Reimbursement 101 2011 - Cardinal Health

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Coverage – Medicare • Coverage under the Medicare program is limited by the Social Security Act to services, procedures, and/or items that are in one of the more than 50 defined benefit categories and are considered reasonable and medically necessary for the diagnosis and treatment of a disease or condition. 26 © Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.
Coverage – Medicare A service or product will generally be considered reasonable and necessary y if the service or product p is: 27 – Safe and effective – Not experimental or investigational – Furnished in accordance with accepted p standards of medical ppractice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body part – Furnished in a setting g appropriate pp p to the ppatient’s condition and needs – Ordered and/or furnished by qualified personnel – Meets, but does not exceed, the patient’s medical need – Is at least as beneficial as an existing available alternative © Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.
Page 1 and 2: Nuclear Medicine Reimbursement 101
Page 5 and 6: Reimbursement Terminology 5 • HCP
Page 7 and 8: Reimbursement Terminology 7 • HOP
Page 9 and 10: NM Reimbursement 101 > A/B MACs 9
Page 11 and 12: A/B Medicare Administrative Contrac
Page 13 and 14: NM Reimbursement 101 > A/B MACs 13
Page 15 and 16: NM Reimbursement 101 15 © Copyrigh
Page 17 and 18: Reimbursement - Hospital Outpatient
Page 19 and 20: Reimbursement - RP in Clinic Settin
Page 21 and 22: Reimbursement - Private Payers 21
Page 23 and 24: Coverage • Most important issue i
Page 25: Coverage - Private Payers • Incre
Page 29 and 30: Coverage - Medicare 29 • In gener
Page 31 and 32: CMS Coverage with Evidence Developm
Page 33 and 34: PET Coverage > Medicare Medicare Na
Page 37 and 38: Coding 37 • ICD-9-CM - Internal C
Page 39 and 40: Coding 39 CPT/HCPCS codes • The n
Page 41 and 42: Coding Modifiers • Two character
Page 43 and 44: Coding - Hospital Revenue Codes •
Page 45 and 46: Coding > Claim Forms • Hospitals
Page 47 and 48: Coding > Claim Form 1450 (Hospital)
Page 53 and 54: Coding > Claim Form 1500 Clinic/Phy
Page 55 and 56: NM Reimbursement 101 - References 5
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Reimbursement 101 2011 - Cardinal Health

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