Medicare Boot Camp® - Critical Access Hospital Version
Course Outline
Day One
Medicare Research: End the confusion over the CMS website and find what you need when you need it
- Researching Medicare issues and finding Medicare resources on the Web
- Understanding statutes, regulations, manuals, transmittals, and other Medicare rules and guidelines
- The role of Medicare contractors
- Overview of the RAC program
Critical Access Hospital (CAH): Overview
- Qualifying for CAH designation
- Understanding the limitations on number of beds and length of stay
- Establishing distinct part units for psychiatric and rehabilitation services
UB–04, Claims Processing System, Appeals, and Other Must–Know Billing Fundamentals
- Key UB–04 fields applicable to CAHs, including proper use of condition codes, revenue codes, HCPCS codes, and diagnosis codes
- Repetitive, non–repetitive, and recurring services, including claims frequency
- Billing for reference laboratory services
- Separation of claims for outpatient and inpatient services on the day of admission
- Medicare claims flow and processing systems, including the outpatient code editor and Medicare (inpatient) code editor
- Medicare appeals process
- Limitations and interest on recoupments
- Appeal levels and timeframes
Day Two
NCCI, MUEs, Modifiers and Other Must–Know Coding Fundamentals
- Composition and application of NCCI edits, including column 1/column 2, mutually exclusive, and medically unlikely edits
- NCCI edits and proper use of modifiers, including –25, –59, –91
- Special considerations and practical issues for CAHs related to NCCI edits
- Application of coding guidelines for outpatient and inpatient services
- Medicare severity diagnosis related groups (MS–DRGs), including MS–DRG grouping, present on admission indicators, and hospital acquired conditions
Medical Necessity and Non–Coverage: What to Know When Medicare is Not Paying the Bill
- Overview of limitations of liability and when advanced notice is required
- Outpatient advanced beneficiary notice (ABN) form and instructions
- How to bill for non–covered outpatient services
- Application of limitation on liability to inpatient services, including hospital–issued notices of non–coverage (HINNs)
- How to bill conditions arising during or from a non–covered stay
- How to bill for never events
Understanding Medicare Revenue: Overview of the Cost–Based Reimbursement System
- Understanding the basics of the cost–based reimbursement system
- Understanding the differences between Method I and Method II billing
- Qualifying for the CRNA pass–through exemption
- How to calculate the patient’s responsibility, including deductible, coinsurance, and life time reserve days
Day Three
Hot Topics: Medical Necessity of Inpatient Admissions
- Understanding when inpatient services begin and the related coverage rules
- Requirements for utilization review
- Patient status changes from inpatient to outpatient, including proper use of condition code 44
- Payment under Part B for services furnished to inpatients
- Conditions arising during or from a non–covered stay
- Special considerations for inpatient–only procedures performed in CAHs
Hot Topics: Medical Necessity of Swing Bed Admissions
- Identifying coverage rules and level of care requirements for swing bed services
- Understand the reimbursement methodology and the patient’s coinsurance responsibility
- Understand how swing beds are excluded from SNF consolidated billing rules
Hot Topics: Outpatient Coverage, Coding, and Billing
- Coverage and proper billing of observation services
- Issues Related to Provider–Based Departments:
- Coverage of hospital outpatient services under the hospital incident–to provisions
- Special consideration for physician supervision of hospital therapeutic and diagnostic services in CAHs
- Proper E/M coding, including clinic, emergency department, critical care and trauma activation
- Proper application of modifier– 25
- Coverage of drugs, including self administered drugs (SADs) and correct reporting of units
- Issues related to surgical and radiology procedures
- Modifiers for terminated/discontinued surgical and radiology procedures
- Surgical procedures implanting devices received at reduced or no cost
- Proper reporting of bilateral procedures
- Issues related to laboratory
- National coverage determinations for laboratory services
- Blood, blood products, and blood processing and storage
(Agenda subject to change without notice.)
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