Medicare Boot Camp® - Hospital Version
Learning Objectives
Module 1: Medicare Basics: Understanding Medicare and Finding Resources on the Web
- Locate key sources of Medicare authority on the Internet
- Differentiate between statutes, regulations, CMS Manuals, CMS Transmittals and other interpretive guidance
- Differentiate between Medicare Part A and Part B
- Differentiate between the UB-04 and CMS 1500
- Identify the role of the MAC (or fiscal intermediary/carrier)
- Identify RAC regions and contractors
- Identify RAC record limitations and new issues
Module 2: UB-04, ICD-9-CM, NPI and other Must Know Billing Fundamentals
- Identify required UB-04 fields applicable to hospital services
- Identify reporting requirements for condition codes, revenue codes, HCPCS codes, outpatient diagnosis codes and present on admission indicators
- Understand ICD-9 coding guidance for outpatient services
Medicare 3: Medicare Claims Processing Fundamentals
- Determine the proper way to bill repetitive, non-repetitive and recurring services
- Identify the correct inpatient admission date for billing purposes
- Identify proper billing for pre-admission services and proper application of the three day payment window
- Determine the Medicare claims flow and processing systems, including the Integrated Outpatient Code Editor (IOCE) and Medicare Code Editor (MCE)
- Differentiate between the five levels of the Medicare Appeals Process and applicable time frames
- Identify recoupment limitations and applicable interest regulations
Module 4: Medical Necessity and Non-Coverage: What to Know When Medicare is Not Paying the Bill
- Determine when the Social Security Act "Limitation on Liability" provisions apply
- Determine when an ABN is necessary to hold the patient responsible for non-covered services
- Identify those circumstances under which an ABN would be ineffective/invalid
- Identify how to properly bill for non-covered outpatient services
- Properly apply limitations on liability to inpatient services, including hospital-issued notices of non-coverage (HINNs)
- Determine how to properly bill for services arising from a non-covered stay
Module 5: NCCI, MUEs, Modifiers and Other Must Know Coding Fundamentals
- Identify the composition and application of NCCI edits
- Differentiate between the Column 1/ Column 2 and the Mutually Exclusive code edits
- Determine special considerations and practical issues for hospitals related to NCCI edits
Module 6: Tools for Understanding and Predicting Medicare Outpatient Revenue: Overview of OPPS
- Understand how the OPPS payment system and Ambulatory Payment Classifications (APCs) work
- Use Addendum A and Addendum B and status indicators to understand payment for a specific HCPCS code
- Understand composite APCs and identify the services that trigger composite payment
- Calculate the Medicare allowable and patient co-insurance for a specific HCPCS code
- Understand and calculate outpatient outlier payments
Module 7: Hospital Provider-Based Departments: E/M Services, Critical Care and Other Hot Topics
- Understand physician supervision requirements applicable to hospital outpatient therapeutic departments and services
- Properly apply "incident to" coverage provisions to hospitals outpatient services
- Understand E/M coding guidance for clinics, emergency departments, critical care and trauma activation
- Identify the proper use of modifier 25 for hospital services
Module 8: The Essentials of Drugs, Biologicals and Devices: How are They Covered and How are They Paid?
- Identify Medicare coverage of drugs, including self-administered drugs
- Understand how to properly bill for drugs, biologicals and devices
- Use status indicators to determine how drugs, biologicals and devices are paid
Module 9: Surgical and Radiology Services under OPPS: Discounts, Modifiers, and More
- Understand physician supervision requirements applicable to hospital outpatient diagnostic departments and services
- Understand how the multiple procedure discount works and how to properly apply modifiers that override the discount
- Understand how to properly apply modifiers for terminated/discontinued surgical and radiology services
- Identify how to properly bill procedures involving devices or radiopharmaceuticals received at reduced or no cost
- Understand how to report bilateral procedures
Module 10: Let's not forget about the Lab: Coverage, Blood Products, and More
- Identify national coverage determinations (NCDs) for laboratory services
- Understand proper billing of non-patient (reference) laboratory services
- Determine the appropriate way to bill for blood products and blood processing and storage
Module 11: Sorting Out Patient Status: Observation Services and Inpatient Admissions
- Determine the appropriate way to bill for covered observation services
- Identify inpatient only procedures and exceptions to the inpatient only payment restriction
- Identify Medicare utilization review requirements
- Determine how to change patient status from inpatient to outpatient, including proper use of condition code 44
- Determine when a service furnished to an inpatient is payable under Part B
Module 12: Tools for Understanding and Predicting Medicare Inpatient Revenue: Overview of the IPPS
- Identify the factors that drive the MS-DRG assignment
- Identify how the MS-DRG assignment and payment is affected by hospital acquired conditions
- Determine the MS-DRG payment for an inpatient case, including appropriate standardized amount and wage index
- Determine the patient responsibility, including applicable deductible, co-insurance and life time reserve days
Module 13: When the DRG Payment is Not What You Expect: Special IPPS Payments and Adjustments
- Identify when a discharge will be treated as a transfer for payment purposes, including post acute transfers
- Identify how to properly bill cases involving devices received at reduced or no cost
- Determine whether an inpatient case qualifies for a new technology payment and the amount
- Identify the factors affecting inpatient outlier payments
- Distinguish between Medicare Dependent Hospitals and Sole Community Hospitals
- Identify the factors that affect the IME operating and capital adjustment factors for a hospital hosting residents
- Determine the DSH percentage and the DSH operating and capital adjustment factors for a hospital
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