HCPro Boot Camp: Medicare Utilization Review Version: Oct. 5-6

Module 1: Medicare Program, Contractors and Resources

• Overview of Medicare Part A, B, C and D

• Medicare contractors, including the MAC, RAC and QIO

Module 2: Medical Necessity Rules and Policies

• Medicare coverage, including guidelines for evaluating medical necessity

• Medicare Coverage Center, including LCDs, NCDs and CED

• Prior authorization for specified outpatient procedures and services

Module 3: Coverage of Observation

• Coverage of observation services

• Coding and billing of observation

• Payment for observation including at PPS and CAH hospitals

Module 4: Medicare Outpatient Notices

• The Medicare Outpatient Observation Notice (MOON)

• Advanced Beneficiary Notice (ABN) for non-covered observation

Module 5: Inpatient Orders and Certification

• Inpatient order requirements

• Inpatient certification requirements, including 96-hour CAH certification

Module 6: Inpatient Admission Guidelines

• Inpatient-only procedures

• The Two-Midnight Benchmark

• Admission on a case-by-case basis

• Livanta Guidance, including clinical examples

Module 7: Inpatient Utilization Review and Billing Requirements

• Utilization review requirements and self-denials

• Concurrent review and billing with condition code 44

• Inpatient Part B payment and billing with condition code W2

Module 8: Medicare Inpatient Notices

• Important Message from Medicare (IM)

• Detailed Notice of Discharge (DN)

• Hospital Issued Notice of Non-Coverage (HINN) for non-covered inpatient services

Module 9: Overview of Inpatient Payment Systems and Patient Liability

• Basics of the Inpatient Prospective Payment System (IPPS)

• Three-day payment window and pre-admission services

• Medicare-severity diagnosis related groups (MS-DRGs)

• Payment for transfers and post-acute care transfers

• Inpatient deductible, coinsurance and lifetime reserve days (LRDs)

Module 10: Outpatient Payment Systems and Patient Liability

• Basics of the Outpatient Prospective Payment System (OPPS)

• Encounter-based Comprehensive Ambulatory Payment Classifications (C-APCs)

• Patient coinsurance under Part B

The course outline is subject to change.