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HCPro Boot Camps
Formerly HRAI Coding Specialists
200 Hoods Lane,
Marblehead, MA 01945
Phone: (877) 207-4036
Fax: (800) 738-1553
Copyright 2000-2008,
HCPro, Inc., All Rights Reserved
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Medicare Boot Camp® - Physician Services Version
Learning Objectives
Module 1: Introduction; Researching Medicare Issues
- Be able to locate the key sources of Medicare authority on the Internet.
- Be able to differentiate between statutes, regulations, transmittals and other interpretative guidance.
- Be able to identify ways to efficiently keep up with operational changes in the Medicare program.
Module 2: Credentialing and Enrollment
- Be able to explain the Medicare physician/supplier enrollment process.
- Be able to determine the appropriate Medicare enrollment form to use.
- Be able to determine the differences between NPIs and UPINs.
- Be able to explain how NPIs and UPINs are reported on Medicare claims.
- Be able to explain how NPIs will be assigned and used.
- Be able to identify the differences between participation and non-participation in the Medicare program.
- Be able to explain the ramifications and process for "opting out" of the Medicare program.
Module 3: Non-Physician Practitioner Services
- Be able to distinguish between "incident to" and "separate enrollment" coverage of non-physician practitioner services.
- Be able to determine whether a particular non-physician practitioner service qualifies for "incident to" coverage.
- Be able to explain when the services of nurse practitioners and physician assistants may be appropriately billed under the "separate enrollment" coverage rules.
Module 4: RBRVS Mechanics
- Be able to explain how Medicare payment is determined under the physician fee schedule.
- Be able to use the data in the Medicare relative value file/physician fee schedule database to make operational billing decisions.
- Be able to explain how Medicare's annual deductible and coinsurance affect beneficiary liability and payment to practitioners.
- Be able to identify situations where the -22 and -52 modifiers should be used.
- Be able to explain the affect of the -22 and -52 modifiers on payment.
Module 5: Claims for Physician/Practitioner Services
- Be able to explain the role and functions of the Medicare carrier.
- Be able to determine Carrier jurisdiction for services furnished to a Medicare beneficiary.
- Be able to use the CMS-1500 08-05 data set instructions to determine proper reporting of services provided.
- Be able to explain how to properly report site of service and the effect of site of service on payment.
- Be able to explain the differences and implications of assigned versus non-assigned claims.
- Be able to determine when and how the "limiting charge" rules apply to both assigned and non-assigned claims.
- Be able to determine when a practitioner may/may not bill for services furnished to a relative.
- Be able to provide an overview of how SNF consolidated billing affects billing for professional services furnished to SNF residents.
- Be able to determine whether a particular reassignment relationship is permissible under the Medicare reassignment regulations/guidelines
Module 6: Advanced Beneficiary Notices and Non-Covered Services
- Be able to determine when the Medicare "financial liability protections" provisions apply to professional services.
- Be able to determine when it would be appropriate/inappropriate to present an ABN to a patient.
- Be able to identify those circumstances under which an ABN would be ineffective or invalid.
- Be able to determine when it would be appropriate to use an NEMB.
- Be able to identify those circumstances where a single ABN will cover an extended course of treatment.
- Be able to identify those circumstances where a routine ABN is permitted.
- Be able to determine how to properly report non-covered services on a professional services claim, including the appropriate use of modifiers.
Module 7: The National Correct Coding Initiative
- Be able to use the CMS web site to locate the NCCI policies and edits applicable to professional services.
- Be able to determine when an NCCI edit applies to an outpatient claim.
- Be able to differentiate between the "column 1/column 2" edits and the "mutually exclusive" NCCI edits.
- Be able to determine the correct way to bill for a code pair that is subject to an NCCI edit, including appropriate use of the "correct coding modifiers."
- Be able to detect automatic denial for Medically Unlikely Edits.
Module 8: Evaluation and Management Services
- Be able to determine the appropriate way to bill for E/M services furnished to a hospital inpatient.
- Be able to determine the appropriate way to bill for E/M services furnished to a hospital observation patient.
- Be able to bill appropriately for a "Welcome to Medicare" visit
- Be able to determine the appropriate way to bill for E/M services furnished to an emergency department.
- Be able to determine the appropriate way to bill for E/M services furnished to a nursing facility patient.
- Be able to determine whether a particular encounter qualifies to be billed as a consultation.
- Be able to identify the circumstances under which Medicare does and does not cover critical care.
- Be able to determine the appropriate way to bill for covered critical care services.
- Be able to determine the appropriate way to bill for concurrent care services.
- Be able to determine the appropriate way to bill for care plan oversight services.
Module 9: Surgical Services
- Be able to determine when a service is and is not included in the global surgical package.
- Be able to determine the applicable postoperative period of a procedure.
- Be able to determine the appropriate way to bill for services furnished during the postoperative period that are not included in the surgical package, including the use of appropriate modifiers.
- Be able to determine how the multiple procedure reduction applies to a particular Medicare claim.
- Be able to determine the appropriate way to bill for bilateral surgeries.
- Be able to determine the appropriate way to bill for assistant surgeons, co-surgeons and team surgeons.
Module 10: Diagnostic Testing
- Be able to determine when the professional and technical component services for a diagnostic test are separately billable.
- Be able to determine when and how to use modifiers to appropriately bill for professional and technical component services.
- Be able to determine the level of physician supervision required for a particular diagnostic test.
- Be able to appropriately bill diagnostic radiology services in a professional practice setting.
- Be able to explain the CLIA requirements applicable for laboratory services furnished in a professional practice setting.
- Be able to locate and effectively use the clinical diagnostic laboratory services fee schedule.
- Be able to locate and effectively use the national coverage determinations (NCDs) applicable to clinical laboratory services.
Module 11: Teaching Physician Issues
- Be able to provide an overview of Medicare coverage of services provided by interns and residents.
- Be able to identify situations in which a teaching/attending physician's presence in required when residents are involved in patient care.
- Be able to determine the proper way to bill for resident involvement of patient care (including the appropriate use of modifiers).
- Be able to explain the documentation requirements applicable to teaching/attending physician services when residents are involved in patient care.
- Be able to determine how to bill appropriately for services furnished an intern or resident functioning as an assistant surgeon.
- Be able to determine if Medicare payment is available for services furnished by a particular moonlighting resident.
Module 12: Audits and Appeals
- Be able to provide an overview of the Medicare program integrity function applicable to services furnished in a professional practice setting.
- Be able to differentiate between "medical review" and "benefit integrity" and their respective purposes.
- Be able to respond to a notice of audit.
- Be able to provide an overview of the Medicare Part B appeals process.
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