Medicare Utilization Review for Clinicians

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Medicare Utilization Review for Clinicians

Product Code: XMURCLN

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Medicare Utilization Review for Clinicians


This course contains three modules: Observation, Inpatient Status and Correcting Patient Status. 

These workshops will explore the detailed rules for observation and inpatient status under Medicare and making determinations under the Conditions of Participation (CoP) for Utilization Review (UR) to effectuate Condition Code 44 changes or post-discharge self-denials. This library is designed for a clinical audience, although anyone seeking more in-depth knowledge of UR concepts would benefit--such as compliance officers, revenue cycle staff, and denials staff working with inpatient denials.

These workshop contain three modules:

  • Observation - This module provides the details of Medicare coverage of observation services, notices required for Medicare patients in observation, and the reporting and payment of observation services under Medicare Part B.
  • Inpatient Status - This module reviews the Medicare inpatient order and certification requirements. The course also provides a detailed discussion of the inpatient admission guidelines, including the two-midnight benchmark, inpatient only procedures, and case-by-case admissions.
  • Correcting Patient Status - This course reviews Medicare patient status designations and Medicare Hospital Conditions of Participation for Utilization Review. The course details the requirements for utilization review determinations and how they act as the basis for condition code 44 changes and self-denial processes, as well as the billing and payment implications of each.

Medicare Utilization Review for Clinicians


Observation Workshop:

  • Comply with Medicare coverage requirements for observation
  • Evaluate circumstances when an Advanced Beneficiary Notice of Non-Coverage (ABN) would be appropriate and useful for patients in observation
  • Differentiate when observation will trigger additional payment and when it will package, resulting in no additional payment

Inpatient Status Workshop:

  • Assess inpatient orders for compliance with Medicare requirements
  • Comply with the two-midnight benchmark
  • Differentiate admission under the two-midnight benchmark with unexpected recovery from case-by-case admissions

Correcting Patient Status Workshop:

  • Differentiate Medicare status designations and hospital status designations
  • Comply with Hospital Conditions of Participations for Utilization Review determinations
  • Evaluate the advantages and disadvantages of the condition code 44 and self-denial processes from a clinical and revenue cycle perspective

Medicare Utilization Review for Clinicians


  • Medicare
  • Revenue Cycle
  • Revenue Integrity
  • Compliance
  • Clinicians

Medicare Utilization Review for Clinicians

Continuing Education

This program has prior approval of the AAPC for 4.5 Continuing Education Units. Granting of this approval in no way constitutes endorsement by the AAPC of the program, content or the program sponsor.

HCPro is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

HCPro designates this educational activity for a maximum of 4.5 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

This program has been approved for 4.5 continuing education units towards fulfilling the requirements of the Certified Clinical Documentation Specialist (CCDS) certification and CCDS-O (outpatient) certification, offered as a service of the Association of Clinical Documentation Integrity Specialists (ACDIS).

This program has been approved for 4.5 continuing education unit(s) (CEUs) for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). Granting of Approved CEUs from AHIMA does not constitute endorsement of the program content or its program provider.

HCPro is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

This educational activity for 4.5 nursing contact hours is provided by HCPro.

The Compliance Certification Board (CCB) has approved this event for up to 5.4 CCB CEUs. Continuing Education Units are awarded based on individual attendance records. Granting of prior approval in no way constitutes endorsement by CCB of this program content or of the program sponsor.

This program has been pre-approved by The Commission for Case Manager Certification to provide 4.5 hours of continuing education credit to CCM board certified case managers.

This program has been approved for 4.5 continuing education units towards fulfilling the requirements of the Certification in Healthcare Revenue Integrity (CHRI), offered as a service of the National Association of Healthcare Revenue Integrity (NAHRI).

Disclosure Statement:
HCPro has confirmed that none of the faculty/presenters, planners, or contributors have any relevant financial relationships to disclose related to the content of this educational activity.

Medicare Utilization Review for Clinicians


You will have access to your courses for 1 year from the purchase/order date.