This course 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 course may feature information on the use of medical and procedural codes, including CPT® codes as they relate to the subject matter presented. The goal of this course is to give revenue cycle and coding professionals an overview of Medicare’s medical necessity rules and guidelines.
This course 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 course may feature information on the use of medical and procedural codes, including CPT® codes as they relate to the subject matter presented. The goal of this course is to give revenue cycle and coding professionals an overview of Medicare’s medical necessity rules and guidelines.
This activity is approved for 0.50 contact hours.
“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.”
Outline:
National Coverage Determination
National Coverage Determination Example
Local Coverage Determinations and Policy Article
Local Coverage Determinations: Example
Local Coverage Determination Rejections
Medical Necessity Documentation
Physician Documentation Tidbits
Subject Matter Expert: Veronica Ziac, MBAJean 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.
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.
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