Module D: Medicare Performance

CE Credits: 1.75


This module looks at how working with the Medicare system offers hospitals the opportunity both to maximize its reimbursement system, while also creating a better patient experience. It begins by looking at how hospitals can acknowledge patients as consumers who want the best experience for their money, while also looking at how certain diagnoses can drive up costs for everyone involved, and fast. Then, the module looks at how implementing good coding and documentation can help hospitals improve reimbursement and avoid denials—to the benefit of hospitals and patients.

Learning objectives: After completing this module case managers will be able to:
» Describe the relationship between patient engagement and revenue margins
» Discuss the impact of high intensity and high cost Medicare diagnoses
» Review the basics of diagnosis and procedure coding and their impact on reimbursement
» Describe clinical documentation improvement (CDI) principles and issues
» Review documentation requirements to achieve maximum reimbursement through diagnosis related groups (DRGs) and ambulatory payment classifications (APCs)


Advance your professional practice: Acting as a link between the patient, healthcare provider and insurer, CMs are uniquely suited to act as a conduit of accurate information and efficient services. By working efficiently with Medicare, we can boost patient satisfaction and lower readmissions.

Improve organizational performance: Preventable readmissions are a critical concern for hospitals, in terms of both patient success and financial implications. When we understand how to work within Medicare’s system for reimbursement and to document our patients’ care with the best accuracy, we can boost revenue, lower denials and offer the most targeted care for our patients’ needs.