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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: 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.
- 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: 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 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 difference between the current ABN form and the Revised ABN form.
- Be able to identify those circumstances under which an ABN would be ineffective/invalid.
- 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: 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 6: The Essentials of Drugs, Biologicals and Devices: How are they covered and how are they paid?
- 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 the payment amount for drugs, biologicals or devices.
- Be able to identify those circumstances under which it is appropriate to bill Medicare for discarded drugs.
Module 7: Hospital provider-based departments: E/M services, critical care and other hot topics
- 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: New Composite APCs: How you still get paid for 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: Surgical and Radiology Services Under OPPS: Discounts, modifiers and more
- Be able to identify the elements for payment the Cardiac Electrophysiologic and Prostate Brachytherapy Composite APCs.
- 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, reduced, and bi-lateral procedures and associated payment policies.
- Be able to determine the appropriate way to charge for procedures which inherently include conscious sedation.
- Be able to identify how to report discontinued, reduced, 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 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: Let's not forget about the lab: Coverage, blood products and more
- Be able to determine the Medicare payment system 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: From 3 Days Before Admission to Post-discharge: What you need to know about Medicare's inpatient policies
- Be able to identify the factors affecting Medicare coverage for inpatient services.
- 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 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 determine when pre-admission services are packaged into the DRG payment for an inpatient case.
Module 12: Tools for Understanding and Predicting Medicare Inpatient Revenue: Overview of the IPPS
- Be able to determine whether payment for a particular service is included in, or excluded from, the MS-DRG payment for a case.
- Be able to identify the factors that drive 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 effect of Medicare Dependant Hospital or Sole Community Hospital status on DRG payments
Module 13: When the DRG Payment is not What You Expect: Post-acute care transfers and reduced cost devices explained
- 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 and 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: Outlier payments: How far in the red do you have to be to qualify?
- 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: Basics of Graduate Medical Education Payments: How to calculate direct payments & the indirect adjustment
- 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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