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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® - Hospital Version
Learning Objectives
Module 1: Overview of the Medicare Program and Researching Medicare Issues
- 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.
- 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.
Module 2: Hospital Claims
- 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.
- Be able to determine the proper way to bill repetitive, non-repetitive and recurring services.
- Be able to identify the Medicare systems that process hospital claims, including the IOCE, FISS, and Common Working File.
Module 3: National Correct Coding Initiative
- Be able to use the CMS web site to locate the NCCI policies and edits applicable to hospital outpatient services.
- Be able to determine when an NCCI edit applies to an outpatient claim.
- 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 identify the differences between the physician and hospital versions of NCCI.
- Be able to identify compliance concerns relating to the NCCI.
Module 4: Outpatient Advance Beneficiary Notices and Non-Covered Services
- Be able to determine when the Social Security Act "Limitation on Liability" provisions apply to an outpatient service.
- Be able to determine when it would appropriate/inappropriate to present an ABN to a patient.
- Be able to identify those circumstances under which an ABN would be ineffective/invalid.
- Be able to determine when it would 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 at least one circumstance where a routine ABN is permitted.
- 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.
Module 5: Outpatient Prospective Payment System (OPPS) Mechanics
- 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 different kinds of packaged services and articulate the payment difference between them.
- 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 6: Drugs, Biologicals and Devices
- 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 determine when the patient, rather Medicare, should be billed for a drug, biological or device.
- Be able to identify those circumstances under which it is appropriate to bill Medicare for discarded drugs.
Module 7: Clinic, Emergency Department and Critical Care Services
- 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 difference between a Type A emergency department and a Type B emergency department.
- Be able to identify the criteria used by CMS in evaluating the appropriateness of a hospital's internal system for assigning E/M code levels for the facility component of clinic and ED visits.
- Be able to identify guidelines for coding critical care and trauma activation.
- Be able to identify those circumstances where it is appropriate to use the -25/-27 modifiers on a hospital claim.
Module 8: 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 how observation services trigger payment for the Extended Assessment and Management Composite APC.
Module 9: Outpatient Surgical and Radiology Services
- 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 reduced procedures and associated payment reductions.
- Be able to identify the proper reporting of bi-lateral procedures.
- Be able to determine the appropriate way to charge for procedures which inherently include conscious sedation.
- Be able to identify inpatient only procedures and exceptions to the inpatient only payment restriction.
- Be able to identify billing requirements and determine the payment adjustment for procedures which implant devices received at no cost or reduced cost.
- Be able to identify the proper reporting of drug eluting stents and angiography at the time of cardiac catheterization.
- Be able to identify the proper billing of mammography services, including film and direct to digital studies.
Module 10: Clinical Diagnostic Lab Services
- Be able to determine the Medicare payment system (i.e., Clinical Diagnostic Lab Fee Schedule versus OPPS) that applies to a particular lab or pathology service.
- Be able to determine the appropriate way to bill for for organ/disease panels and repeat lab tests.
- 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 determine the appropriate way to bill for blood products and blood processing and storage, including used blood.
Module 11: Inpatient Coverage
- Be able to identify the factors affecting Medicare coverage for inpatient services.
- Be able to determine the applicable deductible and co-insurance for an inpatient case.
- Be able to determine when a service furnished to an inpatient is payable under Part B.
- Be able to determine how to properly bill for services arising from a non-covered stay.
- Be able to determine proper usage of the Important Message from Medicare, Detailed Notice of Discharge, Hospital Requested
- Review Notice and Hospital Issues Notices of Non-coverage
- 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 pre-admission services are packaged into the DRG payment for an inpatient case.
Module 12: Inpatient Prospective Payment System (IPPS) Mechanics
- Be able to determine whether payment for a particular service is included in, or excluded from, the DRG payment for a case.
- Be able to identify the factors that drive DRG assignment.
- Be able to determine the DRG payment for an inpatient case.
- Be able to determine the wage index applicable to a particular hospital.
- Be able to identify how the cost report ultimately affects a hospitals payment under IPPS.
- Be able to determine the effect of Medicare Dependant Hospital or Sole Community Hospital status on DRG payments.
Module 13: DRG Payment 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 determine the payment implications of a discharge being treated as a transfer.
- Be able to identify "special payment methodology DRGs" and the payment implications of the "special payment methodology".
- Be able to determine the DSH percentage for a hospital.
- Be able to determine the DSH operating and capital adjustment factors for a hospital.
- 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.
Module 14: Inpatient Outliers
- Be able to calculate the outlier payment, if any, for an inpatient case.
- Be able to determine the implications of changes in a hospital's charge and cost structure on outlier payments.
- Be able to identify the circumstances under which outlier payments will be subject to reconciliation.
Module 15: Direct and Indirect Graduate Medical Education Payments
- Be able to identify the factors that affect the IME operating and capital adjustment factors for a hospital.
- Be able to identify the factors that affect Medicare GME payments.
- Be able to identify rules for reporting resident time, including documentation rules and rules for didactic training.
- Be able to identify rules for counting the initial residency period of a resident.
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