Medicare Boot Camp® - Hospital Version
Course Outline
Day One
1 Medicare Research: End your confusion over the CMS Web site and find what you need
- Researching Medicare Issues and Finding Medicare Resources on the Web
- How to Understand Statutes, Regulations, Manuals, Transmittals and Other Medicare Rules and Guidelines
- The role of Medicare Contractors and Medicare Part A and Part B
2 UB-04, ICD-9-CM, NPI and Other Must Know Billing Fundamentals
- Key UB-04 Fields Applicable to Hospital Services, including proper use of Condition Codes, Revenue Codes, HCPCS Codes, Diagnosis Codes and Present on Admission Indicators
- Review of ICD-9 Coding for Outpatient Services
3 OCE, MCE and Other Medicare Claims Fundamentals
- Repetitive, Non-Repetitive and Recurring Services, Including Claims Frequency
- Inpatient Billing Issues
- Date of Admission
- Pre-Admission Services and the Three Day Rule
- Medicare Claims Flow and Processing Systems, including the Outpatient Code Editor and Medicare (Inpatient) Code Editor
Day Two
4 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
- The Outpatient Advanced Beneficiary Notice (ABN) Forms 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
5 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
- Proper Use of Modifiers with NCCI Edits
- Special Considerations and Practical Issues for Hospitals related to NCCI Edits
6 Tools for Understanding and Predicting Medicare Outpatient Revenue: Overview of the OPPS 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 Separately Paid Services and How They are Paid
- Determine Services that are Packaged
- Understand Composite APCs
- Low Dose Rate Prostate Brachytherapy
- Cardiac Electrophysiology Evaluation and Ablation
- Extended Assessment and Management
- Radiology Family Composites
- How to Calculate Medicare Allowable and Patient Coinsurance
- Understand and Calculate Outpatient Outlier Payments
Day Three
7 The Requirements and Operation of the Recovery Audit Contractor (RAC) Program
- Overview of the RAC Program Requirements and Contractors
- How RACs Identify Issues and the Role of the CMS Issue Review Board in Approving Issues for Review
- Limitation on Claims Available for RAC Review
- Process for Automated and Complex Reviews
- Medicare Records Limits and Payments for Records
- Timeframes for Responses and Reviews
- Results Review Letters and Demand Letters
- Differences between Discussion Period and the Appeal Process
- Timing of Recoupments
8 Hot Topics: Medical Necessity of Inpatient Admissions and Observation Services
- Coverage and Proper Billing of Observation Services
- Identification and Billing of Inpatient Only Procedures
- Inpatient Coverage Rules
- Requirements for Utilization Review
- Changing Patient Status from Inpatient to Outpatient, including Proper use of Condition Code 44
- Payment under Part B for Services Furnished to Inpatients
Day Four
9 Hot Topics: Outpatient Coverage, Coding and Billing
- Issues Related to Provider Based Departments:
- Coverage of Hospital Outpatient Services under the Hospital Incident-To Provisions
- Proper E/M Coding, including Clinic, Emergency Department, Critical Care and Trauma Activation
- Proper Application of Modifier 25
- Issues Related to Drugs, Biologicals and Devices
- Coverage of Drugs, including Self Administered Drugs
- Billing of Packaged Drugs, Biologicals and Devices
- Pass Through and Non-Pass Through Payment for Drugs, Biologicals and Devices
- Issues Related to Surgical, Radiology and Laboratory Procedures
- Modifiers for Terminated/Discontinued Surgical and Radiology Procedures
- Surgical Procedures Implanting Devices Received at Reduced or No Cost
- Proper Reporting of Bilateral Procedures
- National Coverage Determinations for Laboratory Services
- Reference Laboratory Billing
- Blood, Blood Products and Blood Processing and Storage
10 The Medicare Appeals Process
- Limitations on Recoupment and Interest on Recoupments
- Appeal Levels and Timeframes
Day Five
11 Tools for Understanding and Predicting Medicare Inpatient Revenue: Overview of the IPPS system
- Overview of IPPS
- Medicare Severity Diagnosis Related Groups (MS DRGs), including MS-DRG Grouping and the Effect of Hospital Acquired Conditions
- IPPS Payment Calculation
- The Standardized Amounts
- How to Find and Use the Medicare Wage Index and Geographic Adjustment Factor
- Patient Responsibility, including Deductible, Coinsurance and Life Time Reserve Days
12 When the DRG Payment is not What you Expect: Special IPPS Payments and Adjustments
- Payment for Transfers and the Post Acute Care Transfer Payment Policy
- Payment Adjustment for Devices Received without Cost or with Substantial Credit
- New Technology Add-On Payment
- Inpatient Outlier Basics
- Medicare Dependent Hospitals and Sole Community Hospitals
- The Disproportionate Share Hospital (DSH) Adjustment
- Indirect Medical Education ("IME") Adjustment
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