Padilla: Occupational Therapy with Elders: Strategies for the COTA, Third
Chapter 06: The Regulation of Public Policy for Elders
1. Which year was Medicare, or Title 18 of the Social Security Act, passed? Formatted: Highlight
Medicare, or Title 18 of the Social Security Act, was passed in 1965 and implemented in 1966.
2. Which year was Medicaid, a combined federal and state insurance program for low-
income individuals and families, enacted?
Medicaid became law in 1965 as a jointly funded cooperative venture between the Federal and
3. Which of the following services is NOT covered under Medicare Parts A or B? Formatted: Highlight
A. Hospital costs
B. Medical office visits
D. Extended lLong-term care stays beyond 100 days Formatted: Highlight
Medicaid pays a high percentage of nursing care expenditures in the nursing home industry.
Medicaid places an emphasis on institutional care rather than options that might permit elders to
remain in their communities. Medicare can pay up to 100 days of long-term care for those that
qualify, but it is Medicaid that covers extended long-term care stays.
4. What does the term “capitated” mean?
A. Reimbursement rates are set and paid for each day of service provided by a
B. Reimbursement rates to managed care providers are set per treatment or
C. Reimbursement rates at set at a level and do not rise or decrease again.
D. Reimbursement rates are limited to a set dollar amount per year per provider and Formatted: Highlight
are not increased or decreased over time.
Reimbursement rates to managed care providers are capitated, meaning that a set rate is provided
either per treatment or per condition. This payment may not be enough to include extensive
therapy. A capitated system provides financial incentive for physicians to refrain from referring
clients to services such as OT.
5. Which of the following is a the part of the PAI (Patient Assessment Instrument), that Formatted: Highlight
screens for the strengths and deficits a resident has that require further evaluation? Formatted: Highlight
A. Minimum data set (MDS)
C. Resident Assessment Instrument
D. Resident Assessment Protocols
The MDS is a screening tool in which strengths and deficits are recognized and triggered for
6. When does the OT section of the MDS have to be completed by for a new admission to a
long-term care facility?
A. 7 days
B. 14 days
C. 21 days
D. 28 days
COTA involvement in completion of sections of the MDS can be beneficial. Because the initial
MDS does not have to be completed until the 14th day after admission, the resident often has
been evaluated and is being treated by the OTR/COTA team.
7. What is the MDS used to determine?
A. Medicare payment for those residents that meet eligibility qualification.
B. How many days a resident can be admitted for in the SNF.
C. Whether or not the resident can be admitted to the SNF.
D. Whether or not COTAs and OTs will be reimbursed for their services.
Under the regulations for the PPS, a system that regulates Medicare Part A payments in SNFs, Formatted: Highlight
the MDS is also used to determine Medicare payment for those residents that meet the eligibility
qualifications. OT treatment influences that payment system and COTAs may be responsible for
tracking minutes of treatment for sections of the MDS.
8. The MDS is done on admission and at which other time?
A. When the resident is discharged.
B. When the resident has a significant change in condition.
C. When the MDS coordinator at the facility determines it is time.
D. All of the above.
Completion of a new MDS is required when significant changes in the resident’s status have
occurred. COTAs completing any portion of the MDS assessment must certify accuracy of the
sections(s) they complete by signing their name, credentials and the date of their assessment.
9. Along with the COTA, who must sign the MDS to certify the assessment?
A. An Occupational Therapist
B. A physician
C. A Registered Nurse
D. No co-signature is required.
If COTAs complete any portion of the MDS assessment they must certify accuracy of the
section(s) they complete by noting their credentials and the date and indicating the portion of the
assessment completed. The signature of a registered nurse is required to certify completion of the
10. What is the relevance of Physician’s Current Procedural Terminology (CPT) codes?
A. The codes describe patient care outcomes.
B. The codes help calculate reimbursement amounts.
C. Timed codes are used most often by COTAs.
D. All of the above.
Therapy services are billed under a physician fee schedule using Physician’s Current Procedural
Terminology (CPT) codes. Codes describe outcomes. They may be service codes that are billed
only once per day regardless of the amount of time spent in delivering the procedure. Service
codes include evaluation, reevaluation, splint application, and most modalities. Timed codes are
the majority of the codes applicable to interventions provided by the COTA. Formatted: Highlight
11. What type of care involves specific guidelines for reimbursement?
A. Skilled care.
B. Unskilled care.
C. Outpatient care.
D. None of the above.
The concept of skilled and unskilled therapy must be understood to obtain reimbursement from
Medicare for OT intervention. Skilled care involves specific guidelines. For example in skilled
nursing facilities care is covered if performed under the supervision of a professional, and Formatted: Highlight
ordered by a physician and provided on a daily bases.
12. What does “prospective payment system” mean?
A. That payment to skilled nursing facilities (SNF) is based on the number of days
the resident is expected to be in the facility.
B. That payment to skilled nursing facilities (SNF) is based on the expected therapy
to be received by the OT department.
C. That reimbursement occurs prospectively on the basis of a level of care or
anticipated level of care.
D. The reimbursement occurs based on the care already charged to and received by
The Medicare Part A PPS are regulations created to control costs of health care. Reimbursement
occurs prospectively on the basis of a level of care or an anticipated level of care rather than
retrospectively on the basis of what was charged.
13. What is a “RUG”?
A. It is a grouping of the amount and type of therapy services required by the
resident and provided by the OT department and is documented in “minutes” by the therapy
B. It is a group of diagnoses that the resident has and that are reimbursed by charting
detailed notes in the resident’s chart.
C. It is a Rigorous Underlying Group that evaluates how ill and dependent a resident
is compared to other residents at the facility.
D. None of the above.
The PPS is based on resources used by the patient and is divided into Resource Utilizations
Groups (RUGs). Rugs are associated with the amount and type of therapy services.
14. For the “very high” RUG category, how many minutes of therapy must the resident Formatted: Highlight
receive for a 5-day period?
A. 720 minutes
B. 600 minutes
C. 500 minutes
D. 400 minutes
The “very high” RUGs category requires at least 500 minutes from at least one discipline for a
least 5 days.
15. A newly admitted resident needs “unskilled services” in the facility. Which of the
following orders would be written for this resident?
A. Pain medications
B. IV Fluids and IV medications
C. Occupational therapy to increase function, reduce pain.
D. Repetitive exercises including passive range of motion.
Unskilled services would be exercises that are repetitive in nature, passive exercises to maintain
range of motion or strength, and positioning in bed without reference to specific complications.
16. Who pays for Medicare Part B (Supplementary Medical Insurance) premiums?
A. The patients themselves
B. The federal government
C. The federal and state governments
D. The patient’s taxes
This is a voluntary program available to individuals entitled to Medicare Part A. The program
requires enrollment and payment of a monthly premium by the insured.
17. Which of the following services are NOT covered under Medicare Part B?
A. MD Ooffice Vvisits Formatted: Highlight
B. Ambulatory surgery
C. Outpatient rehabilitation
D. Inpatient hospital care.
Part B services include physician, outpatient, and home health services in addition to services
furnished by rural clinics, ambulatory surgery centers, and comprehensive outpatient
18. Which member of the healthcare team “certifies” that a resident or client qualifies for
covered OT services under Medicare?
A. The OT
B. The COTA
C. The RN Supervisor
D. The MD
For OT treatment to qualify for reimbursement under Medicare Part B, a physician must certify
that the therapy services are required and a plan for furnishing the services is established by the
physician and the OTR.
19. Which of the following elders meets the definition for “homebound”?
A. An elder who had a hip replacement 4 weeks ago and ambulates at home with a
walker. Short trips to the MD and the grocery store are the limits of her walking ability.
B. An elder who has terminal cancer and is limited to sitting in a bedside chair
during the day. The elder has not left the home in some time and would need a stretcher to leave
C. An elder who has Alzheimer’s and gets lost frequently. Her daughter lives with
her and takes her to all of her appointments.
D. An elder who is active at home but does not like to leave home to grocery shop or
Homebound means the elder is unable to leave the home without considerable effort and
assistance. The elder does not have to be bedridden. Visiting a physician is an example of a
legitimate reason to leave the home.
20. What did the Olmstead Act do?
A. Implemented Medicare coverage for persons age 65 and older.
B. Implemented Medicaid coverage for needy persons.
C. Implemented the Supplementary Security Income program for elders.
D. Implemented funding for community-based alternatives for disabled persons.
The Olmstead Act allowed and encouraged the promotion of community-based alternatives for
individuals with disabilities, such as accommodations that meet needs of these individuals,
available caregivers to provide assistance, transportation programs, and in some cases