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Persons eligible for Medicare medical coverage for health care services:
- persons 65 or older
- individuals of all ages w/ end stage renal disease/permanent kidney failure that may require dialysis tx or a kidney transplant
- persons w/ a long-term disability who have received government-funded disability benefits for 24 months may be eligible
- retired railroad workers
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Medicare Part A
- inpatient hospitals
- SNF
- home health
- rehab
- hospice
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Medicare Part B
hospital outpatient physician and other professional services including OT provided by independent practitioners
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Medicare criteria for coverage of OT services:
- prescribed by a physician or furnished according to a physician-approved plan of care
- performed by a qualified OT or OTA under the general supervision of an OT
- service is reasonable and necessary for tx of individual's injury or illness
- diagnosis can by physical, psychiatric, or both. There are no diagnostic restrictions
- OT must result in significant, practical improvement in the person's level of functioning w/in a reasonable period of time
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SNF Medicare reimbursement is based upon:
resource utilization groups (RUGs)
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SNF Medicare reimbursement is typically not provided for:
- therapist to carry out the maintenance plan
- or if services can be performed safely and effectively by unskilled personnel
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The restorative potential of a person was determined to:
- NOT be the sole payment criteria for skilled services
- services to prevent or slow deterioration and maintain a person at the highest functional level possible must be recognized as skilled and covered if these services are reasonable and necessary
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PHP
partial hospitalization
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Do psychosocial programs that provide structured diversional, social, and or recreational, services or vocational rehabilitation meet the criteria for active tx in a PHP?
no, therefore, they are not reimbursable under Medicare
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When are rental or purchase expenses for DME covered by Medicare?
- if DME is used in beneficiary's home and if necessary and reasonable to treat an illness or injury or to improve functioning
- physician's prescription is needed and must include diagnosis, prognosis, and reason for DME need
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Are self-help items (bathtub grab bars and raised toilet seats) reimbursable?
no, because other people can use them and they are not considered medically necessary
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Medicaid
for persons who have an income that is below an established threshold and/or have a disability
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Workers' compensation primary focus:
rehab and disability management to return the person to gainful employment
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Structure of goal statement
- patient will... or family/caregiver/teacher will...
- desired functional behavior to increase
- underlying factors that must be remediated to achieve
- circumstances under which behavior must be performed or the conditions (independent, cues, assist)
- degree to which behavior is exhibited (3 out of 4, etc)
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SMART goals
- Specific
- measurable
- attainable
- relevant
- time-limited
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RUMBA goals
- realistic/relevant
- understandable
- measureable
- behavioral
- attainable/achievable
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reasons for discharge
- goals attained
- client no longer making functional gains
- client refuses or is noncompliant w/ intervention
- client moves to another location
- setting not appropriate to individual's needs
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Problem Oriented Medical Record (POMR):
a system of providing structure for progress not writing that is based on a list of problems based on assessments
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What setting must report functional data on their claims in the form of new G-codes?
outpatient occupational therapy services
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Some documentation of improvement must be made at least on a weekly basis, otherwise, tx will be
considered maintenance
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Does Medicare reimburse for OT practitioners to implement maintenance tx?
no, considered unskilled service
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When does transitional planning in the IEP begin?
age 14
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When do transitional services begin in the IEP?
age 16
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