Get Your CEUs
Understanding Medicare MDS 3.0 for the Rehabilitation Professional 2nd edition

Profession: Physical Therapists/Assistants,Occupational Therapists/Assistants
Topic: Clinical,Business Administration
CEU: 1.5 unit
Contact Hours: 15 hours

States Approved:
- Physical Therapists/Assistants : California, Colorado, Hawaii, Indiana, Maine, Massachusetts, Michigan, New York, Rhode Island, South Dakota, Utah, Vermont, Wyoming
- Occupational Therapists/Assistants : Ohio

Skill Level: Beginner


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Course Objectives 

1. Learn the most current and accurate documentation procedures to support skilled therapy services.

2. Improve your skills in MDS completion.

3. Understand the basic concepts and ethics of long-term care administration, such as supervising assistive personnel, restraints, and resident privacy.

4. Maximize treatment and rehabilitation services rendered to the skilled nursing home resident using the most specific RUG IV group.

5. Utilize the most specific ICD-9 and ICD-10 diagnosis code to maximize Medicare reimbursement and support medical necessity.

Course Description

On October 1, 2015 the ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets. The transition to ICD-10 is required for everyone covered by the Health Insurance Portability Accountability Act (HIPAA). Also, the Middle Class Tax Relief and Jobs Creation Act of 2012 (MCTRJCA; Section 3005(g)) published at states that “The Secretary of Health and Human Services shall implement, beginning on January 1, 2013, a claims-based data collection strategy that is designed to assist in reforming the Medicare payment system for outpatient therapy services subject to the limitations of section 1833(g) of the Social Security Act (42 U.S.C. 1395l(g)). Such strategy shall be designed to provide for the collection of data on resident function during the course of therapy services in order to better understand resident condition and outcomes.” 

This reporting and collection system requires claims for therapy services to include non-payable G-codes and related modifiers. These non-payable G-codes and severity/complexity modifiers provide information about the beneficiary’s functional status at the outset of the therapy episode of care, at specified points during treatment, and at the time of discharge. These G-codes and related modifiers are required on specified claims for outpatient therapy services–not just those over the therapy caps. 

This book can help occupational therapists, physical therapists, and speech therapists understand Medicare standards for subacute care programs that aim to be compliant with Medicare MDS 3.0 standards and state regulations. Documenting and billing strategies are also discussed in this book.

This book has been updated to discuss the new MDS assessment schedule, distinct days of therapy, co-treatment, the allocation of group therapy minutes, the revised student supervision provisions, the EOT (End of Therapy) OMRA (Other Medicare Required Assessment) and new resumption items, and the new PPS assessment-COT (Change of Therapy) OMRA.

Appropriate billing and documentation should be present in the medical record. Medicare is increasingly reviewing therapy claims to ensure that the therapy provided did require the skills of a therapist. This book discusses establishing medical necessity, refusing to care for a resident, restraints, safety, creating incident reports, supervising assistive personnel, and resident privacy.

Coding and billing for subacute and long-term care settings are also covered in this book, along with denial and appeal management, regulatory guidelines for insurers, and improving cash flow with denial management strategies. Proper coding and documentation ensures that facilities will keep their money upon a post-payment medical record audit.

The information provided here in no way represents a guarantee of payment. Benefits for all claims will be based on the resident’s eligibility, provisions of the law, and regulations and instructions from the Centers for Medicare & Medicaid Services (CMS). It is the responsibility of each provider or practitioner submitting claims to become familiar with Medicare coverage and its requirements.

Chapter One: Introduction
Medicare; Medicare Part A; Medicare Part B; Medicaid
Advance Beneficiary Notice
Medicare Recovery Audit Contractor
Medicare Administrative Contractors
Medicare Skilled Guidelines; Medical Necessity
Expressing Medical Necessity and Skilled Care
Chapter Two: Maintenance Programs
Evaluation and Maintenance Plan without Rehabilitative Treatment
Skilled Maintenance Therapy for Safety
Individual Activities Concurrent with Rehabilitative Treatment
Evaluation and Maintenance Program without Rehabilitation Therapy
Maintenance Therapy Lawsuit
Chapter Three: Medicare Appeal Deadlines
Appealing Recoupment
Sample Letters of Appeal
Denial Letter for Unanticipated Discharge
Denial Letter which Requires Functional Goals
Program Safeguard Contractor Audits
Chapter Four: Effective Documentation
Late Entries and Supplemental Notes; Documentation Requirements
Documentation Required; Limits on Requirements;
Certifications and Recertifications; Dictated Documentation
Dates for Documentation
Evaluation/Re-Evaluation and Plan of Care
When the Evaluation Serves as the Plan of Care
Re-Evaluations; Progress Reports; Absences; Delayed Reports; Early Reports
Progress Reports for Services Billed Incident to a Physician’s Service
Documenting Clinician Participation in Treatment in the Progress Report
Assistant’s Participation in the Progress Report
Content of Clinician Progress Reports
Objective Evidence; Discharge Notes; Treatment Notes; Describing Pain
Justification for Skilled Services; Risk Factors
Documenting a Patient’s Potential for Rehabilitation
Creating Goals; Plan of Care; Treatment under a Plan; Two Plans; Contents of Plan
Changes to the Therapy Plan
Chapter Five: Functional Status Guidelines
Instructions for Rule of 3
Detailed Coding Instructions for G0110 Column 1 ADL Self-Performance
Functional Rehabilitation Potential
Chapter Six: CPT Codes
Untimed CPT Codes; Timed CPT Codes
Utilization Guidelines and Maximum Billable Units per Date of Service
0183T: Low Frequency, Non-Contact, Non-Thermal Ultrasound (MIST Therapy)
29065: Application of Casts and Strapping Codes
G0283: Electrical Stimulation (CPT G0283 or 97032)
90911: Biofeedback Therapy
95851: Range of Motion Tests
96125: Standardized Cognitive Performance Testing
97001: Physical Therapy Evaluation
97002: Physical Therapy Re-Evaluation
97003: Occupational Therapy Evaluation
97004: Occupational Therapy Re-Evaluation
97010: Hot/Cold Packs
97012: Traction, Mechanical (to one or more areas)
97016: Vasopneumatic Devices (to one or more areas)
97018: Hot Wax/ Paraffin Treatment
97022: Whirlpool
97024: Diathermy (i.e. microwave)
97026: Infrared Therapy
97028: Ultraviolet (to one or more areas)
97033: Iontophoresis
97034: Contrast Baths (to one or more areas)
97035: Ultrasound (to one or more areas)
97036: Hubbard Tank (to one or more areas)
97110: Therapeutic Exercises
97112: Neuromuscular Re-education
97113: Aquatic Therapy with Therapeutic Exercise
97116: Gait Training
97124: Massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) (one or more areas, each 15 minutes)
97140: Manual Therapy
97150: Group Therapy Services
97545: Work Hardening (97545, 97546)
97530: Therapeutic Activities
97532: Development Of Cognitive Skills To Improve Attention, Memory, Problem Solving, (includes compensatory training) direct (one on one) patient contact by the provider, each 15 minutes
97535: Self–Care/Home Management Training
97537: Community/Work Reintegration Training
97542: Wheelchair Management
97597: Selective Debridement
97605: Negative Pressure Wound Therapy
97750: Physical Performance Testing
97755: Assistive Technology
97760: Orthotic Management & Training
97761: Prosthetic Training, upper and/or lower extremity(s), each 15 minutes
97762: Checkout For Orthotic/Prosthetic Use, established patient, each 15 minutes
97799: Unlisted Physical Medicine/Rehabilitation Service Or Procedure, not timed (97799, 97139 or 97039)
Miscellaneous Services (Non-covered)
Chapter Seven: Reporting of Service Units
Timed and Untimed Codes
Counting Minutes for Timed Codes in 15-Minute Units
Group Therapy
Concurrent Therapy (also known as Dovetailing)
Student Supervision
Billing Scenarios Part A vs. Part B
CPT Codes Clarification
Therapy Certifications
Initial Certification
Timing of Initial Certification
Review of Plan and Recertification
Physician/Non-physician Practitioner Options for Certification
Restrictions on Certification
Delayed Certification
Denials Due to Certification
Exceptions for Medically Necessary Services
Appeals Related to Disapproval of Cap Exceptions
Application of New Coding Requirements
Services Affected
Providers and Practitioners Affected
Chapter Eight: Functional Limitation Reporting Under Medicare Part B
Function-related G-codes
Mobility G-code Set
Changing & Maintaining Body Position G-code set:
Carrying, Moving & Handling Objects G-code Set
Self-Care G-code Set
Other PT/OT Primary G-code Set:
Other PT/OT Subsequent G-code Set:
Swallowing G-code Set:
Motor Speech G-code Set:
Spoken Language Comprehension G-code Set:
Spoken Language Expressive G-code Set:
Attention G-code Set:
Memory G-code Set:
Voice G-code Set:
Other Speech-language Pathology G-code Set:
Chapter Nine: G-Codes Clarification
Required Tracking and Documentation of Functional G-codes and Severity Modifiers
Remittance Advice Messages
General Information on the Therapy Cap
Multiple Procedure Payment Reduction (MPPR)
2013 Therapy Cap Limitations
2013 Medicare Copays and Deductibles
Therapy Cap Exceptions Process
Coding Guidelines
Chapter Ten: Major RUG-IV Category
Major RUG-IV Category
Ultra High Rehabilitation Plus Extensive Services
Very High Rehabilitation Plus Extensive Services
High Rehabilitation Plus Extensive Services
Medium Rehabilitation Plus Extensive Services
Low Rehabilitation Plus Extensive Services
Ultra High Rehabilitation
Very High Rehabilitation
High Rehabilitation
Medium Rehabilitation
Low Rehabilitation
Characteristics Associated With Major RUG-IV Category
Medicare Short Stay Assessment
Technical Eligibility Requirements
Clinical Eligibility Requirements
Calculation of Total Rehabilitation Therapy Minutes
Three-Day Policy
Change of Therapy (COT) and Other Medicare Required Assessment (OMRA)
Leave of Absence
Delay in Requiring and Receiving Skilled Services (30-Day Transfer)
Medical Appropriateness Exception (Deferred Treatment)
ARD outside the Medicare Part A SNF Benefit
Distinct Calendar Days of Therapy
Chapter Eleven: Clarifications
Clarification regarding early assessment penalty policy
Clarification regarding the relationship between the Change of Therapy OMRA and the Day of Discharge
Clarification regarding the beginning of a COT observation period
Clarification regarding completion of interview items on COT OMRA
Clarification regarding when a COT evaluation should be completed
Clarification regarding requirements for completing an EOT OMRA
Clarification regarding how to bill an End-of-Therapy OMRA reporting Resumption
Clarification regarding the definition of a resumption of therapy
Chapter Twelve: Using ICD-9 Codes and ICD-10 Codes
Basic Guidelines in Using ICD-9 codes
Transitioning to the ICD-10 Codes
Chapter Thirteen: Administrative Matters
Top 8 Ways to Build Medicare Part B Programming
Common Billing Errors and How to Avoid Them
Restorative Nursing Program
Restorative Nursing Assistant/ Rehabilitation Nursing Assistant (RNA)
Restraints and Safety
Chapter Fourteen: Legal Issues
Elder Abuse; Incident Reports; Medical Equipment
Refusing to Care for a Resident; Unanticipated Outcomes
Noncompliant Residents; Bending the rules
Supervising Assistive Personnel
Infection Control; Resident Privacy; Legal Foundations; Ethical Foundations
The Law of HealthCare Malpractice
Intentional Wrongs; Employment; Business Law & Ethics
Legal and Ethical Issues in Education; Ethics in Focus


CA sealPhysical Therapists/Assistants : Arkansas, California, Colorado, Hawaii, Indiana, Maine, Massachusetts, Michigan, New York, Rhode Island, South Dakota, Utah, Vermont, Wyoming

Physical Therapists, Physical Therapist Assistants: New York: Rehabsurge, Inc. is recognized by the New York State Education Department’s State Board for Physical Therapy as an approved provider for physical therapy and physical therapist assistant continuing education. This seminar is awarded 15 contact hours.

Physical Therapists, Physical Therapist Assistants: California: The Physical Therapy Board of California recognizes Rehabsurge, Inc. as an Approval Agency to Approve Providers of Continuing Competency Courses in California for Physical Therapists and Physical Therapy Assistants. This course is approved for 15 CEs/Contact Hours.

Pricing Information

Self Study Physical Book Only (through $70

Exam Only (through or by mail): $80

Self Study E-Book and Exam(through $150