Medicare Boot Camp® - Long-Term Care Version
Learning Objectives
Module 1: Overview of the Medicare Program/Research
- Identify the key differences between the Medicare Programs (Part A, Part B, Part C, and Part D)
- Differentiate between covered items and services under Medicare Part A and Medicare Part B
- Discuss Medicare eligibility requirements
- Locate key Medicare sources of authority on the Internet
- Differentiate between statutes, regulations, CMS manuals, CMS transmittals, and other interpretive guidance
Module 2: SNF Coverage/Admission
- Define the Medicare qualifying stay requirement for admission into a SNF
- Identify the criteria for determining a skilled need
- Describe the services covered in a skilled stay
- Identify physician certification and recertification requirements for a skilled stay
- Define and calculate a Medicare benefit period
Module 3: The Resident Assessment Instrument and the Minimum Data Set 3.0
- Understand and describe the purpose of the RAI
- Identify key criteria in coding an accurate MDS 3.0
- Troubleshoot problematic areas with appropriate solutions for the use of the RAI and MDS 3.0
- Describe the documentation within the medical record when completing the MDS 3.0
Module 4: SNF PPS Payment
- Describe the difference between a cost-based reimbursement system and a prospective payment system
- Describe the MDS requirements for the PPS reimbursement system
- Differentiate between a Hierarchical and Case Mix Index Maximization case-mix system
- Compute a RUG score
- Describe the impact of the ADLs and ARD on reimbursement
Module 5: SNF Billing Under Part A
- Complete a UB-04 correctly for a SNF claim
- Define CMS requirements for Medicare exhaust and no-pay claims
- Describe the services excluded from SNF consolidated billing
- Determine admission dates, discharge dates, and utilization days appropriately
Module 6: SNF Consolidated Billing
- Describe the services excluded from SNF consolidated billing
- Use the HCPC help file to determine financial responsibility of services provided
- Identify key processes in reviewing invoices received for outside provider services
Module 7: Part B Outpatient Therapy
- Identify and describe the physician order and documentation requirements for the provision of outpatient therapy
- Complete a UB-04 form correctly for a Part B therapy claim
- Select appropriate CPT and ICD-9-CM codes for the provision of outpatient therapy services
- Differentiate between timed and service-based CPT codes
- Understand the recent changes with regards to outpatient therapy caps
Module 8: Part B Ancillary Services and DMEPOS
- Identify services billable by a SNF to Medicare Part B
- Identify the component parts of an NCD
- Identify billing requirements for pneumococcal, influenza, and hepatitis vaccinations, as well as all other preventative services
- Identify DMEPOS covered services in a nursing facility
- Describe the difference between claims that are submitted to the DMERC vs. the MAC
Module 9: Diagnosis Coding for SNFs
- Describe the general diagnosis coding guidelines as appropriate for use of ICD-9-CM codes
- Determine how to utilize ICD-9-CM codes for completion of the MDS
- Determine when to use V codes and late-effects codes
Module 10: Beneficiary Notices Initiative
- Discuss the applicability of ABN requirements to long-term care
- Identify the requirements of a SNF ABN being effective
- Identify the limitations on the use of ABNs
- Discuss the requirements for the Expedited Review process
Module 11: Medicare Medical Review and Appeals Process
- Identify the different types of Medical Review, including: MAC, RAC, ZPIC, and CERT
- Identify the bill review requirements, process, and outcomes
- Identify the correct level of appeals process
- Identify reopening vs. an appeal
- Identify requirements for Medicare claims appeals
- Identify CMS forms used during the appeals process
Module 12: Medicare Compliance and Risk Management
- Discuss the requirements of a compliance plan
- Describe a method to ensure that documentation matches the MDS, the medical record, and the care plan
- State the relationship between CMS' Corporate Compliance Guidelines and assessment and payment areas
- Link changes in resident condition to one risky communication practice
- Construct a staff training strategy to educate different levels of staff on the MDS 3.0
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