Medicare Billing Guidelines | Medicare Parts A, B, C and D – Video

CPC Exam Prep: Medicare Parts A, B, C and D. I think it’s always funny that they named in that because they can think of something more… let’s do the alphabet.

Q: What services are covered under the various parts of Medicare? Got any tips on how to remember this?

A: Now you do need to memorize this. I think that it’s important for us to be upfront and tell you, “No, you don’t have to memorize this. You’ve got resources and you can look them up.” And yet, there are certain things that you probably should just go ahead and memorize and this is one of them.

I found this lovely couple to put on my slides…

Laureen: I’m going to say too, this information shows up on several of the exams. It’s on the new inpatient ones, it’s on outpatient, and I think there’s a little bit on the CPC exam.

Alicia:      Yeah, there is on the CPC exam.

Laureen: And it’s on the billing credentials so that’s four credentials, right off the top of my head, so this is definitely worth memorizing.

Alicia:     Well, I’ll mention after this slide so we don’t mess it up for Boyd when he’s trying to do recordings and stuff.

Medicare coverage is based on 3 main factors: federal and state laws, national coverage decisions made by Medicare about whether something is covered, and local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.

There’s that term again – medical necessity – it’s huge. You’re going to see it continually in the medical field whether you’re working in the front office, back office, whether you’re a clinician, medical necessity is a big deal.

Medicare Billing Guidelines | Medicare Parts A, B, C and D – Video

Medicare Part A – Is going to cover: hospital care, skilled nursing facility care, nursing home care (as long as custodial care isn’t the only care you need), hospice and home health services.

I tell myself that whenever a person needs to be admitted, that it’s probably Part A. You have to be admitted, in the hospital care, skilled nursing facility. Even home health and hospice you have to go through an admit process. So, that’s kind of how I remembered So think drugs, Part D, is the main part of Part D. The reason they have tier plans is that a prescription drug like HCTZ, which is old fashion “water pill” is really inexpensive; however, if there’s a new “water pill” comes out that adds your hypertension medication as well as the “water pill” or something new for diabetes that works for a special type of diabetes or some, of course it’s new so it cost more and therefore it’s on a different tier. But that’s what they’re talking about.

Your actual drug plan costs will vary depending on: the drugs you use, the plan you choose, whether you go to a pharmacy in your plan’s network (just like doctors), whether the drugs you use are on your plan’s formulary, whether you get Extra Help paying your Medicare Part D costs.

So, for somebody that’s considering which Part D plan to go, you really need to know: 1) is there a pharmacy in your area that can handle the prescriptions that you are going to be using, the drugs that you use? So, you just don’t go and pick one, you need to be proactive and think about which one is going to best suit your needs.that. If you’re admitted, it’s probably Part A.

Medicare Part B – This is for clinical research, ambulance services, durable medical equipment (DME- you’re going to see that a lot in your career, so that’s something you need to take note and memorize), mental health (which would be inpatient, outpatient or partial hospitalization), getting a second opinion before surgery, limited outpatient prescription drugs (prescription drugs got its own section, but this is limited outpatient prescription drugs).

I always think of ambulance and the “B” in ambulance is why I remember the “B” and durable medical equipment.

Laureen: I want to add too physical therapy and occupational therapy – that used to be my world so I know very well that Part B cover that. And if you think A is inpatient and B is non-inpatient, that kind of helps.

Alicia:     Yes, except for mental health, but you’re right, that’s an excellent way to think of it.

Medicare Part C – This is different; this is like an outside coverage from Medicare. It’s somewhat like having Medicare divide up in HMOs. It’s not really the same thing, but that’s how I think of it in my mind.

A Medicare Advantage Plan is a type of Medicare health plan offered by a private companies that contracts with Medicare to provide you with all your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If you’re enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage as part of the Medicare Part C.

But you’ll see Medicare Advantage Plan, and let me tell you something, this goes along, this is something you’re going to see with the new HCC course and the risk adjustment.

This is a big deal with them – Medicare Advantage Plans – because they do projections.

Medicare Part D – Each Medicare Prescription Drug Plan has its own list of covered drugs (called a formulary). Many Medicare drug plans place drugs into different “tiers” on their formularies. Drugs in each tier have a different cost. You’ll make these payments throughout the year in a Medicare drug plan: premium, yearly deductible, copayments or coinsurance, costs in the coverage gap, costs if you get Extra Help, costs if you pay a late enrollment penalty.

So think drugs, Part D, is the main part of Part D. The reason they have tier plans is that a prescription drug like HCTZ, which is old fashion “water pill” is really inexpensive; however, if there’s a new “water pill” comes out that adds your hypertension medication as well as the “water pill” or something new for diabetes that works for a special type of diabetes or some, of course it’s new so it cost more and therefore it’s on a different tier. But that’s what they’re talking about.

Your actual drug plan costs will vary depending on: the drugs you use, the plan you choose, whether you go to a pharmacy in your plan’s network (just like doctors), whether the drugs you use are on your plan’s formulary, whether you get Extra Help paying your Medicare Part D costs.

So, for somebody that’s considering which Part D plan to go, you really need to know: 1) is there a pharmacy in your area that can handle the prescriptions that you are going to be using, the drugs that you use? So, you just don’t go and pick one, you need to be proactive and think about which one is going to best suit your needs.

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