This lesson defines important components of Medicare rules and addresses the ways that coverage determinations are made. An understanding of these determinations and of how physician documentation helps prove medical necessity will help to ensure that claims will not be rejected because of documentation errors. This lesson may feature information on the use of medical and procedural codes, including CPT codes as they relate to the subject matter presented.
“This program has been approved for 0.50 continuing education unit(s) for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). Granting prior approval from AHIMA does not constitute endorsement of the program content or its program sponsor.”
This activity is approved for 0.50 contact hours.
Section 1: Introduction
About This Course
The Medicare Act of 1965
Medical Necessity Edits
Section 2: NCDs and LCDs
National Coverage Determination
National Coverage Determination Example
Local Coverage Determinations
Local Coverage Determinations and Policy Article
Local Coverage Determinations: Example
Local Coverage Determination Rejections
Advance Beneficiary Notice
Section 3: Other Factors
Medical Necessity Documentation
Physician Documentation Tidbits
Section 4: Conclusion
Expert Reviewer: Richard R. Cooley, BA, CCS
Deborah is responsible for Elsevier's online solution of education and tools to improve employee performance for Revenue Cycle, Coding, CDI, and Compliance professionals. Deborah has earned BS degrees in Management/Human Resources and Social Psychology. She is a Registered Health Information Management Administrator (RHIA) and is a Certified Coding Specialist, Physician-Based (CCS-P). Prior to joining Elsevier, Deborah held positions such as Revenue Cycle Analyst for Mayo Clinic; Compliance Officer; educator; coding manager; and senior consultant. Deborah actively participates on projects important to the healthcare industry. As an active member of AHIMA, she has participated in the Quality Initiatives & Secondary Data Practice Council, was Chair of the Coding Policy and Strategy Committee and Board member for the Society of Clinical Coding. She has authored journal articles, been a presenter of audio-conferences and a speaker at national and state conventions. Deb was a member of the AHA Editorial Advisory Board for ICD-9-CM Coding Clinic and AHA Editorial Advisory Board for HCPCS.Disclosure: Deborah Neville, RHIA, CCS-P has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Expert Reviewer: Jean C. Russell, MS, RHIT
Richard has more than eighteen years in healthcare consulting. He has developed an expertise in hospital outpatient and inpatient coding, including professional split billing and E/M coding, admission criteria, reimbursement and compliance, and charge master reviews. His areas of expertise include Medicare reimbursement for the Medicare Outpatient Prospective Payment System (OPPS), Medicaid Ambulatory Payment Groups (APGs), as well as commercial payers, and professional reimbursement. He is a certified coder with AHIMA (CCS). Richard earned his Bachelors from Hobart College.Disclosure: Richard R. Cooley, BA, CCS has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Expert Reviewer: Veronica Ziac, MBA
Jean Russell has over thirty years of healthcare and information system experience. Her areas of expertise include the Medicare outpatient prospective payment systems (APCs, and APGs), as well as ICD-10-CM/PCS training, Charge Description Master (CDM), admission status reviews, and outpatient coding and compliance. She is a frequent speaker at the national, state and local levels for HFMA and AHIMA professional groups. Jean has her Masters from the University of Houston in Biomedical Engineering; her Bachelors from Colgate University in Biology; and her RHIT from the independent study program through the American Health Information Management Association.Disclosure: Jean C. Russell, MS, RHIT has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Veronica Ziac, MBA has over twenty years of healthcare administration experience. Her areas of expertise include revenue cycle, information systems, population health and physician practice management. Most recently, she was the Director of Revenue Cycle Integrity at Cobleskill Regional Hospital. Prior to that, Veronica was the Chief Operating Officer for a large multispecialty hospital-based physician practice based in New York. Veronica has an MBA in Healthcare Administration from Union College and a bachelor’s degree from the University at Albany. She is a member of HFMA and MGMA and has been Certified in Healthcare Compliance (CHC) by the Healthcare Compliance Association.Disclosure: Veronica Ziac, MBA has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
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