knr 278 exam 3

CPT codes

current procedural technology, 5 digit code

DRG

diagnostic related group, inpatient

not covered services

diversion, recreation, leisure skill acquisition, non goal directed

human rights

equal opportunity and ADA

managing for accountability

fiscally responsible, document, policies

non-intervention programs

focus on attendance, based on number of times participated or client enjoyment

intervention programs

focus on participation, changes in client behavior as a direct result of participation

evaluation types

formative and summative

alternative funding

fundraisers, sponsorships, grants, nonprofit

TR services not covered

recreation diversional activity palliative care most areas - outpatient physical rehab outpatient rehab (car accident in michigan)

TR implications

reduce length of stay, increase outpatient, increase community services, increase productivity, increase documentation, billing of services

maintenance

safety, risk, upgrade

specific program evaluation types

self report, interview, observation

universal billing code

uniform claim form, used by hospitals with major 3rd party payers, TR-941, 940/949 - other TR services

managed care

up-front premium costs, predesignated and preferred providers, gatekeepers, pre-admission criteria

case manager

usually a nurse, assists patient in getting best health care, some is outside of insurance, can deny costs as unreasonable

negligence

willful and wanton neglect

risk management program

•Purpose is to minimize occurrences of loss or injury •Provide the best possible risk free environment for clients & staff •Minimize legal liability & lawsuits •Review incidents & attempt to prevent future losses or injury •Complies with Organizational Standards •CQI, JCAHO,CARF PDRMA, IPARKS

summative

a method of evaluation that occurs at the conclusion of an activity or program

formative

a method of evaluation that occurs during an activity or program

supplies and equipment

acquisition, inventory, replacement

capital request (large equipment)

acquisition, maintenance, depreciation, typically one a year

rising health costs

aging population, medical technology, rising expectations, waste, defensive medicine, inflation, cost to meet standards

TR program planning model

analysis - conceptualization - investigation - determination - SPD - implementation plan - evaluation plan

contractual losses

breach of service contract being provided

utilization reviews

clinical setting, frequency, duration, intensity

prospective payment

cost determined by 3d party, medicare sets pace for insurance, PPO & HMO

3 hour rule

- "intense level of rehabilitation services" - Interpreted as 3 hours per day

implementation plan and description

-content and process descriptions -sequence sheet/session format -implementation description

comprehensive program

-created from client outcomes -analyze -conceptualization -investigation -determination

specific program

-each program is implemented and evaluated independent of other programs -addresses leisure ability areas (or other models too)

specific program plan contents

-program plan -implementation plan and description -evaluation plan

specific program plan

-puts comprehensive goals and purpose into action -maybe 1 or more programs per comprehensive goal -very detailed so desired outcomes are directly related to the planned interventions

client goals

-smaller behavioral units -used for measurement -must be logical to comprehensive program goal -target actual performance or knowledge -add up to overall program outcomes

evaluation plan

-specific program evaluation -performance sheet (client evaluation)

evaluation

-systematic process -gathering and analyzing select info -make decisions about quality, effectiveness, outcomes

5 program domains for evaluation

1. need for program 2. design of program 3. delivery of program 4. program outcome 5. program efficiency

reimbursement process

1st party - service provider 2nd party - client 3rd party - ?

Medicaid

A federal and state assistance program that pays for health care services for people who cannot afford them.

accident

An unexpected happening that may result in injury, loss, or damage.

CMS

Centers for Medicare and Medicaid Services

gross negligence

Conduct that constitutes a willful or reckless disregard for a duty or standard of care.

types of negligence

Ordinary and gross

RUGS

Resource utilization groups - used in long term care

incident

Something that happens in real life or in a story; an event, often of little importance.

Medicare

health insurance for people over 65 or disabled, Part A: hospital insurance, inpatient, skilled nursing, home health, hospice

product lines

hospitals borrow from business procedures, recognize competition, concentrate on certain quality product lines

how to create a risk management plan

identify/rank risks assess best method to handle risk devise a plan decide who is in charge

covered TR services

inpatient psych outpatient psych partial hospitalization inpatient physical rehab acute care public school TR functional in nature community reintegration sessions life management task session prescriptive therapy sessions

what's included in risk management plan

insurance facility/equipment inspections orientation/training accident/incident reports emergency plans

objectives

minimum thresholds, most natural environment, condition, criteria, degree, ABCD

property loss

natural and human causes

tort liability

negligence and malpractice

ordinary negligence

negligence that is a failure to act, or a simple mistake that causes harm to a patient

risk management plan

policies, organization wide, formal or informal, planned approach

what is risk

possibility of loss or injury

coverage

services must be reasonable and medically necessary, individualized, prescribed, supervised

systems design

specific, consistent, accountability

program plan

statement of purpose, outcomes, goals and objectives

professional duty

the commitment to meeting one's obligations to provide effective physical therapy services to patients/clients, to serve the profession, and to positively influence the health of society.

financial business losses

theft and employee injuries

covered sevices

those intended to restore, remediate, rehabilitate, or eliminate problems associated with particular diagnosis

retrospective payment

traditional cost based system