Intensive, hands-on healthcare coding,
Medicare billing and compliance training
courses offered nationwide

HCPro Boot Camps
200 Hoods Lane,
Marblehead, MA 01945
Phone: (800) 780-0584
Fax: (800) 738-1553
Copyright 2000-2008,
HCPro, Inc., All Rights Reserved

Medicare Boot Camp® - Hospital Version

Learning Objectives

Module 1: Medicare Research: End your confusion over the Medicare Web site and find what you need

Be able to locate key Medicare sources of Medicare authority on the Internet.
Be able to differentiate between statutes, regulations, CMS manuals, CMS transmittals and other interpretative guidance.
Be able to differentiate between the roles of the Medicare Carriers and Intermediaries or Medicare Administrative Contractors.
Be able to differentiate between Medicare Part A and Medicare Part B.
Be able to differentiate between the UB-04 and CMS-1500 claim formats.

Module 2: UB-04, ICD-9-CM, NPI, OCE and Other Must-Know Billing Fundamentals

Be able to determine whether a particular UB-04 field is required for outpatient and inpatient claims.
Be able to use the UB-04 instructions to determine how to report "coded" UB-04 fields (e.g., bill type, condition codes, etc.)
Be able to determine the appropriate revenue codes for covered charges.
Be able to identify coding rules for reporting principle diagnosis and admitting diagnosis for inpatients and outpatients.
Be able to locate diagnosis coding guidelines, including the "Official Guidelines" for ICD-9-CM and Medicare guidelines.
Be able to identify present on admission indicators and locate guidelines for POA assignment.

Module 3: OCE, MCE, and Other Medicare Claims Fundamentals

Be able to determine the proper way to bill repetitive, non-repetitive and recurring services.
Be able to identify the correct inpatient admission date for billing purposes.
Be able to determine when pre-admission services are billed on the inpatient claim or on a separate outpatient claim.
Be able to use the Outpatient Code Editor to identify Medicare edits for outpatient claims.
Be able to identify the Medicare systems that process hospital claims, including the IOCE, FISS, and Common Working File.

Module 4: Medical Necessity and Non-Coverage: What you need to know when Medicare is not paying the bill

Be able to determine when the Social Security Act "Limitation on Liability" provisions apply to an outpatient service.
Be able to determine when an ABN is necessary to hold the patient responsible for non-covered services.
Be able to identify those circumstances under which an ABN would be ineffective/invalid.
Be able to determine how to properly report non-covered services on an outpatient claim.
Be able to identify how to properly bill in a patient "demand" situation or when a denial is required to bill other payors.
Be able to determine proper usage of the three inpatient Hospital Issues Notices of Non-coverage (HINNs).
Be able to determine how to properly bill for services arising from a non-covered stay.

Module 5: NCCI, MUEs, Modifiers and Other Must-Know Coding Fundamentals

Be able to use the CMS web site to locate the NCCI policies and edits applicable to hospital outpatient services.
Be able to identify Medically Unlikely Edits and their effect on an outpatient claim.
Be able to differentiate between the Column 1/Column 2 Code Edits and the Mutually Exclusive Code Edits.
Be able to determine the effect of an NCCI modifier on a code pair subject to an NCCI edit.
Be able to locate guidance on modifier use, including updated guidance on modifier -59.
Be able to identify compliance concerns relating to the NCCI.

Module 6: Tools for Understanding and Predicting Medicare Outpatient Revenue: Overview of the OPPS

Be able to work with the various OPPS "Addendums" to determine how a particular service will be treated under OPPS.
Be able to identify Composite APCs and the services that trigger composite payment.
Be able to determine when and how to bill for packaged services under OPPS.
Be able to identify the two kinds of packaged services and when payment is made separately for otherwise packaged services.
Be able to calculate the APC payment amount (including co-insurance) for a separately payable APC.
Be able to calculate an outlier payment for an APC that qualifies as an outlier.

Module 7: The Requirements and Operation of the Recovery Audit Contractor (RAC) Program

Be able to identify the four RAC regions and their contractors.
Be able to identify how RACs identify new issues for review.
Be able to determine medical records limitations and timeframes for response to RAC requests.
Be able to differentiate between automated and complex RAC reviews.
Be able to identify one method to stop recoupment from a RAC overpayment determination.

Module 8: Hot Topics: Medical Necessity of Inpatient Admissions and Observation Services

Be able to identify the circumstances under which Medicare does and does not cover observation services.
Be able to determine the appropriate way to bill for covered observation services.
Be able to identify inpatient only procedures and exceptions to the inpatient only payment restriction.
Be able to identify the factors affecting Medicare coverage for inpatient services.
Be able to identify Medicare utilization review requirements for inpatient admissions.
Be able to identify how to apply condition code 44 and how to bill services when condition code 44 criteria are not met.
Be able to determine when a service furnished to an inpatient is payable under Part B.

Module 9: Hot Topic: Outpatient Coverage, Coding and Billing

Be able to determine whether the facility component of a clinic/ED visit is covered under Medicare's "incident to" criteria.
Be able to identify the criteria for proper coding of the facility component of clinic and ED visits, critical care and trauma activation.
Be able to identify those circumstances where it is appropriate to use the -25 modifier on a hospital claim.
Be able to determine when Medicare will cover a particular drug furnished to a hospital outpatient.
Be able to determine when Medicare will pay separately for a covered drug furnished to a hospital outpatient.
Be able to differentiate between pass-through and non-pass through drugs and biologicals.
Be able to identify the multiple procedure payment reduction and how modifiers may be used to override when appropriate.
Be able to identify how to report discontinued and bi-lateral procedures and associated payment policies.
Be able to identify billing rules and payment adjustments for procedures implanting devices received at no cost or reduced cost.
Be able to use the Lab NCD manual to determine when an ABN is required for a lab service covered by an NCD.
Be able to properly bill reference lab services.
Be able to determine the appropriate way to bill for blood products and blood processing and storage, including used blood.

Module 10: The Medicare Appeals Process

Be able to differentiate between the five levels of the Medicare Appeals Process.
Be able to identify timeframes for recoupments, stopping recoupments and filing appeals.

Module 11: Tools for Understanding and Predicting Medicare Inpatient Revenue: Overview of the IPPS

Be able to identify the factors that drive the MS-DRG assignment.
Be able to identify how MS-DRG assignment and payment is affected by hospital acquired conditions or "never" events.
Be able to determine the MS-DRG payment for an inpatient case, including the wage index and GAF adjustments.
Be able to determine the applicable deductible and co-insurance for an inpatient case.

Module 12: When the DRG Payment is not What You Expect: Special IPPS Payments and Adjustments

Be able to identify when a discharge will be treated as a transfer for payment purposes, including post acute transfer policies.
Be able to identify "special payment methodology DRGs" and the payment implications of the "special payment methodology".
Be able to identify how to properly bill for admissions which include surgeries implanting a device received at reduced cost.
Be able to determine whether an inpatient case qualifies for a new technology payment and, if so, the amount of the payment.
Be able to identify factors affecting outlier payments.
Be able to identify the circumstances under which outlier payments will be subject to reconciliation.
Be able to determine the effect of Medicare Dependant Hospital or Sole Community Hospital status on DRG payments.
Be able to determine the DSH percentage and the DSH operating and capital adjustment factors for a hospital.
Be able to identify the factors that affect the IME operating and capital adjustment factors for a hospital.