DPT772: OUTPATIENT DOCUMENTATION AND BILLING EXAM
QUESTIONS AND ANSWERS WITH COMPLETE SOLUTIONS
VERIFIED
Covered Therapy Services
Outpatient therapy services furnished to a beneficiary are payable only when the
following conditions of coverage are met:
Medical necessity = services are or were required because the individual needed
therapy services
Plan of Care = a plan for furnishing such services has been established by a
physician/NPP or by the therapist providing such services and is periodically reviewed
by a physician/NPP
- Services are or were furnished while the individual is or was under the care of a
physician
- Services must be furnished on an outpatient basis
- All of the conditions are met when a physician/NPP certifies an outpatient plan of care
for therapy. Certification is required for coverage and payment of a therapy claim.
Maintenance Programs
- January 2013 = Jimmo vs. Sebelius Medicare contractors (MACs) were inappropriately
applying an "Improvement Standard"
, - Coverage cannot be denied based on the absence of potential for improvement or
restoration
- Goals could describe the maintenance of an achieved level of function or the manner
in which further deterioration can be slowed or prevented
- If they demonstrate that they required the skill, knowledge, and clinical judgement of a
therapist
- Periodic reevaluation of the patient's functional status, these would also be covered.
- The Medicare BPM (Chapter 15, Section 220) provides several examples, including
patient scenarios that illustrate the appropriate application of this area of the Medicare
benefit.
Documentation
Written treatment plan must include:
- Patient's diagnosis
- Long-term treatment goals for entire episode (not just for one interval of care)
- Amount = number of times in a day the treatment is provided
- Frequency = number of times in a week
- Duration = number of weeks or number of treatment sessions for this plan of care
- The signature and professional credentials of the person who established the plan, as
well as the date, must be recorded on the plan
- POC must be developed BEFORE treatment begins by:
-- Physician or
QUESTIONS AND ANSWERS WITH COMPLETE SOLUTIONS
VERIFIED
Covered Therapy Services
Outpatient therapy services furnished to a beneficiary are payable only when the
following conditions of coverage are met:
Medical necessity = services are or were required because the individual needed
therapy services
Plan of Care = a plan for furnishing such services has been established by a
physician/NPP or by the therapist providing such services and is periodically reviewed
by a physician/NPP
- Services are or were furnished while the individual is or was under the care of a
physician
- Services must be furnished on an outpatient basis
- All of the conditions are met when a physician/NPP certifies an outpatient plan of care
for therapy. Certification is required for coverage and payment of a therapy claim.
Maintenance Programs
- January 2013 = Jimmo vs. Sebelius Medicare contractors (MACs) were inappropriately
applying an "Improvement Standard"
, - Coverage cannot be denied based on the absence of potential for improvement or
restoration
- Goals could describe the maintenance of an achieved level of function or the manner
in which further deterioration can be slowed or prevented
- If they demonstrate that they required the skill, knowledge, and clinical judgement of a
therapist
- Periodic reevaluation of the patient's functional status, these would also be covered.
- The Medicare BPM (Chapter 15, Section 220) provides several examples, including
patient scenarios that illustrate the appropriate application of this area of the Medicare
benefit.
Documentation
Written treatment plan must include:
- Patient's diagnosis
- Long-term treatment goals for entire episode (not just for one interval of care)
- Amount = number of times in a day the treatment is provided
- Frequency = number of times in a week
- Duration = number of weeks or number of treatment sessions for this plan of care
- The signature and professional credentials of the person who established the plan, as
well as the date, must be recorded on the plan
- POC must be developed BEFORE treatment begins by:
-- Physician or
