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HCPro Boot Camps
75 Sylvan Street, Suite A-101
Danvers, MA 01923
Phone: (800) 780-0584
Fax: (800) 738-1553
Copyright 2000-2008,
HCPro, Inc., All Rights Reserved
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Medicare Boot Camp® - Critical Access Hospital Version
Learning Objectives
Module 1: Medicare Research: Find What You Need When You Need It
- 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: Critical Access Hospital (CAH) - An Overview
- Be able to identify the qualifications necessary to receive CAH designation.
- Be able to identify the limitations on the number of acute care beds and length of stay.
Module 3: UB-04, ICD-9-CM, 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 determine the proper way to bill repetitive, non-repetitive and recurring services.
- Be able to properly bill reference lab services.
- Be able to determine when outpatient and inpatient claims on the same date of service need to be billed as separate encounters.
- 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: 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.
- Be able to locate diagnosis coding guidelines, including the "Official Guidelines" for ICD-9-CM and Medicare guidelines.
- Be able to determine the factors that drive the MS-DRG assignment and its use for a CAH.
- Be able to identify present on admission indicators and locate guidelines for POA assignment.
- Be able to identify how MS-DRG assignment and payment is affected by hospital acquired conditions or "never" events.
Module 5: 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 6: Understanding Medicare Revenue: Overview of the Cost-Based Reimbursement System
- Be able to identify the components of the cost-based system.
- Be able to determine when Method I or Method II billing is being used.
- Be able to identify when a hospital qualifies for Health Professional Shortage Area (HPSA) bonus.
- Be able to calculate the patient's coinsurance, deductible and Life Time Reserve Days.
- Be able to determine the differences between an acute care bed and a swing bed.
Module 7: Hot Topics: Medical Necessity of Inpatient Admissions
- Be able to identify the factors affecting Medicare coverage for inpatient services.
- Be able to identify the correct inpatient admission date for billing purposes.
- 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 8: Hot Topics: Medical Necessity of Swing Bed Admissions
- Be able to identify the factors affecting Medicare coverage for swing bed services.
- Be able to identify the level of care requirements.
- Be able to identify the documentation requirements to support medical necessity.
- Be able to determine reimbursement and coinsurance for swing bed services.
- Be able to identify which services are excluded from SNF consolidated billing rules.
Module 9: Hot Topic: Outpatient Coverage, Coding and Billing
- 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 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 identify how to report discontinued and bi-lateral procedures.
- 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 10: 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 11: 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.
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