (efficient, but be careful) ---The right to choose a personal physician and have access to medical records ---The right to be free of unnecessary and inappropriate physical and chemical restraints. Provided in the school setting -Work closely with educational staff -Federal funding has short, remainder of funds must come from state and local taxes -National Education Association represents teachers for bargaining on salaries and benefits -PT's are not eligible to be members, yet are bound to the same salary scales as accepted by the NEA union -Physicians often not involved in IEP process and 'orders to treat' from MD often not in place, 'lifelong affliction' caveat -Care plans and documentation do not focus on 'medically necessary' but 'learning relevant' models.

License/registration to practice in any state or country ever been voluntarily or involuntarily revoked, suspended, restricted, or conditioned? Complaints against you relative to the practice of physical therapy, reprimanded or censured by any physical therapy society or licensing board? Defendant in any malpractice lawsuits, had any malpractice settlement, or have any pending? Denied, restricted, or revoked staff affiliations with a hospital, nursing home, clinic, or other health care facility?

Criminal charges filed against you? Disorderly conduct, assault or battery, or domestic abuse, whether the charges were misdemeanor, gross misdemeanor, or felony; also includes any offenses which have been expunged or otherwise removed 13. Driving While Intoxicated (DWI) or Driving Under the Influence (DUI) or other impaired driving offenses involving alcohol or other chemicals filed against you?