Medicare 101 understanding medicare final
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  • A+ Coding Institute Facilitator's Guide January 16, 2011 Course overview: The Medicare Resident, Practicing Physician, and Other Health Care Professional Training Program is a customized instructor-led course that offers learners general Medicare information and resources. The course is based on information found in the Medicare Physician Guide: A Resource for Residents, Practicing Physicians, and Other Health Care Professionals . Audience: All health care professionals may attend this course. The primary target audience is residents who are preparing to establish their own medical practice within six months of attendance at a course. Time: The delivery time for this course is approximately three hours. 05 3 Hour Medicare Program Training Module Information for Facilitators
  • A+ Coding Institute Facilitator's Guide January 16, 2011 05 3 Hour Medicare Program Training Module Chapter 1
  • A+ Coding Institute Facilitator's Guide January 16, 2011 The Reference Information hand out contains some useful documents. These are the glossary, lists of acronyms, and contact information. These documents can also be found in the back of your Medicare Physician Guide . Please take out the Pre-Assessment(s) package for chapter(s) [ insert chapter numbers that you will be presenting ]. The purpose of the Pre-Assessment is to determine your knowledge of Medicare prior to today's course. Please take a few minutes now to take the Pre-Assessment, marking your answers on the answer sheet included in the package. Note for Facilitators : Each chapter has a separate Pre-Assessment package. Learners should receive the corresponding Pre-Assessment package, depending on which chapter(s) you are presenting. 05 3 Hour Medicare Program Training Module Pre-Assessment
  • A+ Coding Institute Facilitator's Guide January 16, 2011 The Centers for Medicare & Medicaid Services (CMS), which is an agency within the U.S. Department of Health and Human Services (HHS), administers and oversees the Medicare Program and a portion of the Medicaid Program. CMS awards contracts to organizations called Medicare Contractors who perform claims processing and related administrative functions. Medicare is the nation’s largest health insurance program. It processes over one billion claims annually. Since over 44 million enrollees are entitled to Medicare benefits, it is likely that you will treat and interact with Medicare beneficiaries during your practice. Your actual Medicare patient ratio is dependent upon where your practice is located and your specialty. 05 3 Hour Medicare Program Training Module Chapter 1
  • A+ Coding Institute Facilitator's Guide January 16, 2011 When an individual becomes entitled to Medicare, CMS or the Railroad Retirement Board (RRB) will issue a health insurance card. The following information can be found on the health insurance card: Name; Sex; Medicare Health Insurance Claim number; and Effective date of entitlement to Part A and/or Part B. Office staff should regularly request the beneficiary’s health insurance card and picture identification to verify that services are furnished only to individuals eligible to receive Medicare benefits. Copies of the health insurance card and picture identification should be made for the beneficiary’s medical file. 05 3 Hour Medicare Program Training Module Chapter 1
  • When you have Original Medicare, you use your red, white, and blue Medicare card when you get health care. This is a sample of a red, white, and blue Medicare card. The Medicare card shows the Medicare coverage (Part A hospital coverage and/or Part B medical coverage) and the date the coverage starts. Note: Your card may look slightly different from this one; it’s still valid. The Medicare card also shows your Medicare claim number. For most people, the claim number has 9 numerals and 1 letter. There also may be a number or another letter after the first letter. The 9 numerals show which Social Security record your Medicare is based on. The letter or letters and numbers tell how you are related to the person with that record. For example, if you get Medicare on your own Social Security record, you might have the letter “A,” “T,” or “M” depending on whether you get both Medicare and Social Security benefits or Medicare only. If you get Medicare on your spouse’s record, the letter might be a B or a D. For railroad retirees, there are numbers and letters in front of the Social Security number. These letters and numbers have nothing to do with having Medicare Part A or Part B. Your use of the Medicare card will differ depending on the type of Medicare health plan option you choose. If you choose Original Medicare, you will use the red, white, and blue Medicare card when obtaining health care. If you choose another Medicare health plan, your plan may give you a card to use when you get health care services and supplies. You should contact Social Security (or the Railroad Retirement Board if you receive railroad retirement benefits), if any information on the card is incorrect.
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Medicare consists of four parts: Part A, hospital insurance; Part B, medical insurance; Part C, Medicare Advantage (MA); and Part D, prescription drug plan (PDP). 05 3 Hour Medicare Program Training Module Chapter 1
  • Medicare covers many types of services, and people have options for how they can get their Medicare coverage. Medicare has four parts. Part A (Hospital Insurance) helps pay for inpatient hospital stays but also helps cover skilled nursing care, home health care, and hospice care. Part B (Medical Insurance) helps cover medically-necessary services like doctors visits and outpatient care. Part B also covers some preventive services including screening tests and shots, diagnostic tests, some therapies, and durable medical equipment like wheelchairs and walkers. Part C (Medicare Advantage) is another way to get your Medicare benefits. It combines Parts A and B, and sometimes Part D (prescription drug coverage). Medicare Advantage Plans are managed by private insurance companies approved by Medicare. These plans must cover medically-necessary services. However, plans can charge different copayments, coinsurance, or deductibles for these services. Part D (Medicare prescription drug coverage) helps pay for outpatient prescription drugs and may help lower your prescription drug costs and help protect against higher costs in the future. Note: This chart is provided in the corresponding workbook (see Appendix A).
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Some of the services that Part A, hospital insurance, helps pay for include: Inpatient hospital care; Inpatient care in a Skilled Nursing Facility (SNF) following a covered hospital stay; Some home health care; and Hospice care. To be eligible for premium-free Part A, an individual must first be insured based on his or her own earnings or those of a spouse, parent, or child. To be insured, a worker must have a specified number of quarters of coverage (QC). 05 3 Hour Medicare Program Training Module Chapter 1
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Some of the services that Part B, medical insurance, helps pay for include: Medically necessary services furnished by physicians in a variety of medical settings; Home health care for individuals who do not have Part A; Ambulance services; Clinical laboratory and diagnostic services; Surgical supplies; Durable medical equipment, prosthetics, orthotics, and supplies; Hospital outpatient services; and Services furnished by practitioners with limited licensing. Individuals residing in the United States, except residents of Puerto Rico, who become entitled to premium-free Part A are automatically enrolled in Part B. Those individuals who do not want coverage may refuse enrollment. 05 3 Hour Medicare Program Training Module Chapter 1
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Disabled insured - A disabled person who is entitled to Social Security or Railroad Retirement benefits on the basis of disability is automatically entitled to Part A after 24 months of entitlement to such benefits. Disabled persons who are not insured for monthly Social Security disability benefits but would be insured for such benefits if their QCs from government employment were Social Security QCs are also deemed to be entitled to disability benefits and automatically entitled to Part A after being disabled for 29 months. End-Stage Renal Disease (ESRD) insured - Individuals are eligible for Part A if they receive regular dialysis treatments or a kidney transplant, have filed an application, and meet one of the following conditions: Have worked the required amount of time under Social Security, the RRB, or as a government employee; Are receiving or are eligible for Social Security or Railroad Retirement benefits; or Are the spouse or dependent child of an individual who has worked the required amount of time under Social Security, the RRB, or as a government employee or who is receiving Social Security or Railroad Retirement benefits. 05 3 Hour Medicare Program Training Module Chapter 1
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Part C or MA is a program through which organizations that contract with CMS furnish or arrange for the provision of health care services to Medicare beneficiaries who: Are entitled to Part A and enrolled in Part B; Permanently reside in the service area of the MA Plan; and Elect to enroll in a MA Plan. Individuals with ESRD are generally excluded from MA Plans. 05 3 Hour Medicare Program Training Module Chapter 1
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Part D, the prescription drug plan, provides prescription drug coverage to all beneficiaries who elect to enroll in a PDP or MA PDP. Beneficiaries may be eligible for defined standard coverage or low income subsidies. 05 3 Hour Medicare Program Training Module Chapter 1
  • Increases the base beneficiary Part D premium for beneficiaries with incomes above the thresholds used to compute the income-related adjustment to the Part B premium. Effective January 2011 The income thresholds and corresponding percentage reductions in government premium contributions are the same as those in the Part B income-related premium adjustment. CMS is directed to provide information annually to the Social Security Administration on the national Part D base beneficiary premium to calculate premium adjustment amount as well as data on the threshold amounts. For information on how the Part B income-related premium is determined, see SSA Pub. 10161 at socialsecurity.gov/pubs/10161.html . DRAFT
  • A+ Coding Institute Facilitator's Guide January 16, 2011 There are many organizations that impact the Medicare Program. The Social Security Administration determines eligibility for Medicare benefits and enrolls individuals in Part A and/or Part B and the Federal Black Lung Benefit Program. The Office of Inspector General protects the integrity of HHS programs and the health and welfare of beneficiaries of those programs through a nationwide network of audits, investigations, inspections, and other mission-related functions. Quality Improvement Organizations improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries. The State Health Insurance Assistance Program offers free one-on-one counseling and assistance to people with Medicare and their families. 05 3 Hour Medicare Program Training Module Chapter 1
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Next we’ll discuss some of the recent laws that impact the Medicare Program. The Medicare Improvements for Patients and Providers Act of 2008 includes the following provisions: The mid-year 2008 Medicare Physician Fee Schedule rate reduction of -10.6 percent was retroactively replaced with the fee schedule rates in effect from January 2008 – June 2008 reflecting a 0.5 percent update from 2007 rates; The therapy caps exceptions process was reinstated for the period July 1, 2008 – December 31, 2009; and Delayed the Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Competitive Billing Program. The Medicare, Medicaid, and State Children’s Health Insurance Program (SCHIP) Extension Act of 2007 authorized the continuation of the Physician Quality Reporting Initiative. 05 3 Hour Medicare Program Training Module Chapter 1
  • On March 23, 2010, the President signed into law H.R. 3590, the Patient Protection and Affordable Care Act (PPACA; P.L. 111-148), as passed by the Senate on December 24, 2009, and the House on March 21, 2010. The new law will, among other things, make numerous statutory changes to the Medicare program. On March 30, 2010, the President signed into law H.R. 4872, the Health Care and Education Reconciliation Act of 2010 (the "Reconciliation Act," or HCERA; P.L. 111-152), which modifies a number of Medicare provisions in PPACA and adds several new provisions.  Together, PPACA and HCERA are referred to as the “Affordable Care Act.” DRAFT
  • Some highlights of the Affordable Care Act include: Closes the Medicare Prescription Drug Coverage “Donut Hole” Strengthens the financial health of Medicare. Invests in fighting waste, fraud, and abuse. Reforms payments to reduce harmful and unnecessary hospital admissions and health care acquired infections. Together, these proposals will extend the financial health of Medicare by 12 years. Not a penny of Medicare taxes or trust funds will be used for health reform. Changes the annual enrollment period. This is discussed in more detail later in the presentation. Eliminates deductibles, copayments, and other cost-sharing for preventive care in Medicare, and provides free annual wellness check-ups starting in 2011. Today, seniors must pay 20% of the cost of many preventive services and office visits. DRAFT
  • Promotes better care after a hospital discharge Creates the Center for Medicare & Medicaid Innovation to test innovative payment and service delivery models, reduce program expenditures, preserve or enhance the quality of care (20 possible models could be tested), and provide a report to Congress on these activities. To be effective no later than January 1, 2011. Provides $5 billion in financial assistance to employer health plans that cover early retirees. This temporary program will make it easier for employers to provide early retirees coverage and will provide premium relief of up to $1,200 for every family with insurance through those employers. Establishes a temporary reinsurance program to provide reimbursement to participating employment-based plans for part of the cost of providing health benefits to retirees (age 55-64) and their families. The program reimburses participating employment-based plans for 80% of the cost of benefits provided per enrollee in excess of $15,000 and below $90,000. The plans are required to use the funds to lower costs borne directly by participants and beneficiaries, and the program incentivizes plans to implement programs and procedures to better manage chronic conditions. More information is available at hhs.gov/news/press/2010pres/06/20100629a.html. Provides access to affordable insurance for uninsured Americans with pre-existing conditions through a temporary subsidized high-risk pool to help protect them from medical bankruptcy. This high risk pool will serve as a bridge to a reformed health insurance marketplace. Effective in 2014, prohibits insurance companies from denying coverage or charging more based on a person’s medical history and limits the amount an insurance company can increase an individual’s premium simply based on their age. DRAFT
  • Extends dependent coverage to age 26 Eliminates limits on benefits Health Resources and Services Administration (HRSA), an agency of the U.S. Department of Health and Human Services, is the primary Federal agency for improving access to health care services for people who are uninsured, isolated or medically vulnerable. The ACA provides $11B to HRSA for additional Federally Qualified Health Centers (FQHCs). FQHCs are “safety net” providers such as community health centers, public housing centers, outpatient health programs funded by the Indian Health Service, and programs serving migrants and the homeless. The main purpose of the FQHC Program is to enhance the provision of primary care services in underserved urban and rural communities. *Reference: cms.gov/MLNProducts/downloads/fqhcfactsheet.pdf DRAFT
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Let’s review the material we covered in this chapter. What are Medicare’s four parts? Answer – Part A, hospital insurance; Part B, medical insurance; Part C, Medicare Advantage; and Part D, prescription drug plan. Medicare Part A and Part B are available to what four groups of individuals? Answer – Aged insured; Aged uninsured; Disabled insured; and End-Stage Renal Disease insured. 05 3 Hour Medicare Program Training Module Chapter 1
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Chapter Two discusses how to become a Medicare provider or supplier. The learning objectives for Chapter Two are: Identify Part A and Part B providers and suppliers. Define the Medicare physician and practitioner. Describe the Medicare Program enrollment process. Identify how providers and suppliers can promote cultural competency. Materials required: None. Time required to complete this chapter: Approximately 35 minutes. 05 3 Hour Medicare Program Training Module Chapter 2
  • A+ Coding Institute Facilitator's Guide January 16, 2011 The Reference Information hand out contains some useful documents. These are the glossary, lists of acronyms, and contact information. These documents can also be found in the back of your Medicare Physician Guide . Please take out the Pre-Assessment(s) package for chapter(s) [ insert chapter numbers that you will be presenting ]. The purpose of the Pre-Assessment is to determine your knowledge of Medicare prior to today's course. Please take a few minutes now to take the Pre-Assessment, marking your answers on the answer sheet included in the package. Note for Facilitators : Each chapter has a separate Pre-Assessment package. Learners should receive the corresponding Pre-Assessment package, depending on which chapter(s) you are presenting. 05 3 Hour Medicare Program Training Module Pre-Assessment
  • A+ Coding Institute Facilitator's Guide January 16, 2011 The Medicare Program recognizes a broad range of providers and suppliers who furnish necessary services and supplies to meet the health care needs of beneficiaries. Medicare makes payment under Part A for certain services furnished by the following types of entities (this is not an all-inclusive list): Critical Access Hospitals; Federally Qualified Health Centers; Home Health Agencies (including sub-unit); Hospice; Hospitals (acute care inpatient services); Inpatient Rehabilitation Facilities; Long Term Care Hospitals; Rural Health Clinics; and Skilled Nursing Facilities (SNF). 05 3 Hour Medicare Program Training Module Chapter 2
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Services furnished by the following are paid under Part B (this is not an all-inclusive list): Ambulance services suppliers; Ambulatory Surgical Centers; Comprehensive Outpatient Rehabilitation Facilities; End-Stage Renal Disease Facilities; Home Health Agencies (outpatient Part B services); Hospitals (outpatient services); Nurse practitioners; Other non-physician practitioners; Physicians; and SNFs (outpatient services). 05 3 Hour Medicare Program Training Module Chapter 2
  • A+ Coding Institute Facilitator's Guide January 16, 2011 The Medicare Program defines physicians to include the following: Doctors of medicine and doctors of osteopathy; Doctors of dental surgery or dental medicine; Doctors of podiatry or surgical chiropody; Doctors of optometry; or Chiropractors. In addition, Medicare physicians must be legally authorized to practice by a State in which he or she performs this function. 05 3 Hour Medicare Program Training Module Chapter 2
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Interns and residents include physicians who: Participate in approved Graduate Medical Education (GME) programs; or Are not in approved GME programs, but are authorized to practice only in a hospital setting. Also included in this definition are interns, residents, and fellows in GME programs recognized as approved for purposes of direct GME and Indirect Medical Education payments made by Fiscal Intermediaries or A/B Medicare Contractors. 05 3 Hour Medicare Program Training Module Chapter 2
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Teaching physicians are physicians (other interns or residents) who involve residents in the care of their patients. Generally, teaching physicians must be present during all critical or key portions of the procedure and immediately available to furnish services during the entire service in order for it to be payable under the Medicare Physician Fee Schedule (MPFS). 05 3 Hour Medicare Program Training Module Chapter 2
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Medicare defines practitioners as any of the following to the extent that an individual is legally authorized to practice by the State and otherwise meets Medicare requirements: Physician assistants; Nurse practitioners; Clinical nurse specialists; Certified registered nurse anesthetists; Certified nurse midwives; Clinical psychologists; Clinical social workers; or Registered dieticians or nutrition professionals. 05 3 Hour Medicare Program Training Module Chapter 2
  • A+ Coding Institute Facilitator's Guide January 16, 2011 The following steps must be completed in order to enroll in and obtain reimbursement from Medicare: Obtain a National Provider Identifier, which is a standard unique identifier for health care providers that replaces health care provider identifiers that were previously used in standard transactions. It eliminates the need to use different identification numbers when conducting Health Insurance Portability and Accountability Act standard transactions with multiple plans. Complete the appropriate Medicare Enrollment Application. 05 3 Hour Medicare Program Training Module Chapter 2
  • A+ Coding Institute Facilitator's Guide January 16, 2011 The following forms are often required in addition to the Medicare Enrollment Application: Form CMS-588/Electronic Funds Transfer Authorization Agreement; Form CMS-460/Medicare Participating Physician or Supplier Agreement; CMS Standard Electronic Data Interchange Enrollment Form; State medical license; Occupational or business license; and Certificate of Use. You can find the enrollment and agreement forms on the Centers for Medicare & Medicaid Services (CMS) website. After all forms have been completed and signed, the packet is then mailed to the appropriate Medicare Contractor for processing. 05 3 Hour Medicare Program Training Module Chapter 2
  • A+ Coding Institute Facilitator's Guide January 16, 2011 There are two types of providers and suppliers in Part B of the Medicare Program: participating and nonparticipating. First we will discuss participating providers and suppliers. When you complete and sign Form CMS-460, you have formally notified CMS that you wish to participate in the Medicare Program and will accept assignment of benefits for all covered services for all Medicare beneficiaries. Assignment means that you will be paid the Medicare allowed amount as payment in full for your services. Participation is for a yearlong period from January 1 through December 31. Active participants receive a participation package during the Contractor Open Enrollment Period, which is usually in November. During this period, you can change your participation status for the following year. If you wish to continue participating, you do not need to sign an agreement each year. 05 3 Hour Medicare Program Training Module Chapter 2
  • A+ Coding Institute Facilitator's Guide January 16, 2011 As a participating provider or supplier, you will receive the following benefits: Higher MPFS allowances; Limiting charge provisions are not applicable; and Included in the Physician and Other Healthcare Professional Directory. 05 3 Hour Medicare Program Training Module Chapter 2
  • A+ Coding Institute Facilitator's Guide January 16, 2011 The nonparticipating provider or supplier may choose to accept assignment of Medicare claims on a claim-by-claim basis. They are held to a limiting charge when submitting nonassigned claims and may collect up to the limiting charge, which is the maximum amount that can be charged for the services furnished (unless prohibited by State law). The limiting charge applies to the following regardless of who furnishes or bills for them: Physicians’ services; Services and supplies commonly furnished in physicians’ offices that are incident to physicians’ services; Outpatient physical and occupational therapy services furnished by an independently practicing therapist; Diagnostic tests; and Radiation therapy services. 05 3 Hour Medicare Program Training Module Chapter 2
  • A+ Coding Institute Facilitator's Guide January 16, 2011 This slide shows an example of a limiting charge. The MPFS allowed amount for procedure “X” is $200.00. The nonparticipating provider or supplier allowed amount for procedure “X” is 5 percent lower than the MPFS allowed amount. So you would multiply $200.00 by .95, which equals $190.00. The limiting charge for procedure “X” is 115 percent of the MPFS allowed amount. So you would multiply $190.00 by 1.15, which equals $218.50. The beneficiary coinsurance is 20 percent of $190.00 (the nonparticipating provider or supplier allowed amount), which equals $38.00. And to get the limiting charge portion that is due to the provider or supplier, you would subtract $190.00 from $218.50, which equals $28.50. The total amount the beneficiary pays the provider or supplier is $38.00 plus $28.50, which equals $66.50. 05 3 Hour Medicare Program Training Module Chapter 2
  • A+ Coding Institute Facilitator's Guide January 16, 2011 This slide depicts the payment amounts that participating and nonparticipating providers and suppliers receive. Note that the coinsurance amount due to the provider or supplier is paid after the deductible has been met. And payment for nonassigned claims goes to the beneficiary, who is responsible for paying the provider or supplier. 05 3 Hour Medicare Program Training Module Chapter 2
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Our country is becoming increasingly diverse. Racial and ethnic minorities make up 30 percent of the American population and are expected to increase to 40 percent by 2030. Addressing a patient’s social and cultural background will assist providers and suppliers in delivering high quality, effective health care and increase patient satisfaction, improve patient compliance, and reduce racial and ethnic health disparities. You may be interested in a free interactive web-based training cultural competency course available on the Culturally and Linguistically Appropriate Services in Health Care website titled A Physician’s Practical Guide to Culturally Competent Care . The course offers a variety of continuing education types. 05 3 Hour Medicare Program Training Module Chapter 2
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Let’s review the material we covered in this chapter. What are the steps that must be taken in order to enroll in and obtain reimbursement from Medicare? Answer – Obtain a National Provider Identifier; and Complete the appropriate Medicare Enrollment Application. What are the benefits of becoming a Medicare participating provider or supplier? Answer – Receive higher Medicare Physician Fee Schedule allowances; Limiting charge provisions are not applicable; and Included in the Physician and Other Healthcare Professional Directory. 05 3 Hour Medicare Program Training Module Chapter 2
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Chapter Three explains the Medicare reimbursement process. The learning objectives for Chapter Three are: Describe how Medicare providers and suppliers are reimbursed for the items and services they furnish. Identify when Medicare is the secondary payer. Recognize physician incentive and bonus payments. Describe the Medicare Physician Fee Schedule. Identify notices you may use or receive from Medicare. Describe the other health insurance plans beneficiaries may be enrolled in. Materials required: None. Time required to complete this chapter: Approximately 20 minutes. 05 3 Hour Medicare Program Training Module Chapter 3
  • A+ Coding Institute Facilitator's Guide January 16, 2011 The Reference Information hand out contains some useful documents. These are the glossary, lists of acronyms, and contact information. These documents can also be found in the back of your Medicare Physician Guide . Please take out the Pre-Assessment(s) package for chapter(s) [ insert chapter numbers that you will be presenting ]. The purpose of the Pre-Assessment is to determine your knowledge of Medicare prior to today's course. Please take a few minutes now to take the Pre-Assessment, marking your answers on the answer sheet included in the package. Note for Facilitators : Each chapter has a separate Pre-Assessment package. Learners should receive the corresponding Pre-Assessment package, depending on which chapter(s) you are presenting. 05 3 Hour Medicare Program Training Module Pre-Assessment
  • A+ Coding Institute Facilitator's Guide January 16, 2011 A claim is a request for payment of Medicare benefits or services received by a beneficiary. When you furnish covered services to Medicare beneficiaries, you are required to submit a claim for your services and cannot charge beneficiaries for completing or filing a claim. In general, fee-for-service claims must be filed timely. This means that claims must be filed on or before December 31 of the calendar year following the year in which services were furnished. Services furnished in the last quarter of the fiscal year (FY) are considered furnished in the following FY. 05 3 Hour Medicare Program Training Module Chapter 3
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Providers and suppliers are not required to file claims on behalf of Medicare beneficiaries when the claim: Is for services for which Medicare is the secondary payer, the primary insurer’s payment is made directly to the beneficiary, and the beneficiary has not furnished the information needed to submit the Medicare secondary claim; Is for services furnished outside the U.S; Is for services initially paid by third-party insurers who then file Medicare claims to recoup what Medicare pays as the primary insurer; Is for other unusual services; or Is for excluded services (some supplemental insurers who pay for these services may require a Medicare claim denial notice before making payment). Providers and suppliers also are not required to file claims when they have opted out of the Medicare Program by signing a private contract with the beneficiary or they have been excluded or debarred from the Medicare Program. 05 3 Hour Medicare Program Training Module Chapter 3
  • A+ Coding Institute Facilitator's Guide January 16, 2011 All providers and suppliers must submit claims electronically via Electronic Data Interchange (EDI) in the Health Insurance Portability and Accountability Act format, except in limited situations. You will receive a sender number after you complete the Centers for Medicare & Medicaid Services (CMS) Standard EDI Enrollment Form. This sender number is required in order to submit electronic claims. You may submit electronic claims using one of the following: Electronic media claims; Electronic billing software vendor or clearinghouse; Billing agent; or Medicare’s free billing software. 05 3 Hour Medicare Program Training Module Chapter 3
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Providers and suppliers must collect unmet deductibles, coinsurance, and copayments from the beneficiary. The deductible is the amount the beneficiary must pay for covered services and supplies before Medicare begins to pay. These amounts can change every year. Under Original Medicare or a Private Fee-for-Service Plan, coinsurance is a percentage of covered charges that the beneficiary may have to pay after he or she has met the applicable deductible. Providers and suppliers should determine whether a beneficiary has supplemental insurance that will pay for deductibles and coinsurance before billing him or her for them. In some Medicare plans, a copayment is the amount paid by the beneficiary for each medical service. On assigned claims, the beneficiary is responsible for: Unmet deductibles, applicable coinsurance and copayments, and charges for services and supplies that are not covered. 05 3 Hour Medicare Program Training Module Chapter 3
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Medicare law requires that providers and suppliers determine whether Medicare is the primary or secondary payer prior to submitting a claim. The Coordination of Benefits Contractor assists providers and suppliers with the following: Answering general questions regarding Medicare Secondary Payer; Verifying Medicare’s primary/secondary status; Reporting changes to a beneficiary’s health insurance or coverage; and Reporting a beneficiary’s accident/injury. 05 3 Hour Medicare Program Training Module Chapter 3
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Physicians (including psychiatrists) who furnish care in an area designated as a geographic-based, primary care Health Professional Shortage Area (HPSA) and psychiatrists who furnish care in an area designated as a geographic-based mental health HPSA are eligible for a 10 percent HPSA incentive payment for outpatient professional services. Physicians who furnish outpatient professional services in a Physician Scarcity Area (PSA) receive a five percent bonus payment. If a physician furnishes services in an area that is both an eligible HPSA and an eligible PSA, he or she will receive a 15 percent bonus payment. The HPSA and PSA payments are based on the paid amount of the claim and are paid automatically on quarterly basis. 05 3 Hour Medicare Program Training Module Chapter 3
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Medicare Part B pays for physician services based on the Medicare Physician Fee Schedule, which lists the more than 7,000 covered services and their payment rates. Physician services include the following: Office visits; Surgical procedures; and A broad range of other diagnostic and therapeutic services. Payment rates for an individual service is based on three components: Relative Value Units (RVU) – Consist of work, practice expense, and malpractice RVUs; Conversion Factor (CF) – After each separate RVU is adjusted by the corresponding geographic cost index, this sum is multiplied by the CF to determine the payment amount for each service; and Geographic Practice Cost Indices – Adjustments that are applied to each of the three relative values used in calculating a physician payment to account for geographic variations in the costs of practicing medicine in different areas within the country. 05 3 Hour Medicare Program Training Module Chapter 3
  • A+ Coding Institute Facilitator's Guide January 16, 2011 These are notices that you may use or receive from Medicare: Advance Beneficiary Notice, which is a written notice that a provider or supplier gives to a beneficiary under certain circumstances before items or services are furnished to advise him or her that specified items or services may not be covered by Medicare; Certificate of Medical Necessity and Durable Medical Equipment Medicare Administrative Contractor Information Forms, which are included with claims for certain items that require additional information (for example, durable medical equipment and parenteral and enteral nutrition); and Remittance Advice, which is a notice of payments and adjustments that is sent to the provider, supplier, or biller. The Medicare Summary Notice is a notice that beneficiaries receive that lists all services or supplies that were billed to Medicare. 05 3 Hour Medicare Program Training Module Chapter 3
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Beneficiaries may be enrolled in these other health insurance plans: Medicare Advantage (MA) is a program through which organizations that contract with CMS furnish or arrange for the provision of health care services to Medicare beneficiaries who are entitled to Part A and enrolled in Part B, permanently reside in the service area of the MA Plan, and elect to enroll in a MA Plan; Medicaid is a cooperative venture funded by Federal and State governments that pays for medical assistance for certain individuals and families with low incomes and limited resources. Medicare covered services are paid first by the Medicare Program since Medicaid is always the payer of last resort; and Medigap is a health insurance policy sold by private insurance companies to fill gaps in Original Medicare Plan coverage. 05 3 Hour Medicare Program Training Module Chapter 3
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Let's review the material we covered in this chapter. What is a Health Professional Shortage Area incentive payment? Answer - A 10 percent payment for outpatient professional services that physicians (including psychiatrists) are eligible to receive for care furnished in an area designated as a geographic-based, primary medical care Health Professional Shortage Area (HPSA) and that psychiatrists are eligible to receive for care furnished in an area designated as a geographic-based mental health HPSA. What is the Advance Beneficiary Notice? Answer – A written notice that a provider or supplier gives to a beneficiary under certain circumstances before items or services are furnished to advise him or her that specified items or services may not be covered by Medicare. 05 3 Hour Medicare Program Training Module Chapter 3
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Chapter Four explains Medicare payment policies. The learning objectives for Chapter Four are: Determine Medicare covered services. Identify incident to services. Determine the services that are not covered by Medicare. Materials required: None. Time required to complete this chapter: Approximately 15 minutes. 05 3 Hour Medicare Program Training Module Chapter 4
  • A+ Coding Institute Facilitator's Guide January 16, 2011 The Reference Information hand out contains some useful documents. These are the glossary, lists of acronyms, and contact information. These documents can also be found in the back of your Medicare Physician Guide . Please take out the Pre-Assessment(s) package for chapter(s) [ insert chapter numbers that you will be presenting ]. The purpose of the Pre-Assessment is to determine your knowledge of Medicare prior to today's course. Please take a few minutes now to take the Pre-Assessment, marking your answers on the answer sheet included in the package. Note for Facilitators : Each chapter has a separate Pre-Assessment package. Learners should receive the corresponding Pre-Assessment package, depending on which chapter(s) you are presenting. 05 3 Hour Medicare Program Training Module Pre-Assessment
  • A+ Coding Institute Facilitator's Guide January 16, 2011 In general, Medicare covered services are considered medically reasonable and necessary to the overall diagnosis and treatment of the beneficiary’s condition. Services or supplies are considered medically necessary if they: Are proper and needed for diagnosis or treatment of the beneficiary’s medical condition; Are furnished for the diagnosis, direct care, and treatment of the beneficiary’s medical condition; Meet standards of good medical practice; and Are not mainly for convenience of the beneficiary, provider, or supplier. Medicare pays for provider professional services that are furnished in the U.S. and in the home, office, institution, or at the scene of an accident. 05 3 Hour Medicare Program Training Module Chapter 4
  • Medicare Part B also covers preventive services like exams, lab tests, screening and shots to help prevent, find, or manage a medical problem. Preventive services may find health problems early when treatment works best. Talk to your doctor about which preventive services you need and if you meet the criteria for coverage. The Medicare & You handbook includes guidelines for who is covered and how often Medicare will pay for these services. Currently Medicare helps pay for: “ Welcome to Medicare” physical exam (one-time review of your health, as well as education and counseling about the preventive services you need. To be covered, you must have the physical exam within the first 12 months you have Medicare Part B.) Physical Exam (yearly wellness exam beginning January 2011) as result of ACA Abdominal aortic aneurysm screening * Bone mass measurement Cardiovascular disease screenings Colorectal cancer screenings Diabetes screenings EKG Screening* Flu Shots These services are discussed in depth in Module 7. Glaucoma tests Hepatitis B shots HIV Screening Screening mammograms Pap test and pelvic exam (includes clinical breast examination) Prostate cancer screening Pneumococcal pneumonia shots Smoking cessation (counseling to stop smoking)
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Subject to certain conditions, limitations, and exceptions, the following inpatient hospital or inpatient Critical Access Hospital (CAH) services are furnished to an inpatient of a participating hospital or participating CAH or, in the case of emergency services or services in foreign hospitals, to an inpatient of a qualified hospital: Bed and board; Nursing and other related services; Use of hospital or CAH facilities; Medical social services; Drugs, biologicals, supplies, appliances, and equipment; Certain other diagnostic or therapeutic services; Medical or surgical services furnished by certain interns or residents in training; and Transportation services, including transport by ambulance. 05 3 Hour Medicare Program Training Module Chapter 4
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Covered Part B services include the following (this is not an all-inclusive list): Surgery, consultations, office visits, and institutional calls; Services and supplies furnished incident to physician professional services; Outpatient hospital services furnished incident to physician services; Outpatient physical, occupational, and speech-language pathology services; Diagnostic services; Ambulance services; and Preventive Services. 05 3 Hour Medicare Program Training Module Chapter 4
  • A+ Coding Institute Facilitator's Guide January 16, 2011 To be covered incident to the services of a physician, services and supplies must meet the following requirements: Commonly furnished in physicians' offices or clinics; Furnished by the physician or auxiliary personnel under the direct personal supervision of a physician; Commonly furnished without charge or included in the physician's bill; and An integral, although incidental, part of the physician's professional service. 05 3 Hour Medicare Program Training Module Chapter 4
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Services that are not covered by Medicare include the following: Excluded services; Services that are considered not medically necessary; Services that have been denied as bundled or included in the basic allowance of another service; and Claims that have been rejected as “unprocessable.” Providers and suppliers should give a beneficiary an Advance Beneficiary Notice before items or services are furnished to advise him or her that specified items or services may not be covered by Medicare. 05 3 Hour Medicare Program Training Module Chapter 4
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Let's review the material we covered in this chapter. What are medically necessary services and supplies? Answer – Services that are proper and needed for diagnosis or treatment of the beneficiary’s medical condition; Services that are furnished for the diagnosis, direct care, and treatment of the beneficiary’s medical condition; Services that meet the standards of good medical practice; and Services that are not mainly for convenience of the beneficiary, provider, or supplier. What services are not covered by Medicare? Answer – Excluded services; Services that are considered not medically necessary; Services that have been denied as bundled or included in the basic allowance of another service; and In addition, Medicare does not pay for claims that have been rejected as “unprocessable.” 05 3 Hour Medicare Program Training Module Chapter 4
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Chapter Five summarizes evaluation and management documentation. The learning objectives for Chapter Five are: Identify the seven general principles of documentation. Identify the seven components that define the levels of evaluation and management services. Materials required: Medicare Physician Guide . Time required to complete this chapter: Approximately 45 minutes. 05 3 Hour Medicare Program Training Module Chapter 5
  • A+ Coding Institute Facilitator's Guide January 16, 2011 The Reference Information hand out contains some useful documents. These are the glossary, lists of acronyms, and contact information. These documents can also be found in the back of your Medicare Physician Guide . Please take out the Pre-Assessment(s) package for chapter(s) [ insert chapter numbers that you will be presenting ]. The purpose of the Pre-Assessment is to determine your knowledge of Medicare prior to today's course. Please take a few minutes now to take the Pre-Assessment, marking your answers on the answer sheet included in the package. Note for Facilitators : Each chapter has a separate Pre-Assessment package. Learners should receive the corresponding Pre-Assessment package, depending on which chapter(s) you are presenting. 05 3 Hour Medicare Program Training Module Pre-Assessment
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Medicare pays physicians based on diagnostic and procedure codes that are derived from medical documentation. Evaluation and management (E/M) documentation is the pathway that translates a physician’s patient care work into the claims and reimbursement mechanism. This pathway’s accuracy is critical in: Ensuring that physicians are paid correctly for their work; Supporting the correct E/M code level; and Providing the validation required for medical review. 05 3 Hour Medicare Program Training Module Chapter 5
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Please turn to the Documentation Guidelines for Evaluation & Management Services in the Reference Section of the Medicare Physician Guide . Medical record documentation is required in order to record pertinent facts, findings, and observations about an individual’s health history including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record facilitates: The ability to evaluate and plan the patient’s immediate treatment and to monitor his or her health over time; Communication and continuity of care among physicians and other health care professionals; Accurate and timely claims review and payment; Appropriate utilization review and quality of care evaluations; and Collection of data that may be useful for research and evaluation. 05 3 Hour Medicare Program Training Module Chapter 5
  • A+ Coding Institute Facilitator's Guide January 16, 2011 The seven general principles of documentation are applicable to all types of medical and surgical services in all settings. For E/M services, the nature and amount of physician work and documentation varies by type of service, place of service, and the patient’s status. The first principle is: The medical record should be complete and legible. 05 3 Hour Medicare Program Training Module Chapter 5
  • A+ Coding Institute Facilitator's Guide January 16, 2011 The third principle is: If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred. The fourth principle is: Past and present diagnoses should be accessible to the treating and/or consulting physician. The fifth principle is: Appropriate health risk factors should be identified. 05 3 Hour Medicare Program Training Module Chapter 5
  • A+ Coding Institute Facilitator's Guide January 16, 2011 The sixth principle is: The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented. And the seventh principle is: CPT and ICD codes reported on the health insurance claim form or billing statement should be supported by documentation in the medical record. For example, a patient presents with signs and systems that suggest a cold. When the claim is submitted, it has a procedure code that correlates to a foot x-ray and a diagnosis code of cold. This would be considered conflicting information. 05 3 Hour Medicare Program Training Module Chapter 5
  • A+ Coding Institute Facilitator's Guide January 16, 2011 The seven components that define the levels of E/M services are: History; Examination; Medical decision making; Counseling; Coordination of care; Nature of presenting problem; and Time. 05 3 Hour Medicare Program Training Module Chapter 5
  • A+ Coding Institute Facilitator's Guide January 16, 2011 This is the “New Patient Visit” Table that we will use to determine the appropriate level of service provided to a new patient. Procedure codes that determine the level of service and amount of reimbursement are listed in the left column labeled “Procedure Code.” The three key components in selecting the levels of E/M services are “History,” “Examination,” and “Medical Decision Making.” In order to select the appropriate procedure code, each of the three key components must meet or exceed the requirements for that procedure code. An exception to the three key component rule are visits that consist predominantly of counseling or coordination of care such as when 50 percent or more of your time must be spent face-to-face with the patient counseling and/or coordinating care, for which time is the key or controlling factor to qualify for a particular level of E/M service. 05 3 Hour Medicare Program Training Module Chapter 5
  • A+ Coding Institute Facilitator's Guide January 16, 2011 The levels of E/M services are based on four levels of history: Problem Focused; Expanded Problem Focused; Detailed; and Comprehensive. Each type of history includes some or all of the following elements: Chief complaint (CC); History of present illness (HPI); Review of systems (ROS); and Past, family, and/or social history (PFSH). 05 3 Hour Medicare Program Training Module Chapter 5
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Let’s say your patient had an “Extended” HPI. This means that you must document at least four or more elements in the patient’s medical record. The ROS is a series of questions that a physician will ask a patient in order to identify signs and/or symptoms the patient is experiencing or has experienced. Let’s say you have an “Extended” ROS. This means the medical record must reflect that the patient was asked questions about the system directly related to the CC and two to nine additional systems. Let’s say you have selected a “Pertinent” PFSH. This means the medical record must reflect that at least one specific item was documented from any of the three PFSH areas. Because the levels of HPI, ROS, and PFSH meet on the same row, the appropriate level of history is “Detailed.” 05 3 Hour Medicare Program Training Module Chapter 5
  • A+ Coding Institute Facilitator's Guide January 16, 2011 The levels of E/M services are based on four types of examinations: Problem Focused, which is a limited examination of the affected body area or organ system; Expanded Problem Focused, which is a limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s); Detailed, which is an extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s); and Comprehensive, which is a general multi-system examination or complete examination of a single organ system and other symptomatic or related body area(s) or organ system(s). Physicians can choose to perform either a general multi-system or single organ system examination. General multi-system and single organ system examinations can be performed by any physician, regardless of specialty. 05 3 Hour Medicare Program Training Module Chapter 5
  • A+ Coding Institute Facilitator's Guide January 16, 2011 This slide depicts the content and documentation requirements for each level of examination for the general multi-system examination, which includes several organ systems or body areas. A Problem Focused Examination should include one to five elements identified by a bullet in one or more organ system(s) or body area(s); An Expanded Problem Focused Examination should include at least six elements identified by a bullet in one or more organ system(s) or body area(s); A Detailed Examination should include at least two elements identified by a bullet from at least six organ systems or body areas or at least twelve elements identified by a bullet in two or more organ systems or body areas; and A Comprehensive Examination should include all the elements identified by a bullet in at least nine organ systems or body areas; for each system/area at least two elements identified by a bullet. The specific requirements for each organ system or body area must be met in order to receive credit for performing that part of the examination. 05 3 Hour Medicare Program Training Module Chapter 5
  • A+ Coding Institute Facilitator's Guide January 16, 2011 The separate and distinct examinations for several single organ systems are located in the “Single Organ System Examination” Tables. The same four levels of examination apply; however, the requirements are a little different because some areas of the “Single Organ System Examination” Tables are shaded. When selecting the level of examination, physicians must ensure that all requirements for the shaded and unshaded boxes have been met. 05 3 Hour Medicare Program Training Module Chapter 5
  • A+ Coding Institute Facilitator's Guide January 16, 2011 The levels of E/M services recognize four levels of medical decision making: Straightforward; Low complexity; Moderate complexity; and High complexity. 05 3 Hour Medicare Program Training Module Chapter 5
  • A+ Coding Institute Facilitator's Guide January 16, 2011 The “Table of Risk” may be used to help determine whether the risk of significant complications, morbidity and/or mortality is minimal, low, moderate, or high. Since the determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk. The highest level of risk in any one category – presenting problem(s), diagnostic procedure(s) ordered, or management options – determines the overall risk. 05 3 Hour Medicare Program Training Module Chapter 5
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Let’s review the new patient visit. A “Detailed” level of history, “Detailed” level of examination, and “High Complexity” of medical decision making was performed and documented. Procedure code 99203 should be selected since each of the three key components meet or exceed the requirements for that procedure code. 05 3 Hour Medicare Program Training Module Chapter 5
  • A+ Coding Institute Facilitator's Guide January 16, 2011 This table shows that for the established patient visit, two of the three key components must meet on the same row as the procedure code selected. Procedure code 92214 should be selected since “Detailed History” and “Detailed Examination” meet on the same row as that procedure code. 05 3 Hour Medicare Program Training Module Chapter 5
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Let's review the material we have covered in this chapter. What are the seven components that define the levels of evaluation and management services? Answer – History, examination, medical decision making, counseling, coordination of care, nature of presenting problem, and time. What are the four levels of medical decision making? Answer – Straightforward, low complexity, moderate complexity, and high complexity. 05 3 Hour Medicare Program Training Module Chapter 5
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Chapter Six explains how the Medicare Trust Fund is protected. The learning objectives for Chapter Six are: Identify the goal of the Medicare Integrity Program. Describe the medical review process. Determine the two types of coverage determinations. Define Federal health care fraud. Define program abuse. Identify the potential legal actions that may be imposed if a provider, supplier, or health care organization has committed health care fraud and program abuse. Materials required: None. Time required to complete this chapter: Approximately 15 minutes. 05 3 Hour Medicare Program Training Module Chapter 6
  • A+ Coding Institute Facilitator's Guide January 16, 2011 The Reference Information hand out contains some useful documents. These are the glossary, lists of acronyms, and contact information. These documents can also be found in the back of your Medicare Physician Guide . Please take out the Pre-Assessment(s) package for chapter(s) [ insert chapter numbers that you will be presenting ]. The purpose of the Pre-Assessment is to determine your knowledge of Medicare prior to today's course. Please take a few minutes now to take the Pre-Assessment, marking your answers on the answer sheet included in the package. Note for Facilitators : Each chapter has a separate Pre-Assessment package. Learners should receive the corresponding Pre-Assessment package, depending on which chapter(s) you are presenting. 05 3 Hour Medicare Program Training Module Pre-Assessment
  • A+ Coding Institute Facilitator's Guide January 16, 2011 The goal of the medical review program is to: Analyze data; Take action to prevent and/or address identified errors; and Publish local medical review policies that provide guidance to the public and the medical community regarding payment eligibility under the Medicare statute. 05 3 Hour Medicare Program Training Module Chapter 6
  • A+ Coding Institute Facilitator's Guide January 16, 2011 There are two types of coverage determinations that assist providers and suppliers in coding correctly and billing Medicare only for covered items and services. The first type is called a National Coverage Determination (NCD) which sets forth the extent to which Medicare will cover specific services, procedures, or technologies on a national basis. Medicare Contractors are required to follow NCDs. Prior to an NCD taking effect, the Centers for Medicare & Medicaid Services (CMS) must first issue a Manual Transmittal, ruling, or Federal Register Notice. If a NCD and a Local Coverage Determination (LCD) exist concurrently regarding the same coverage policy, the NCD takes precedence. A NCD is a reasonable and necessary determination made by the Secretary of the Department of Health and Human Services. Therefore, a failure to meet the terms of the NCD will make the item or service not reasonable and necessary, which is one of the categories of items and services Medicare is prohibited from paying and for which a beneficiary is given liability protection if he or she did not know in advance that Medicare was prohibited from paying. 05 3 Hour Medicare Program Training Module Chapter 6
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Local Medicare Contractors may develop LCDs to further define a NCD or in the absence of a specific NCD. LCDs are coverage decisions made at the Contractor’s own discretion to provide guidance to the public and the medical community within a specified geographic area. LCDs cannot conflict with NCDs. LCDs are administrative and educational tools that assist providers in submitting correct claims for payment by outlining coverage criteria, defining medical necessity, and providing references upon which a policy is based and codes that describe what is and is not covered when the codes are integral to the discussion of medical necessity. 05 3 Hour Medicare Program Training Module Chapter 6
  • A+ Coding Institute Facilitator's Guide January 16, 2011 CMS emphasizes early detection and prevention of Federal health care fraud and program abuse. An estimated 10 percent of Medicare costs are wrongly spent on incidences of fraud and abuse. The efforts of many groups help deter fraud and abuse and protect beneficiaries from harm by: I dentifying suspicious Medicare charges and activities; Investigating and punishing those who commit Medicare fraud and abuse; and Ensuring that money lost to fraud and abuse is returned to the Medicare Trust Fund. 05 3 Hour Medicare Program Training Module Chapter 6
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Federal health care fraud generally involves a person or entity’s intentional use of false statements or fraudulent schemes to obtain payment for, or to cause another person or entity to obtain payment for, items or services payable under a Federal health care program. Some examples of health care fraud are: Billing for services not furnished; S oliciting, offering, or receiving a kickback, bribe, or rebate; and Consistently using billing or revenue codes that describe more extensive services than those actually performed or upcoding. 05 3 Hour Medicare Program Training Module Chapter 6
  • A+ Coding Institute Facilitator's Guide January 16, 2011 In general, program abuse, which may be intentional or unintentional, directly or indirectly results in unnecessary or increased costs to the Medicare Program. Many abusive practices are subsequently determined to be fraudulent. For example, if a provider or supplier ignores Medicare guidance, education efforts, warnings, or advice that abusive conduct is inappropriate and he or she continues to engage in the same or similar conduct, the conduct could be considered fraudulent. 05 3 Hour Medicare Program Training Module Chapter 6
  • A+ Coding Institute Facilitator's Guide January 16, 2011 It is a Federal crime to commit fraud against the U.S. Government, including the Medicare Program. A provider, supplier, or health care organization that has been convicted of fraud may receive a significant fine, prison sentence, or be temporarily or permanently excluded from Medicare and other Federal health care programs. In some states, providers, suppliers, and health care organizations may also lose their licenses. A Program Safeguard Contractor or Medicare Contractor Benefit Integrity unit investigates and documents potential fraud and abuse and, when appropriate, refers such matters to the Office of Inspector General (OIG). Many violations of Medicare laws and regulations are subject to the imposition of Civil Monetary Penalties (CMP). Depending on the violation, the CMP amount may be up to $10,000 per violation. 05 3 Hour Medicare Program Training Module Chapter 6
  • A+ Coding Institute Facilitator's Guide January 16, 2011 CMS has the authority to deny an individual or entity’s application for Medicare provider billing privileges or to revoke a provider’s billing privileges if there is evidence of impropriety (for example, previous convictions, falsifying information on the application, or State or Federal licensure or certification requirements are not met). CMS has the authority to suspend payment to individuals and entities when there is reliable information that an overpayment, fraud, or willful misrepresentation exist or that payments to be made may not be correct. The OIG has the authority to exclude individuals and entities from participation in all Federal health care programs. No payment will be made by any Federal health care program for any items or services directly or indirectly furnished, ordered, or prescribed by an excluded or debarred individual or entity. 05 3 Hour Medicare Program Training Module Chapter 6
  • A+ Coding Institute Facilitator's Guide January 16, 2011 To report suspected health care fraud or program abuse you may contact the OIG on their Hotline or via e-mail or fax: HHS TIPS Hotline – (800) 447-8477 E-mail – HHSTips@oig.hhs.gov Fax – (800) 223-8164 05 3 Hour Medicare Program Training Module Chapter 6
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Let's review the material we have covered in this chapter. What are the two types of coverage determinations that assist providers and suppliers in coding correctly and billing Medicare only for covered items and services? Answer – National Coverage Determination; and Local Coverage Determination. What is program abuse? Answer – May be intentional or unintentional and directly or indirectly results in unnecessary or increased costs to the Medicare Program. 05 3 Hour Medicare Program Training Module Chapter 6
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Chapter Seven discusses inquiries, overpayments and appeals. The learning objectives for Chapter Seven are: Describe how providers and suppliers can find answers to inquiries. Identify the reasons overpayments are often paid. Identify the five levels of the fee-for-service appeals process. Define a reopening. Materials required: None. Time required to complete this chapter: Approximately 20 minutes. 05 3 Hour Medicare Program Training Module Chapter 7
  • A+ Coding Institute Facilitator's Guide January 16, 2011 The Reference Information hand out contains some useful documents. These are the glossary, lists of acronyms, and contact information. These documents can also be found in the back of your Medicare Physician Guide . Please take out the Pre-Assessment(s) package for chapter(s) [ insert chapter numbers that you will be presenting ]. The purpose of the Pre-Assessment is to determine your knowledge of Medicare prior to today's course. Please take a few minutes now to take the Pre-Assessment, marking your answers on the answer sheet included in the package. Note for Facilitators : Each chapter has a separate Pre-Assessment package. Learners should receive the corresponding Pre-Assessment package, depending on which chapter(s) you are presenting. 05 3 Hour Medicare Program Training Module Pre-Assessment
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Medicare providers and suppliers may submit inquiries about claims, coverage, and reimbursement guidelines to Medicare Contractors either by telephone or in writing. Customer Service Representatives (CSR) are available to handle telephone inquiries continuously during normal business hours for all time zones of the geographic area serviced, Monday through Friday. Contractors also provide automated self-help tools such as Interactive Voice Response (IVR) services, which may be available up to 24 hours a day. You can find information about the following topics via IVR: Normal business hours; CSR service hours of operation; General Medicare Program; General appeal rights and actions required to exercise appeal rights; Claims in process and claims completed; and Definitions of the most frequently used Remittance Advice Remark Codes and/or Claim Adjustment Reason Codes. 05 3 Hour Medicare Program Training Module Chapter 7
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Overpayments are funds that a provider, supplier, or beneficiary has received in excess of amounts due and payable under Medicare statutes and regulations. Once a determination of overpayment has been made, the overpayment becomes a debt owed to the Federal government. Federal law requires the Centers for Medicare & Medicaid Services to seek recovery of an overpayment, regardless of how it is identified or caused. Overpayments are often paid due to: Duplicate submission of the same service or claim; Payment to the incorrect payee; Payment for excluded or medically unnecessary services; or Payment made as the primary insurer when Medicare should have paid as the secondary insurer. If Medicare pays more than the correct amount in error, providers and suppliers should make voluntary/unsolicited refunds as soon as possible, without waiting for notification. 05 3 Hour Medicare Program Training Module Chapter 7
  • A+ Coding Institute Facilitator's Guide January 16, 2011 If a party is dissatisfied with the reconsideration decision or if the adjudication period for the QIC to complete its consideration has elapsed, he or she can request a third level of appeal – a hearing before an Administrative Law Judge (ALJ). There is an AIC requirement, which will be adjusted annually in accordance with the percentage increase in the medical care component of the Consumer Price Index (CPI). A party must file a written request for an ALJ hearing within 60 calendar days of receipt of the QIC reconsideration notice. The appellant or any other party to the ALJ hearing may request a fourth level of appeal, which is the Medicare Appeals Council review of the ALJ’s decision or dismissal. The request for Medicare Appeals Council review must be filed within 60 calendar days of receipt of the ALJ hearing decision or dismissal. At this level of appeal, there is no AIC requirement. A party to an Medicare Appeals Council decision or an appellant who requests an escalation of Medicare Appeals Council review may request a fifth level of appeal – judicial review – if the case meets the AIC requirement. The AIC amount is adjusted annually in accordance with the percentage increase in the medical care component of the CPI. 05 3 Hour Medicare Program Training Module Chapter 7
  • No matter how you get your Medicare, you have certain rights and protections designed to do the following: Protect you when you get health care Make sure you get the health care services that the law says you can get Protect you against unethical practices Protect your privacy This chart shows the appeals process in Parts A, B, C, and D of Medicare. This chart is provided as a handout in the back of the corresponding workbook. For more information about appeals, go to www.medicare.gov and view the publication Your Medicare Rights and Protections , CMS Publication No. 10112. Module 2 explains this in more detail. Note: This chart is provided in the corresponding workbook (see Appendix H).
  • A+ Coding Institute Facilitator's Guide January 16, 2011 A reopening is a remedial action taken to change a final determination or decision that resulted in either an overpayment or an underpayment, even though the determination or decision was correct based on the evidence of record. A reopening allows the correction of minor errors or omissions without initiating a formal appeal. If a claim is denied because a Contractor did not receive requested documentation during medical review and the party later requests a redetermination, the Contractor must process the request as a reopening. A Contractor must also process clerical errors such as mathematical or computational mistakes, inaccurate data entry, or denials of claims as duplicates. 05 3 Hour Medicare Program Training Module Chapter 7
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Let's review the material we have covered in this chapter. Under what circumstances are overpayments often paid? Answer – Duplicate submission of the same service or claim; Payment to the incorrect payee; Payment for excluded or medically unnecessary services; or Payment made as the primary insurer when Medicare should have paid as the secondary insurer. What are the five levels in the appeals process? Answer – Redetermination by Medicare Contractor Reconsideration by Qualified Independent Contractor Hearing by Administrative Law Judge Medicare Appeals Council Review Judicial Review 05 3 Hour Medicare Program Training Module Chapter 7
  • A+ Coding Institute Facilitator's Guide January 16, 2011 Are there any questions concerning the material we discussed today? I’m handing out the Post-Assessment(s)and Course Evaluation now. Please take the Post-Assessment(s) and mark your answers on the answer sheet(s) included in the package. After you have taken the Post-Assessment(s), please complete the Course Evaluation. The feedback that you provide will be used to continually improve the Medicare Resident, Practicing Physician, and Other Health Care Professional Training Program. Please hand in both the Course Evaluation and Post-Assessment(s) before you leave today. Thank you. Note for Facilitators : Each chapter has a separate Post-Assessment package. Learners should receive the corresponding Post-Assessment package, depending on which chapter(s) you have presented. 05 3 Hour Medicare Program Training Module Post-Assessment

Medicare 101 understanding medicare final Presentation Transcript

  • 1. MEDICARE 101: Understanding CMS Speaker: Tara Ritter-Sellers, CPC, CPC-H, CPC-I
  • 2. INTRODUCTION TO THE MEDICARE PROGRAM CHAPTER 1
  • 3. Chapter 1 Pre-Assessment
  • 4. Introduction to the Medicare Program
    • Largest health insurance program
    • Over 1 billion claims annually
    • Over 44 million individuals entitled
  • 5. Identifying Beneficiaries
    • Health insurance card contains
    • - Name
    • - Sex
    • - Medicare Health Insurance Claim number
    • - Date of entitlement
  • 6. Medicare Card (front) Jane Doe
  • 7. Introduction to the Medicare Program
    • 4 parts
    • - Part A, hospital insurance
    • - Part B, medical insurance
    • - Part C, Medicare Advantage
    • - Part D, prescription drug plan
  • 8.
    • You have choices in how you get your Medicare health and drug coverage
    Medicare has Four Parts Part A – Hospital Insurance Helps cover inpatient care in hospitals and skilled nursing facilities, hospice and home health care. Part B – Medical Insurance Helps cover doctors’ services, outpatient care, home health care and some preventive services. Part C – Medicare Advantage Plans Another way to get Medicare benefits. Combines Parts A and B. Usually includes Part D coverage. Run by private insurance companies approved by and under contract with Medicare. Part D – Medicare Prescription Drug Coverage Helps cover the cost of prescription drugs. Run by private insurance companies approved by and under contract with Medicare.
  • 9. Part A Hospital Insurance
    • Inpatient hospital care
    • Inpatient care in a Skilled Nursing Facility following covered hospital stay
    • Some home health care
    • Hospice care
  • 10. Part B Medical Insurance
    • Physician and practitioner services
    • Home health care
    • Ambulance services
    • Clinical laboratory and diagnostic services
    • Surgical supplies
    • Durable medical equipment, prosthetics, orthotics, and supplies
    • Hospital outpatient services
  • 11. Medicare Part A and Part B Eligibility
    • Aged insured
    • Aged uninsured
    • Disabled insured
    • End-Stage Renal Disease insured
  • 12. Part C Medicare Advantage
    • Organizations contract with CMS to furnish or arrange for provision of health care services to beneficiaries who
    • - Are entitled to Part A and enrolled in
    • Part B
    • - Permanently reside in service area of Plan
    • - Elect to enroll in Medicare Advantage Plan
  • 13. Part D Prescription Drug Plans
    • All who elect to enroll are covered
    • Standard coverage or low income subsidies
    • Higher income people pay higher Part D premium
      • Modified adjusted gross income is above a certain amount
      • Uses same thresholds used to compute income-related adjustments to the Part B premium
        • As reported on your IRS tax return from 2 years ago
    • Effective January 2011
    ACA Section 3308
  • 14. Income-Related Adjustment to Part D Premium
    • Base beneficiary Part D premium increases
      • People with incomes above the thresholds used to compute income-related adjustment to Part B premiums
    ACA Section 3308 If your Yearly Income in 2009 was In 2011 You Pay File Individual Tax Return File Joint Tax Return $85,000 or below $170,000 or below Base Premium $85,001–$107,000 $170,001–$214,000 Higher premium $107,001–$160,000 $214,001–$320,000 Higher premium $160,001–$214,000 $320,001–$428,000 Higher premium above $214,000 above $428,000 Higher premium
  • 15. Organizations That Impact Medicare
    • Social Security Administration
    • Office of Inspector General
    • Quality Improvement Organizations
    • State Health Insurance Assistance Program
  • 16. Recent Laws That Impact Medicare
    • Medicare Improvements for Patients and Providers Act of 2008
    • Medicare, Medicaid, and State Children’s Insurance Program Extension Act of 2007
  • 17.
    • Patient Protection and Affordable Care Act (PPACA)
      • Signed into law H.R. 3590 on March 23, 2010
      • Makes numerous statutory changes to Medicare program
    • The Health Care and Education Reconciliation Act of 2010 (HCERA)
      • Signed into law H.R. 4872 on March 30, 2010
      • Modifies PPACA and adds several new provisions
    • Together called the Affordable Care Act
    New Legislation – Health Reform
  • 18. Highlights of Affordable Care Act
    • Closes prescription drug coverage “Donut Hole”
    • Strengthens the financial health of Medicare
      • Invests in fighting waste, fraud, and abuse
      • Will extend the financial health of Medicare by 12 years
    • Changes annual enrollment period for MA and PDP
    • Improves preventive services coverage
      • Lower costs
      • Free annual wellness check-ups starting in 2011
  • 19. Highlights of Affordable Care Act (continued)
    • Promotes better care after a hospital discharge
    • Creates the Center for Medicare & Medicaid Innovation
    • Help for early retirees (before age 65)
      • Temporary program to offset cost of expensive premiums
    • Help for people with pre-existing conditions
      • Health insurance through temporary high-risk pools
      • In 2014, insurance companies can’t deny coverage
  • 20. Highlights of Affordable Care Act (continued)
    • Extends dependent coverage to age 26
    • Eliminates limits on benefits
    • Provides $11B for Federally Qualified Health Centers
      • Outpatient primary care and preventive services
      • “ Safety net” providers
        • Community health centers
        • Public housing centers
        • Outpatient programs funded by the Indian Health Service
        • Programs serving migrants and the homeless
    ACA Section 1001
  • 21. Let's Review
    • What are Medicare’s 4 parts?
    • Medicare Part A and Part B are available to what 4 groups of individuals?
  • 22. BECOMING A MEDICARE PROVIDER OR SUPPLIER CHAPTER 2
  • 23. Chapter 2 Pre-Assessment
  • 24. Part A Providers and Suppliers
    • Inpatient Rehabilitation
    • Facilities
    • Long Term Care
    • Hospitals
    • Rural Health Clinics
    • Skilled Nursing Facilities
    • Critical Access Hospitals
    • Federally Qualified
    • Health Centers
    • Home Health Agencies
    • Hospice
    • Hospitals (acute care inpatient)
  • 25. Part B Providers and Suppliers
    • Ambulances service suppliers
    • Ambulatory Surgical Centers
    • Comprehensive Out- patient Rehabilitation Facilities
    • End-Stage Renal Disease Facilities
    • Home Health Agencies (outpatient Part B)
    • Hospitals (outpatient)
    • Nurse practitioners
    • Other non-physician practitioners
    • Physicians
    • Skilled Nursing
    • Facilities (outpatient)
  • 26. Medicare Physicians
    • Doctors of medicine and osteopathy, dental surgery or dental medicine, podiatry or surgical chiropody, optometry
    • Chiropractors
    • Legally authorized to practice by State
  • 27. Interns and Residents
    • Participate in approved Graduate Medical Education programs
    • Not in approved programs, but authorized
    • to practice only in hospital setting
    • Also includes interns, residents, and fellows in programs approved for purposes of direct Graduate Medical Education and Indirect Medical Education payments
  • 28. Teaching Physicians
    • Involve residents in care of their patients
    • Present during all critical or key portions of procedure
    • Immediately available to furnish services during entire service
  • 29. Practitioners
    • Physician assistants
    • Nurse practitioners
    • Clinical nurse
    • specialists
    • Certified registered
    • nurse anesthetists
    • Certified nurse midwives
    • Clinical psychologists
    • Clinical social workers
    • Registered dieticians or nutrition professionals
    Legally authorized to practice by State and otherwise meets Medicare requirements
  • 30. Enrolling in Medicare
    • Obtain National Provider Identifier
    • Complete Medicare Enrollment Application
  • 31. Enrolling in Medicare
    • Include with Medicare Enrollment Application
    • - Forms CMS-588 and CMS-460
    • - CMS Standard Electronic Data
    • Interchange Enrollment Form
    • - State medical license
    • - Occupational or business license
    • - Certificate of Use
  • 32. Participating Provider/Supplier
    • Accepts assignment
      • Accept the Medicare-approved amount
          • As full payment for covered services
          • Only charge Medicare deductible/coinsurance amount
      • They submit your claim to Medicare directly
      • Applies to Original Medicare Part B claims
      • We say “accepts assignment”
    • 1 year participation period
  • 33. Participating Provider/Supplier Benefits
    • Higher Medicare Physician Fee Schedule allowances
    • Limiting charge provisions not applicable
    • Included in Physician and Other Healthcare Professional Directory
  • 34. Nonparticipating Provider/Supplier
    • May accept assignment of claims on claim-by-claim basis
    • Held to limiting charge on nonassigned claims
    • May collect up to the limiting charge
      • “ Limiting Charge” means the physican can only charge you up to 15% over the Medicare-approved amount.
      • The limiting charge applies only to certain services and doesn’t apply to some supplies and durable medical equipment.
  • 35. Limiting Charge Example
    • MPFS Allowed Amount for
    • Procedure “X”
    • Nonparticipating Provider/
    • Supplier Allowed Amount
    • for Procedure “X”
    • Limiting Charge for
    • Procedure “X”
    • Beneficiary Coinsurance
    • and Limiting Charge Portion
    • Due to Provider/Supplier
    • $200.00
    • $190.00
    • $218.50
    • $ 66.50
  • 36. Payment Amounts Example Participating Provider/ Supplier Nonparticipating Provider/Supplier Who Accepts Assignment Nonparticipating Provider/Supplier Who Does Not Accept Assignment Submitted $125.00 $125.00 $109.25 Amount MPFS Allowed $100.00 $ 95.00 $ 95.00 Amount 80 Percent of $ 80.00 $ 76.00 $ 76.00 MPFS Allowed Amount Beneficiary $ 20.00 $ 19.00 $ 33.25 Coinsurance Total Payment $100.00 $ 95.00 $109.25 ($95.00 x 1.15 To Provider/ limiting charge) Supplier
  • 37. Cultural Competency
    • Addressing a patient’s social and cultural background assists in delivering high quality, effective health care
  • 38. Let's Review
    • What are the steps that must be taken in order to enroll in and obtain reimbursement from Medicare?
    • What are the benefits of becoming a Medicare participating provider or supplier?
  • 39. CHAPTER 3 MEDICARE REIMBURSEMENT
  • 40. Chapter 3 Pre-Assessment
  • 41. Medicare Claims
    • Must submit claims for services
    • Cannot charge for completing or filing claim
    • File on or before December 31 of year following year services furnished
  • 42. Exceptions to Mandatory Filing
    • Certain secondary payer claims
    • Services furnished outside the U.S.
    • Services initially paid by third-party insurers
    • Claims for unusual or excluded services
    • Claims when provider/supplier opted out, excluded, or debarred
  • 43. Electronic Claims
    • Claims must be submitted electronically, except in limited situations, using
    • - Electronic media claims
    • - Electronic billing software vendor or
    • clearinghouse
    • - Billing agent
    • - Medicare’s free billing software
  • 44. Deductible, Coinsurance, and Copayment
    • Deductible – amount beneficiary must pay before Medicare begins to pay
    • Coinsurance – percentage of covered charges beneficiary may pay after meeting deductible
    • Copayment – amount beneficiary pays for each medical service
  • 45. Medicare Secondary Payer
    • Must determine whether Medicare is the primary or secondary payer prior to submitting a claim
    • Coordination of Benefits Contractor – provides assistance to providers and suppliers
  • 46. Incentive/Bonus Payments
    • Health Professional Shortage Area Incentive Payment – 10 percent
    • Physician Scarcity Area Bonus Payment – 5 percent
  • 47. Medicare Physician Fee Schedule
    • Basis for payment of physician services under Medicare Part B
    • 3 components
    • - Relative Value Units
    • - Conversion Factor
    • - Geographic Practice Cost Indices
  • 48. Medicare Notices
    • Advance Beneficiary Notice
    • Certificate of Medical Necessity and Durable Medical Equipment Medicare Administrative Contractor Information Forms
    • Remittance Advice
    • Medicare Summary Notice
  • 49. Other Health Insurance Plans
    • Medicare Advantage
    • Medicaid
    • Medigap
  • 50. Let's Review
    • What is a Health Professional Shortage Area incentive payment?
    • What is the Advance Beneficiary Notice?
  • 51. MEDICARE PAYMENT POLICIES CHAPTER 4
  • 52. Chapter 4 Pre-Assessment
  • 53. Medicare Covered Services
    • Services and supplies must be medically necessary
    • Proper and needed for diagnosis or treatment of medical condition
    • Furnished for diagnosis, direct care, treatment of medical condition
    • Meet standards of good medical practice
    • Not mainly for convenience
    • Some Preventive Health Care Services
  • 54. Covered Preventive Services
    • One time “Welcome to Medicare” physical exam
    • Physical Exam (yearly “Wellness Exam”) Starts 2011
    • Abdominal aortic aneurysm screening*
    • Bone mass measurement
    • Cardiovascular disease screenings
    • Colorectal cancer screenings
    • Diabetes screenings
    • EKG Screening*
    • Flu shots
    • Glaucoma tests
    • Hepatitis B shots
    • HIV Screening
    • Mammograms (screening)
    • Pap test/pelvic exam/clinical breast exam
    • Prostate cancer screening
    • Pneumococcal shots
    • Smoking cessation
    *When referred during Welcome to Medicare physical exam Health Reform Section 4103
  • 55. Part A Inpatient Hospital Services
    • Bed and board
    • Nursing and related services
    • Use of hospital or Critical
    • Access Hospital facilities
    • Medical social services
    • Drugs, biologicals, supplies, appliances, and equipment
    • Diagnostic or therapeutic services
    • Medical or surgical services furnished by interns or residents in training
    • Transportation services
  • 56. Part B Services
    • Surgery, office visits, and institutional calls
    • Services, supplies, and outpatient hospital services furnished incident to physician services
    • Outpatient physical, occupational, and speech-language pathology services
    • Diagnostic services
    • Ambulance services
    • Preventive services
  • 57. Incident to Physician Services
    • Commonly furnished in physicians’ offices or clinics
    • Furnished by physician or auxiliary personnel under direct personal supervision of physician
    • Furnished without charge or included in physician’s bill
    • Integral, although incidental, part physician’s professional service
  • 58. Services not Covered by Medicare
    • Excluded services
    • Services considered not medically necessary
    • Services denied as bundled or included in basic allowance of another service
    • In addition, Medicare does not pay for claims rejected as “unprocessable”
  • 59. Let's Review
    • What are medically necessary services and supplies?
    • What services are not covered by Medicare?
  • 60. EVALUATION AND MANAGEMENT DOCUMENTATION CHAPTER 5
  • 61. Chapter 5 Pre-Assessment
  • 62. Background – Evaluation and Management Documentation
    • Translates patient care work into claims
    • and reimbursement mechanism; accuracy
    • is critical in
    • Ensuring correct payment for work
    • Supporting correct evaluation and management code level
    • Providing validation for medical review
  • 63. Medical Record Documentation
    • Records pertinent facts, findings, and observations about patient’s health history
    • Facilitates
    • - Evaluating and planning treatment and
    • monitoring treatment and health of patient
    • - Communication and continuity of care
    • - Claims review and payment
    • - Utilization review and quality of care evaluations
    • - Collection of data
  • 64. 7 General Principles of Documentation
    • Medical record should be complete and legible
    • Each encounter should include
    • - Reason for encounter and relevant history, physical examination findings, and prior test results
    • - Assessment, clinical impression, or diagnosis
    • - Plan for care
    • - Date and legible identity of observer
  • 65. 7 General Principles of Documentation
    • 3. Rationale for ordering diagnostic tests and ancillary services should be easily inferred if not documented
    • 4. Past and present diagnoses accessible to treating and/or consulting physician
    • 5. Appropriate health risk factors identified
  • 66. 7 General Principles of Documentation
    • 6. Patient’s progress, response to and changes in treatment, and revision of diagnosis documented
    • CPT and ICD codes reported on health insurance claim form or billing statement supported by documentation in medical record
  • 67. Levels of Evaluation and Management Services
    • H istory
    • E xamination
    • M edical decision making
    • Counseling
    • Coordination of care
    • Nature of presenting problem
    • Time
  • 68. 3 Key Components (HEM)
    • Procedure History Examination Medical Decision Making
    • Code
    • 99201 ® Problem Focused Problem Focused Straightforward
    • 99202 Expanded Expanded Straightforward
    • Problem Focused Problem Focused
    • 99203 Detailed Detailed Low Complexity
    • 99204 Comprehensive Comprehensive Moderate Complexity
    • 99205 Comprehensive Comprehensive High Complexity
    • CPT only copyright 2008 American Medical Association. All rights reserved.
  • 69. History
    • 4 levels
    • - Problem Focused
    • - Expanded Problem
    • Focused
    • - Detailed
    • - Comprehensive
    • Elements
    • Chief complaint
    • History of present illness
    • Review of systems
    • Past, family, and/or
    • social history
  • 70. History
    • HPI ROS PFSH Level of History
    • Brief N/A N/A Problem Focused
    • (1 – 3 elements)
    • Brief Problem Pertinent N/A Expanded Problem Focused
    • (1 – 3 elements)
    • Extended Extended Pertinent Detailed
    • (4 or more elements)
    • Extended Complete Complete Comprehensive
    • (4 or more elements)
    • Elements : ROS : PFHS areas :
    • location, quality, constitutional, eyes, ears past history
    • severity, duration, nose, mouth, throat, family history
    • timing, context, cardiovascular, respiratory, social history
    • modifying factors, gastrointestinal, gastro-
    • associated signs urinary, musculoskeletal
    • and symptoms integumentary, neuro-
    • logical, psychiatric,
    • endocrine, hematologic/
    • lymphatic, allergic/
    • immunologic
  • 71. Examination
    • 4 types
    • - Problem Focused
    • - Expanded Problem Focused
    • - Detailed
    • - Comprehensive
    • General multi-system or single organ system
  • 72. General Multi-System Examination
    • Level of Examination Perform and Document
    • Problem Focused 1– 5 elements identified by a bullet in 1 or more organ system(s) or body area(s)
    • Expanded Problem At least 6 elements identified by a bullet in 1 or
    • Focused more organ system(s) or body area(s)
    • Detailed At least 2 elements identified by a bullet from
    • at least 6 organ systems or body areas or at
    • least 12 elements identified by a bullet in 2 or
    • more organ systems or body areas
    • Comprehensive All elements identified by a bullet in at least
    • 9 organ systems or body areas; for each system/area, at least 2 elements identified by a
    • bullet
  • 73. Single Organ System Examination
    • Level of Examination Perform and Document
    • Problem Focused 1 – 5 elements identified by bullet in box with
    • either shaded or unshaded border
    • Expanded Problem At least 6 elements identified by bullet in box
    • Focused with either shaded or unshaded border
    • Detailed At least 12 elements identified by bullet in box with either shaded or unshaded border (except
    • eye and psychiatric examinations)
    • Comprehensive Perform all elements identified by bullet in box with either shaded or unshaded border; document every element in each box with
    • shaded border and at least 1 element in box
    • with unshaded border
  • 74. Medical Decision Making
    • Straightforward
    • Low complexity
    • Moderate complexity
    • High complexity
  • 75. Medical Decision Making
    • Number of Amount and/or Risk of Type of Medical
    • Diagnoses/ Complexity of Complications, Decision Making
    • Management Data to be Morbidity, and/or
    • Options Reviewed Mortality
    • Minimal Minimal or None Minimal Straightforward
    • Limited Limited Low Low Complexity
    • Multiple Moderate Moderate Moderate
    • Complexity
    • Extensive Extensive High High Complexity
  • 76. New Patient Visit
    • Procedure History Examination Medical Decision Making
    • Code
    • 99201 ® Problem Focused Problem Focused Straightforward
    • 99202 Expanded Expanded Straightforward
    • Problem Focused Problem Focused
    • 99203 Detailed Detailed Low Complexity
    • 99204 Comprehensive Comprehensive Moderate Complexity
    • 99205 Comprehensive Comprehensive High Complexity
    • CPT only copyright 2008 American Medical Association. All rights reserved.
  • 77. Established Patient Visit
    • Procedure History Examination Medical Decision
    • Code Making
    • 99211 ® N/A N/A N/A
    • 99212 Problem Focused Problem Focused Straightforward
    • 99213 Expanded Problem Expanded Problem Low Complexity
    • Focused Focused
    • 99214 Detailed Detailed Moderate Complexity
    • 99215 Comprehensive Comprehensive High Complexity
    • CPT only copyright 2008 American Medical Association. All rights reserved.
  • 78. Let's Review
    • What are the 7 components that define the levels of evaluation and management services?
    • History
    • Examination
    • Medical Decision Making
    • Counseling
    • Coordination of Care
    • Nature of Presenting Problem
    • Time
  • 79. PROTECTING THE MEDICARE TRUST FUND CHAPTER 6
  • 80. Chapter 6 Pre-Assessment
  • 81. Medical Review Program
    • Analyze data
    • Take action to prevent and/or address identified errors
    • Publish local medical review policies
  • 82. National Coverage Determination
    • Identifies extent to which Medicare covers specific services, procedures, or technologies on national basis
  • 83. Local Coverage Determination
    • Developed to further define a National Coverage Determination or in absence of a specific National Coverage Determination
    • Made at Contractor’s discretion to provide guidance to public and medical community within specified geographic area
  • 84. Deterring Health Care Fraud and Program Abuse
    • Identify suspicious Medicare charges and activities
    • Investigate and punish those who commit Medicare fraud and abuse
    • Ensure money is returned to Medicare Trust Fund
  • 85. Federal Health Care Fraud
    • Intentional use of false statements or fraudulent schemes to obtain payment for, or to cause another person or entity to obtain payment for, items or services payable under a Federal health care program
  • 86. Program Abuse
    • Intentional or unintentional
    • Directly or indirectly results in unnecessary or increased costs to the Medicare Program
  • 87. Potential Legal Actions
    • Fine
    • Prison sentence
    • Temporary or permanent exclusion from Medicare or other health care programs
    • Lose license
    • Civil Monetary Penalties
  • 88. Potential Legal Actions
    • Deny individual or entity’s application for Medicare provider billing privileges
    • Revoke provider’s billing privileges
    • Suspend payment
    • Exclusion from participation
  • 89. Report Suspected Fraud or Abuse
    • Office of Inspector General
    • TIPS Hotline – (800) 447-8477
    • E-mail – [email_address]
    • Fax – (800) 223-8164
  • 90. Let's Review
    • What are the 2 types of coverage determinations that assist providers and suppliers in coding correctly and billing Medicare only for covered items and services?
    • What is program abuse?
  • 91. INQUIRIES, OVERPAYMENTS, AND APPEALS CHAPTER 7
  • 92. Chapter 7 Pre-Assessment
  • 93. Inquiries
    • Submit by telephone or in writing
    • Interactive Voice Response Services
  • 94. Overpayments
    • Funds that a provider, supplier, or beneficiary received in excess of amounts due and payable
  • 95. 5 Levels of Fee-For-Service Appeals
    • First level – Redetermination by Medicare Contractor
    • Second level – Reconsideration by Qualified Independent Contractor
    • Third level – Hearing by Administrative Law Judge
    • Fourth level – Medicare Appeals Council Review
    • Fifth level – Judicial Review
  • 96.
  • 97. Reopening
    • Remedial action to change a final determination or decision that resulted in an overpayment or an underpayment
    • Allows correction of minor errors or omissions without initiating a formal appeal
  • 98. Let's Review
    • Under what circumstances are overpayments often paid?
    • What are the 5 levels in the appeals process?
  • 99. Post-Assessment Course Evaluation
      • Evaluation of course will be sent via email
      • Completion of evaluation required
      • Thank you for your feedback