Reimbursement & Regulation

OPPT: Functional Limitation Reporting under Medicare Part B - begins Jan. 1, 2013: FAQ from APTA
APTA webinar with explanation of reporting.
One the acceptable tools for Functional Limitation Reporting is "OPTIMAL" (described below).

October, 2012: Federal District Court rules Medicare will pay for services if they are needed to “maintain the patient’s current condition or prevent or slow further deterioration,” regardless of whether the patient’s condition is expected to improve.
Robert Pear. Settlement Eases Rules for Some Medicare Patients. New York Times. October 22, 2012.

Centers for Medicare and Medicaid Services (CMS)
US Dept. Health and Human Services

1. "Medicare & You" (2021)
This is the pamphlet that is mailed to all beneficiaries each year. It is in lay language and easy to follow.
Note: there are active links (blue font) within the pdf document for definitions.

• p.25: Part A coverage
• p.26: Part A, hospice
• p.27: Part A, hospital
• p.28: Part A, skilled nursing unit
  
• p.29-50: Part B coverage...
• p.40: Part B home health PT coverage
  
• p.43: Part B physical therapy coverage
  

2. PACE: Program of All-Inclusive Care for the Elderly

3. Quality Evaluations by the CMS (Centers for Medicare and Medicaid Service)
Hospital comparisons
Nursing Home comparisons
Home Health Agency comparisons

4.  Physician Quality Reporting System (PQRS):  a Medicare requirement for OPPT.
Log on to APTA for the most current details.

5. Medicaid
Missouri Medicaid Basics "MO HealthNet"
published by the Missouri Foundation for Health, spring 2014

6. There are two different federal programs related to disabled and low income persons:

SSDI: Social Security Disability Insurance
What is it, and what are the Qualifications?

SSI: Supplemental Security Income
What is it, and what are the Qualifications?

Eligibility_Criteria_Documentation

7. APTA - Defensible Documentation for Patient/Client Managment: "Documentation of a Visit/Encounter"

8. FIM: Terminology for Level of Assistance for Functional Skills

10. Part A: Admission criteria for: SNF & for Inpatient Rehab Facility (IRF)

11. Part A: Home Health:

1. CMS definition of homebound status (effective 11-19-2013)
2. The Outcome and Assessment Information Set: OASIS documentation form used in Home Health.
   (OASIS-C, version 2, October 2009)    
   

12. SNF: Medicare coverage

13. Rehab Service Documentation

14. Part A: Hospice Admission Criteria

15. Adult Day Connection: eligibility criteria

16. Medicare B: coverage of Therapeutic Footwear for people with diabetes

17. DME (Kelly DellaRocca PT, serves in an advisory capacity to a local pharmacy on management of DME.)

• 17.a  DME: definitions and eligibility
• 17.b  Q&A about wheelchairs
• 17.c  Walkers & Rollators
• 17.d  U-Step 2: 4-wheeled walker/rollator designed for persons with PD (manufacturer's brochure)
• 17.e Bateni, et al. examines benefits and possible increased fall risk from use of an ambulation aide.
  Bateni H, Maki BE. (2005). Assistive devices for balance and mobility: Benefits, demands, and adverse consequences. Arch Phys Med Rehabil. 86:134-145.

18. Veterans Administration: VA Health Care Benefits

Q&A: rehabilitation for veterans  (V. Knoll, personal communication 1-31-2012)

19. ICD-10: Index to Diseases Version 2010

20. Compare Health Coverage Plans from various Insurance Companies
National Committee for Quality Assurance (NCQA)

21. Physician Owned Physical Therapy Services (POPTS)

• APTA informational brochure with citations
• APTA position paper "white paper"
  
• Mitchell JM, Scott E. (1992). Physician ownership of physical therapy services. Effects on charges, utilization, profits, and service characteristics.  JAMA. 268(15):2055-9.
• APTA website: Top PT Issues in the Statehouse (members only access)
• Relevant Missouri statutes: search for Statutes 334.252, and 334.253

Missouri Division of Professional Registration
... from the left-side menu, choose: "Physical Therapists/Physical Therapist Assistants"
... from the drop-down menu, choose: "Rules & Statutes"
... then choose "Statutes"

• Direct Access (334.506)
• Continuing Education Requirements (334.507)
• Supervision of PTAs (334.650)

23. Directory of Services for Seniors  (pdf version, published by the Senior Network, Boone County, MO)
Services for Seniors - Boone County Directory (online version, published by Daniel Boone Regional Library, Columbia MO)

Senior Citizens Handbook: Laws and Programs Affecting Senior Citizens in Missouri

Legal Services of Eastern Missouri. (2011). Senior Citizens Handbook: Laws and Programs
Affecting Senior Citizens in Missouri. 18th ed. Legal Services of Eastern Missouri, Inc. and The Bar Association of Metropolitan St. Louis. Retrieved 9-23-2013. http://www.mobar.org/uploadedFiles/Home/Publications/Legal_Resources/Brochures_and_Booklets/seniorcitizen.pdf