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DC109 Prospective Payment System

Description: In this module the learner will develop an understanding of the clinical requirements for a Medicare Part A stay under the Prospective Payment System, what areas to manage for compliance, and how to capture and keep the dollars you have earned.

You will learn:

109.1. Describe the clinical components of the Prospective Payment System
109.1.1. Define the technical eligibility requirements for a Medicare Part A stay.
109.1.2. Define the clinical eligibility requirements for a Medicare Part A stay
109.1.3. Define “Skilled Services”
109.1.4. Identify Skilled RUG-III categories
109.1.5. Define “Deemed Skilled”
109.1.6. Define “Benefit Period”
109.1.7. Define “Spell of Illness”
109.1.8. Define “Break in Spell of Illness”
109.1.9. Define the physician certification requirements.
109.1.10. Describe the relationship between the MDS and the Medicare bill, the UB-04
109.2. Discuss the Resource Utilization Groups
109.2.1. List the 8 RUG-III categories
109.2.2. Describe the difference between hierarchical and index maximizing
109.2.3. Name the source document for Medicare Part A.
109.3. Discuss the MDS PPS assessment schedule
109.3.1. List the 6 scheduled assessments
109.3.2. List the two unscheduled assessments that can change the payment rate
109.3.3. Discuss how the Assessment Reference Date impacts payment
109.4. Discuss obstacles to capturing and keeping the payment you earn
109.4.1. Describe a methodology for pre-screening potential patients for admission under the Medicare Part A payment system
109.4.2. Describe a methodology to facilitate communication between members of the
109.4.3. Interdisciplinary Team (IDT)
109.4.4. Discuss methodology for determining who sets the ARD
109.4.5. Describe an auditing methodology for MDS and claim accuracy
109.4.6. Describe the Additional Data Review (ADR) process
109.4.7. Describe what to send the Fiscal Intermediary (FI) for an ADR
109.5. Generate an action plan for capturing and keeping the dollars you have earned
109.5.1. Describe the basic elements of process improvement
109.5.2. Describe a new employee orientation program to encourage comprehensive skilled documentation
109.5.3. Describe a new employee orientation program to encourage accurate MDS coding
109.5.4. Identify the components of a policy and procedure to assure payment accuracy
109.5.5. Identify four data collection tools you will use to assure payment accuracy

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