Medicare Boot Camp® - Hospital Version
Course Outline
1 Finding and Understanding Medicare Information
- Researching Medicare issues and finding Medicare resources
- How to understand statutes, regulations, manuals, transmittals and other Medicare rules and guidelines
- Medicare Part A and B
- The role of Medicare contractors, including MAC and RAC
2 Decoding the UB-04
- Key UB-04 fields applicable to hospital services, including proper use of condition codes, revenue codes, and HCPCS codes
- Review of ICD-9 coding for outpatient services
- Review of POA coding guidance
3 Medicare Claims Submission: Must know Fundamentals
- Timely Filing
- Repetitive, non-repetitive and recurring services
- The three-day payment window and preadmission services
4 Medicare Systems and Processes related to Claims
- Medicare claims flow and processing systems, including the outpatient code editor and Medicare (inpatient) code editor
- Medicare Secondary Payer, including conditional payments
- Medicare appeals process
5 Outpatient Medical Necessity and ABNs
- Overview of limitations of liability and when notice is required
- The advanced beneficiary notice (ABN) forms and instructions
- How to bill for non-covered outpatient services
6 Correct Coding Edits, including the Proper use of Modifiers
- Column 1/Column 2 (bundling) and mutually exclusive edits
- Medically Unlike Edits (MUEs) for excess units of service
- Proper use of modifiers with NCCI edits
7 Nuts and Bolts of the Outpatient Prospective Payment System
- Overview of the OPPS system and ambulatory payment classifications (APCs)
- How to use Addendum A and B and status indicators to understand APCs
- Determining how separately paid services are paid
- Determine services that are packaged
- Understand composite APCs
8 Calculating Outpatient Payment and Outliers
- How to calculate the Medicare allowable for a HCPCS
- How to calculate the patient's coinsurance
- Understand and calculate outpatient outlier payments
9 Hospital Provider-Based Departments and Clinics
- Incident to Coverage of Outpatient Therapeutic Services
- Elements of Incident to Coverage including Physician supervision
- E/M coding for Clinics and Emergency departments
- Critical care and trauma activation
- Proper application of modifier- 25
10 Drugs, Biologicals and Devices
- Coverage of drugs, including self administered drugs
- Billing of packaged drugs, biologicals, and devices
- Separately paid drugs, biologicals, and devices
- Discarded Drugs
11 Surgical and Radiology Services under OPPS
- Physician supervision of hospital diagnostic services
- Terminated/discontinued surgical and radiology procedures
- Surgical procedures implanting devices received at reduced cost
- Proper reporting of bilateral procedures
- Never Event Procedures
12 Laboratory Services
- National coverage determinations for laboratory services
- Clinical Diagnostic Laboratory Fee Schedule
- Reference laboratory billing
- Blood, blood products, and blood processing and storage
13 Patient status: Observation services and inpatient admissions
- Coverage and proper billing of observation services
- Identification and billing of inpatient only procedures
- Inpatient coverage rules
- Requirements for utilization review
- Changing patient status with condition code 44
- Payment under Part B for services furnished to inpatients
14 Inpatient Hospital Payment System and Special Billing Issues
- Overview of the Inpatient Prospective Payment System
- Medicare severity diagnosis related groups (MS DRGs)
- Hospital Acquired Conditions (HACs)
- Hospital Issued Notices of Non-coverage (HINNs)
- How to bill conditions arising during or from a non-covered stay
15 Calculating Inpatient Payment
- How to find and use standardized amounts and wage indices
- The effect of the Indirect Medical Education (IME) and Disproportionate Share Hospital (DSH) adjustments
- Inpatient deductible, coinsurance, and life time reserve days
16 Inpatient Payment Adjustments
- Payment for transfers and the post acute care transfer policy
- Policy for devices received without cost or with substantial credit
- New technology add-on payment
- Inpatient outlier basics
Course agenda subject to change
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