A Day with
Medicare
An educational event focusing on the
Comprehensive Error Rate Testing (CERT) Program
6/11/2015
Overland Park Convention Center
6000 College Blvd
Overland Park, KS 66211
(913) 339-3000
7/22/2015
St Charles Convention Center
1 Convention Center Plaza
St Charles, MO 63303
(636) 669-3000
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Table of Contents
Please write to us at [email protected] if you have questions or
concerns
Continuing Education Credits (CEUs)…… 3
Responding to Coding Questions……….. 3
Disclaimers………………………………... 3
Daily Schedule……………………………... 4
Registration………………………………… 4
Breakfast……………………………………. 4
Lunch……………………………………...... 4
Materials…………………………………..... 4
Breakout Sessions………………………… 5
Session Descriptions…………………….. 6
WPS Medicare Staff Bios…………………. 13
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Continuing Education Credits (CEUs)
CEUs for CMS-sponsored webinars and workshops are accepted by the American Academy of
Professional Coders (AAPC) at a rate of one CEU per hour. These CEUs may come from CMS or
Medicare Administrative Contractor (MAC) offices. A certificate of attendance or completion with the
CMS logo is necessary to show participation.
To claim CEUs, attendees will enter certificate information onto their CEU Tracker using the “No
Index Number” option. A copy of the certificate does not need to be provided to AAPC unless the
member is selected for verification purposes.
Responding to Coding Questions
Contractors are prohibited from providing coding advice. Based on CMS’ Medicare Contractor
Beneficiary and Provider Communications Manual, Publication 100-09, Chapter 6, Section 30.1.1,
providers are responsible for determining the correct diagnostic and procedural coding for the
services they furnish to Medicare beneficiaries. For details, please refer to:
http://cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/com109c06.pdf
Disclaimers
These presentations are a tool to assist providers. Every reasonable effort has been made to ensure
the accuracy of the information; however, the provider has the ultimate responsibility for correct
submission of claims. WPS Medicare bears no liability for the results or consequences of the misuse
of this information. The official Medicare Program provisions are contained in the relevant laws,
regulations, and rulings.
We will not be able to answer specific claims questions as no system access will be available.
We reserve the right to change a participant’s sessions (only if necessary).
Recording or videotaping these educational presentations is prohibited.
Thank you for silencing your cell phone during all sessions.
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Daily Schedule
8:30 – 9:00 AM Registration and Breakfast
9:00 – 9:20 AM Welcome and General Session
9:30 – 10:30 AM Breakout Session 1 (5 concurrent sessions)
10:30 – 10:40 AM Break
10:40 – 11:40 AM Breakout Session 2 (5 concurrent sessions)
11:40 – 1:00 PM Complimentary Lunch/Keynote Speaker
1:10 – 2:10 PM Breakout Session 3 (5 concurrent sessions)
2:10 – 2:20 PM Break
2:20 – 3:20 PM Breakout Session 4 (5 concurrent sessions)
3:20 – 3:30 PM Refreshments
3:30 – 4:30 PM Questions and Answers with WPS Medicare Staff
Registration
Staff at the registration table will be available all day to answer questions and assist with locating
sessions.
Breaks
Morning and afternoon breaks will consist of a beverage service.
Light refreshments will be offered prior to and during the Question and Answer session.
Breakfast
A Continental breakfast will be available beginning at 8:30 AM.
Lunch
Please join us for lunch following Session 2.
Materials
All materials and handouts will be provided at the event.
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Breakout Sessions
Event Title Provider Type
Session 1
Physician Inpatient Hospital Services - The Good, the Bad and the Ugly A/B
The Comprehensive Error Rate Testing Program - Get the Scoop! A/B
Signed, Sealed and Delivered - Ensuring Orders, Signatures and Notes Support
What is Billed
A/B
The CERT Forecast - If It Gets Stormy, Will You Be Ready? A
Documenting Medical Necessity for Major Joint Replacements (Hip and Knee) A/B
Session 2
Moving to the Next Level - Using the Medicare Appeals Process to Your Advantage A/B
Part B CERT Errors - All Hands on Deck! B
No Denials, No Recoupments, No Errors! A
Avoiding Recoupment and Retaining Dollars - SNF Certification/Recertification
Statements
A
Hospital Admission Criteria A/B
Session 3
SNF Consolidated Billing - To Bill, or Not to Bill, That is the Question A/B
Evaluation and Management (E/M) Services - Reducing Errors Through Education
(Part 1)
A/B
Increase Your Inpatient Psychiatric Facility (IPF) Revenue by Decreasing Your
Errors
A
Take Aim at Reducing Part B Claim Errors B
The Do’s and Don’ts of Diagnostic Laboratory Tests A/B
Session 4
Avoid Payment Errors – Present on Admission (POA) Indicators and Patient
Discharge Status Codes
A
Documentation Through the Eyes of Medicare Reviewers A/B
Who’s Reviewing Your Claims? A/B
The ABC’s of the Initial Preventive Physical Exam & Annual Wellness Visit A/B
Evaluation and Management (E/M) Services - Reducing Errors Through Education
(Part 2)
A/B
You will select the sessions you wish to attend during the online registration process.
If a topic does not appear, that session is full. Note: If you are selecting Evaluation and
Management two sequential sessions are offered and you are required to register for
and attend both.
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General Categories and Session Descriptions
Appeals
Moving to the Next Level – Using the Medicare Appeals Process to Your Advantage
Janet Mateo, Analyst, Provider Outreach & Education
Thom Ryan, Senior Analyst, Provider Outreach & Education
What does a provider do if they disagree with an initial determination? Do you know how the claim
reopening process differs from the appeals process? Learn about the Medicare Appeals process, the
new coding requirements for reopening a claim, the difference between the claim reopening and the
appeals process, and receive guidance on filing both actions correctly. Also, learn what happens
when a change or addition to a claim is discovered beyond the timely filing limits.
Target Audience: Part A & B, Coders, Billers, Office Staff
Comprehensive Error Rate Testing (CERT)
Part B CERT Errors – All Hands on Deck!
Sue Brewer, Analyst, Provider Outreach & Education
Mary Muchow, Senior Analyst, Provider Outreach & Education
Denise Stanley, Supervisor, MR CERT
Join us for an interactive experience where you will review examples of actual documentation
reviewed by the CERT contractor and test your knowledge of Medicare Part B regulations! After a
short overview of the most common Part B CERT error findings, all participants will dive into the
documentation. You will then bring to the surface your decision of whether a CERT error was
assessed for each case. Providers, clinicians, coders, billers, and compliance staff should consider
attending this informative session to learn more about how to avoid denials with proper
documentation of Medicare claims.
Target Audience: Part B, Coders, Billers, Office Staff
No Denials, No Recoupments, No Errors! Aileen Sigler, Analyst, Provider Outreach & Education Karen Kroupa, Analyst, Provider Outreach & Education Tanya Hardiman, Analyst, Provider Outreach & Education Stay on top of your game and don’t get struck out by denials on your Part A claims. In this session,
we’ll examine some of the latest errors found by the CERT contractor. Join your Part A teammates
and develop a game plan for hitting a home run on every claim by avoiding denials.
Target Audience: Part A, Administrators, Billers, Office Staff, Clinicians, Coders
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Take Aim at Reducing Part B Claim Errors
Sue Brewer, Analyst, Provider Outreach & Education
Mary Muchow, Senior Analyst, Provider Outreach & Education
With the implementation of CMS medical review initiatives, comes the likelihood that your Part B
Medicare claim may be selected for medical review by one of CMS’ contractors. Based on historical
data, the error categories and types of errors have remained quite consistent. Providers, clinicians,
coders, billers, office staff, and compliance staff should consider attending this informative session to
learn the most common Part B claim errors, and how to avoid them. In addition to the identification of
historical and forecasted Part B claim errors, we will demonstrate, through the use of the WPS
Medicare website, the multitude of educational resources created to prevent and avoid the same
errors in the future.
Target Audience: Part B, Coders, Billers, Office Staff
The CERT Forecast – If It Gets Stormy, Will You Be Ready?
Jan Ervin, Analyst, Provider Outreach & Education
This session will focus on the services CERT is projecting to look at when conducting reviews. We’ll
look at reasons why CERT is forecasting these services and what they’ll be looking for. Don’t miss
this opportunity to prepare your facility to weather the storm.
Target Audience: Part A, Coders, Billers, Office Staff, Administrators
The Comprehensive Error Rate Testing Program – Get the Scoop!
Denise Stanley, Supervisor, MR CERT
You may have seen CERT in the headlines, but do you have all of the information you need to fully
understand why it was implemented, how it works and what your role is in the process? This
informative session will help you better understand the fine print about the CERT contractors, the
process, CERT review results, CMS goals and potential outcomes. Designed for practitioners,
coders, billers, office staff, and compliance staff, participants will benefit from gaining a better
understanding of the CERT program and its importance to all Medicare contractors and providers
alike.
Target Audience: Part A & B, Coders, Billers, Office Staff, Administrators
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Claim Review
Who’s Reviewing Your Claims?
Sue Brewer, Analyst, Provider Outreach & Education
Mary Muchow, Senior Analyst, Provider Outreach & Education
Denise Stanley, Supervisor, MR CERT
CMS has implemented a multitude of program integrity and medical review initiatives, each with a
slightly different focus, but all with an eye toward the goal of detecting and correcting improper
payments to and from Medicare. These efforts are an important step toward the prevention of waste,
fraud and abuse in the Medicare program. Join us to better understand how the role of the Medicare
Administrative Contractor medical review staff and CMS medical review contractors differ, what
contractors are reviewing, and the potential outcomes of all respective medical review activities.
Designed for practitioners, clinicians, coders, billers, office staff, and compliance staff, participants will
recognize the importance of complete and correct documentation, preparation and submission of
Medicare claims and the impact of those claims on the national paid claims error rate.
Target Audience: Part A & B, Coders, Billers, Office Staff, Compliance Staff
Documentation
Documenting Medical Necessity for Major Joint Replacements (Hip and Knee)
Mary Sue Gardner, RN/BSN, Senior Nurse Analyst, Provider Outreach & Education
Cheyenne Santiago, RN, Senior Nurse Analyst, Provider Outreach & Education
Please join us for a discussion on documenting medical necessity for major joint replacements (hips
and knees). This educational event is intended to improve compliance with documentation
requirements for major joint replacement surgery.
Target Audience: Part A & B, Utilization Review Staff, Admitting Personnel, Physicians, Practitioners
Documentation Through the Eyes of Medicare Reviewers
Mary Sue Gardner, RN/BSN, Senior Nurse Analyst, Provider Outreach & Education
Cheyenne Santiago, RN, Senior Nurse Analyst, Provider Outreach & Education
What do claim review contractors look for? What are the top errors and how can these be avoided?
What needs to be included in the documentation? Find out the answers to these questions and more
in this session that will focus on reviews performed by various Medicare contractors. Based on
historical data, we will share information on the most common error findings and will provide tips and
resources to prevent future documentation and coding issues.
Target Audience: Part A & B, Coders, Billers, Practitioners, Compliance Staff
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Signed, Sealed and Delivered – Ensuring Orders, Signatures and Notes Support What is Billed Aileen Sigler, Analyst, Provider Outreach & Education
Would your claim get a stamp of approval? Are all the components of your documentation in place,
complete and accurate to support payment for the services you’ve billed? In this session, we will
review orders and signature requirements and how any missing pieces can affect receiving proper
reimbursement from Medicare.
Target Audience: Part A & B, Administrators, Billers, Clinicians, Coders The Do’s and Don’ts of Diagnostic Lab Tests
Mary Sue Gardner, RN/BSN, Senior Nurse Analyst, Provider Outreach & Education
Cheyenne Santiago, RN, Senior Nurse Analyst, Provider Outreach & Education
Laboratory denials continue to be a growing error across all review entities. Join us as we discuss:
• Beneficiary information required to be submitted with each claim or order for laboratory services
• The medical condition for which a laboratory test is reasonable and necessary
• The medical documentation that is required by a Medicare contractor at the time a claim is submitted for a laboratory test
• Record keeping requirements in addition to any information required to be submitted with a claim, including physicians’ obligations regarding these requirements.
Target Audience: Part A & B, Coders, Billers, Practitioners, Compliance Staff
Evaluation and Management Services (E/M)
Evaluation and Management (E/M) Services – Reducing Errors Through Education – Parts 1
and 2
Ellen Berra, Senior Analyst, Provider Outreach & Education
PLEASE NOTE – THIS BREAKOUT CONSISTS OF 2 PARTS – Those choosing this breakout
must register for both sessions.
In this session, you will be provided information on the CMS guidelines for choosing an E/M
procedure code based on the documentation. We will discuss the three key components used in
choosing a procedure code and when an alternative method may be used. We will have examples of
recent CERT results on actual documentation submitted. This will be a lively discussion on one of the
areas of concern in the CERT program!
Target Audience: Part A & B, Practitioners, Compliance Staff, Coders, Billers, Office Staff
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Physician Inpatient Hospital Services – The Good, the Bad and the Ugly
Ellen Berra, Senior Analyst, Provider Outreach & Education
Karen Kroupa, Analyst, Provider Outreach & Education
Tanya Hardiman, Analyst, Provider Outreach & Education
Medicare has identified inpatient hospital visits as an area of concern. Come join us to discuss the
documentation requirements for these services. We will discuss the E/M components and what we
and other reviewers are expecting to see in the documentation. We will provide documentation
examples of the good, the bad and the ugly and discuss the concerns of the reviewers along with
additional helpful hints.
Target Audience: Part A & B, Administrators, Billers, Clinicians, Coders
Facility Based Services
Avoid Payment Errors – Present on Admission (POA) Indicators and Patient Discharge Status Codes Janet Mateo, Analyst, Provider Outreach & Education
Are you reporting Present on Admission indicators correctly? Did you know that inaccurate reporting
of a patient discharge status code can lead to an underpayment or overpayment? During this session,
we will review the POA reporting guidelines and discuss common miscoded POAs. We will also
review common patient discharge code errors and look at how incorrect coding leads to claim errors.
Target Audience: Part A, Coders, Billers, Office Staff
Avoiding Recoupment and Retaining Dollars - SNF Certification/Recertification Statements
Jan Ervin, Analyst, Provider Outreach & Education
The CERT Contractor has been recouping dollars from Skilled Nursing Facilities due to their failure to
obtain proper certification or recertification statements. Don’t let this happen to you! During this
session, we will discuss common medical practices and how to properly document acceptable
certification and recertification statements.
Target Audience: Part A, Skilled Nursing Facilities – All Staff
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Hospital Admission Criteria
Mary Sue Gardner, RN/BSN, Senior Nurse Analyst, Provider Outreach & Education
Cheyenne Santiago, RN, Senior Nurse Analyst, Provider Outreach & Education
CMS has fundamentally altered the manner in which hospitals define how inpatient status and
outpatient observation is determined. It is critically important for physicians and hospitals to work
together to apply the correct payment policy for Medicare patients. Join us for this session on
hospital admission criteria and learn what you need to know when requesting a hospital bed.
Target Audience: Part A & B, Utilization Review Staff, Admitting Personnel, Physicians, Practitioners
Increase Your Inpatient Psychiatric Facility (IPF) Revenue by Decreasing Your Errors
Janet Mateo, Analyst, Provider Outreach & Education
Jan Ervin, Analyst, Provider Outreach & Education
Is your facility losing money on denials resulting from insufficient documentation errors, medically
unnecessary services, or treatment errors? In this session we will review the IPF CERT errors,
provide examples of IPF improper payments and provide guidance to avoid errors.
Target Audience: Part A, Billers, Office Staff
Preventive Services
The ABC’s of the Initial Preventive Physical Exam (IPPE) & Annual Wellness Visit (AWV)
Thom Ryan, Senior Analyst, Provider Outreach & Education
Aileen Sigler, Analyst, Provider Outreach & Education
The IPPE and AWV focus on disease detection, prevention and lifestyle modifications that can help
beneficiaries live longer, healthier lives. Many providers still have questions and struggle with
completing all the elements to make it a covered service. Join us as we explore the fundamentals of
these important benefits. Topics include: the components of the IPPE and AWV, who can perform the
service, how to correctly bill for them and so much more!
Target Audience: Part A & B, Coders, Billers, Office Managers, Compliance Staff
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Skilled Nursing Facility Consolidated Billing
SNF Consolidated Billing – To Bill, or Not to Bill, That is the Question
Karen Kroupa, Analyst, Provider Outreach & Education
Tanya Hardiman, Analyst, Provider Outreach & Education
Thom Ryan, Senior Analyst, Provider Outreach & Education
Join us in this audience participation session to get your SNF Consolidated Billing questions
answered. This unique breakout session brings Part A SNFs and all other providers together for an
interactive discussion on when to bill the SNF or Medicare program for services rendered. Learn how
to use best practices to bill correctly the first time. We’ll show you resources recommended by CMS
to add to your own best practices to make SNF CB easier.
Target Audience: Part A & B, Coders, Billers, Office Staff, Compliance Staff
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WPS Medicare Staff Bios
Bringing you over 200 years of Medicare experience!
Ellen Berra, POE Senior Analyst, has over 25 years of experience in the Medicare program and
joined Provider Outreach and Education in 1996. Ellen’s experience in Medicare includes Claims,
Appeals, Congressional Inquiries, and Fair Hearings. She has led many teams in creating Medicare
educational material for standard educational topics and specific material for specialty societies and
associations. She contributes educational articles on many different subjects to the website, e-News
and Communiqué.
Sue Brewer, POE Analyst, has 25 years of Medicare experience. Her responsibilities include
presenting seminars on a variety of topics. Previous positions held include Supervisor of Claims
Development and Medicare Secondary Payer (MSP) units, Training Specialist and Fair Hearing
Officer. Sue graduated from the University of Wisconsin at Madison.
Maria Diaz, POE Customer Service Specialist, has over 13 years of Medicare experience and has
been in her current position for the last 5 years. She is responsible for reporting, assisting with
educational material, and working with the provider community. Prior to this, Maria held positions as
a Medicare Customer Service Representative, assisting providers with billing questions; as an
internal trainer, teaching staff all aspects of Medicare billing, system usage and regulations; and in
the technical department testing new implementations and solving technical issues with claims.
Jan Ervin, POE Analyst, has over 9 years of Medicare experience and has been in her current
position since 2008. Her Medicare background began with Mutual of Omaha Medicare in 2006 as a
Cost Report Auditor. Her primary job responsibilities involve facilitating educational seminars,
webinars and teleconferences for various facilities throughout the United States. Jan earned her
BSBA in accounting at University of Nebraska at Omaha.
Mary Sue Gardner, RN/BSN, POE Senior Nurse Analyst, brings over 13 years of Medicare
experience the POE team. She has a Bachelor of Science in Nursing (RN/BSN) from Methodist
College of Nursing, in Omaha, Nebraska. Prior to working in Medicare, Mary Sue spent many years
practicing clinically in various inpatient and outpatient settings. She has worked in the Medical Review
department as well as POE. Mary Sue provides clinical education in all WPS contracts of work
throughout the United States.
Tanya Hardiman, POE Analyst, brings 11 years of Medicare experience to her current position. She
spent three years as a Customer Service Representative before joining the POE team. Her duties
include conducting Medicare seminars, teleconferences, and webinars as well as developing “self-
service” educational tools on various Medicare topics. Tanya is a graduate of Southwest Minnesota
State University with a degree in Sociology.
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Karen Kroupa, POE Analyst, has over 11 years of experience in various Medicare departments. She
started as a Claims Examiner, then as a Customer Service Representative before joining POE. Prior
to working for Medicare, she worked in Mutual of Omaha Insurance Company’s Large Group Health
Plan department. Karen has a BA in English, Art and Art History from the University of Nebraska at
Omaha.
Janet Mateo, POE Analyst, has over 16 years of Medicare experience. Janet’s primary job
responsibilities include education and training for Medicare providers in various states. Before joining
Mutual of Omaha in 1999, Janet was employed by the National Multiple Sclerosis Society for 10
years at local chapters in New Jersey and Illinois. Janet possesses a Masters in Social Work
Administration and a Bachelor of Science degree from Rutgers University in New Brunswick, New
Jersey. Janet also received training from the Center for Postgraduate Studies in Psychotherapy in
Red Bank, New Jersey.
Mary E. Muchow, POE Senior Analyst, has over 34 years of Medicare experience. Mary held
previous positions in Claims Examination/Entry, Medical Review, and Training. Prior to joining the
POE team, Mary worked in the Benefit Integrity Unit as an investigator and trainer. Later, as the
Medicare Fraud Information Specialist (MFIS), Mary represented multiple contractors as a liaison
between federal investigators, prosecutors, CMS, and other agencies. In this role, Mary often
presented relevant Medicare fraud and abuse topics to law enforcement and audiences on a national
level. Mary joined POE in 2003 where she provides outreach activities, provider education and the
development of partnerships with various societies and associations.
Thom Ryan, POE Senior Analyst, has over 10 years of Medicare experience. He began his career
with WPS in the Tricare division. In 2005, he joined POE where his primary focus is technology and
face-to-face education. Thom holds a bachelor degree in Social Work from Winona State University.
K. Cheyenne Santiago, RN, POE Senior Nurse Analyst, brings over 8 years of experience to the
POE team. She is responsible for clinical education for the provider community including training on
Medicare rules, regulations and clinical coverage criteria, as well as current health care practice
trends. She holds an Associate of Science in Nursing (RN/ASN) from Excelsior College School of
Nursing, in Albany, New York.
Aileen Sigler, Outreach Analyst, has over 17 years of Medicare experience. Her primary job
responsibilities include developing and facilitating seminars, teleconferences and webinars for the
provider community. She held prior positions in the Claims, Customer Service and internal Training
departments before joining Provider Outreach & Education in June of 2005.
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Denise Stanley, Supervisor, has 17 years of experience in the Medicare program, including 5 years
in the Benefit Integrity Unit investigating potential fraud and abuse. Denise is currently the CERT
Supervisor in the Medical Review department. In this role, she serves as a liaison between the CERT
contractors and the provider community. Her responsibilities include analysis of CERT review
findings, providing current content for the WPS Medicare CERT web page, responding to provider
inquiries for CERT review results and collaboration with POE for educational events.
Sheryl Torres, Manager, has 20 years of experience in the Medicare program. In this role, she
oversees the day to day operations of Provider Outreach and Education activities. In addition to her
current role, Sheryl has held various positions in Customer Service, Quality Assurance and prior POE
responsibilities.
Thank you for joining us today!
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