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Medicare Screening & Preventive Services. Kentucky Health Department Training April 30, 2010. Today’s Presenters. Lindy Lady, CPC Donna R. Morton, CPC. Disclaimer. - PowerPoint PPT Presentation
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Medicare Screening & Preventive
ServicesKentucky Health Department
TrainingApril 30, 2010
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National Government Services, Inc.
Today’s Presenters• Lindy Lady, CPC• Donna R. Morton, CPC
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Disclaimer• National Government Services, Inc. has produced this material
as an informational reference for providers furnishing services in our contract jurisdiction. National Government Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the Centers for Medicare & Medicaid Services (CMS) Web site at http://www.cms.hhs.gov.
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Objective• Assist our health departments with correct
billing and coding for screening and preventive services covered by Medicare.
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Acronyms• ABN – Advance Beneficiary Notice of Non-
coverage• BMI – Body Mass Index• CMS – Centers for Medicare and Medicaid
Services • CPC – Certified Professional Coder• DES – Diethylstilbestrol• DSMT– Diabetes Self Management Training• HBV - Hepatitis B virus
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Acronyms• HIV - Human immunodeficiency virus• HDL - High-density lipoproteins• MLN - Medicare Learning Network• MMR – Medicare Monthly Review• MNT – Medical Nutrition Therapy• MPFS – Medicare Physician Fee Schedule• PPV - Pneumococcal polysaccharide vaccine• SIA – Supplemental Instruction Article
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Services Not Included in the
Screening & Preventive Services Benefit
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Services Not Part of Screening & Preventive Benefits
• 99385-99387, 99395-99397 Preventive Medicine Services (Not covered)
• S0613 Clinical Breast Exam (Not billed separately – part of G0101)
• 87491 Chlamydia (No LCD or NCD)• 87591 Gonorrhea (No LCD or NCD)• 86592 Syphilis test (L28535, A48037)
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Services Not Part of Screening & Preventive Benefits
• 86701 – HIV-1 (NCD 210.7)• 88142 – Cytopathology, cervical or vaginal
(NCD 210.2)
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Resource for Local and National Coverage Determinations
• www.NGSMedicare.com– Sign in as Part B Provider– Quick Links– Select Medical Policy Center
• In addition to LCD – review Supplemental Instruction Article (SIA)
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Screening & Preventive Services
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Frequency Count• Begin with the month after the last covered
service• Frequency of 24 months, 23 months must have
passed• Frequency of 12 months, 11 months must have
passed• Example – low risk patient, service paid
February 2010– Begin count March 2010– 11 months have elapsed as of February 2011
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Screening Pelvic Exam
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Screening Pelvic Exam • Medicare guidelines
– No physician order needed– State law may require order
• Performed by doctor of medicine or osteopathy, or authorized practitioner
• For all female beneficiaries• Includes a clinical breast exam
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Screening Pelvic Examination
• Frequency– High-risk female
• Once every 12 months
– Asymptomatic female• Once every 24 months
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Screening Pelvic Examination
• Childbearing age and presence of cervical or vaginal cancer within past three years
• Cervical/vaginal cancer risk factors– Early onset of sexual activity (under 16 years of age)– Multiple sexual partners (five or more in a lifetime)– History of a sexually-transmitted disease (including HIV
infection)– Fewer than three negative or any pap smears within the
previous seven years– DESexposed daughters of women who took DES during
pregnancy
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Screening Pelvic Examination
• Coding– Exam
• G0101 Cervical or vaginal screening; pelvic and clinical breast examination
– Diagnosis• Low risk patient
– V72.31, V76.2, V76.47, V76.49
• High risk patient– V15.89
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Screening Pelvic Exam • Must include at least 7 of the elements
CMS requires• Document in medical record all elements
performed• Review elements on page 116 of the CMS
Guide to Preventive Services– (ICN 006439)
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Screening Pelvic Exam Reimbursement
• Based on the MPFS• Medicare Part B deductible does not apply• Coinsurance does apply
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Screening Pap Tests
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Screening Pap Tests• Medicare guidelines
– Physician order needed• Ordered and collected by doctor of
medicine or osteopathy, or authorized practitioner
• For all female beneficiaries
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Screening Pap Tests• Frequency
– High-risk female• Once every 12 months
– Asymptomatic female• Once every 24 months
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Screening Pap Tests• Childbearing age and presence of cervical or vaginal
cancer within past three years• Cervical/vaginal cancer risk factors
– Early onset of sexual activity (under 16 years of age)– Multiple sexual partners (five or more in a lifetime)– History of a sexually-transmitted disease (including HIV
infection)– Fewer than three negative or any pap smears within the
previous seven years– DESexposed daughters of women who took DES during
pregnancy
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Screening Pap Tests• Coding
– Screening pap test• G0123, G0143, G0144, G0145, G0147, G0148,
P3000– Physician’s interpretation of screening pap
tests• G0124, G0141, P3001
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Screening Pap Tests• Coding
– Physician obtains, prepares, and conveys smear to laboratory
• Q0091
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Screening Pap Tests• Coding
– Diagnosis• Low-risk patient
– V72.31, V76.2, V76.47, V76.49
• High-risk patient– V15.89
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Screening Pap Tests• Reimbursement
– Q0091, G0124, G0141, P3001 paid under physician fee schedule
• Deductible does not apply• Coinsurance applicable
• Other pap test codes paid under clinical fee schedule (100%)
• ABN for frequency limits
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Smoking and Tobacco Use Cessation
Counseling
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Smoking & Tobacco Use Cessation Counseling
• Furnished by physician or qualified non-physician practitioner
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Smoking & Tobacco Use Cessation Counseling
• Patient must meet one of these criteria:– Uses tobacco and has a disease or adverse
health effect linked to tobacco use– Takes a therapeutic agent whose metabolism
or dosing is affected by tobacco use
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Smoking & Tobacco Use Cessation Counseling
• Cessation counseling session defined– Face-to-face patient contact at one of
two levels• Intermediate (greater than 3 minutes up to
10 minutes) or• Intensive (greater than 10 minutes)
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Smoking & Tobacco Use Cessation Counseling
• Cessation counseling attempt defined– Physician or NPP
• Determines beneficiary meets eligibility requirements
• Initiates treatment with cessation counseling attempt
– Cessation counseling attempt includes• Up to four cessation counseling sessions (one
attempt equals up to 4 sessions)
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Smoking & Tobacco Use Cessation Counseling
• Frequency– Two cessation counseling attempts
every 12 months (up to 8 cessation counseling sessions)
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Smoking & Tobacco Use Cessation Counseling
• Coding– Counseling
• 99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes
• 99407 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes
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Smoking & Tobacco Use Cessation Counseling
• Coding– Diagnosis
• Appropriate and reflect patient eligibility for counseling
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Smoking & Tobacco Use Cessation Counseling
• Payment from Medicare carrier– MPFS– 80% of approved– Deductible and co-insurance applyhttp://www.cms.hhs.gov/MLNMattersArticles/
downloads/MM5878.pdf
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Diabetes Related Services
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Diabetes• Diabetes
– Fasting blood glucose 126 mg/dL or above– Two-hour post glucose challenge 200 mg/dL or
above– Random glucose test over 200 mg/dL
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Diabetes• Pre-diabetes
– Fasting glucose level of 100-125 mg/dL– Two-hour post-glucose challenge of 140-199
mg/dL
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Diabetes Screening Tests• Eligibility determined by risk factors
– Patient must have at least one• Hypertension• Dyslipidemia• Obesity (BMI 30 kilograms/m2 or above)• Previous elevated impaired fasting glucose or
glucose tolerance
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Diabetes Screening Tests• Eligibility determined by risk factors
– Patient must have at least two• Overweight (BMI of greater than 25 but less than
30 kilograms/m2)• Family history of diabetes• Age 65 or older• History of gestational diabetes or baby weighing
more than nine pounds.
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Diabetes Screening Tests• Physician or qualified NPP referral
required
• Frequency– Tested but not diagnosed pre-diabetic or
never tested• One test within a 12-month period
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Diabetes Screening Tests• Frequency
– Diagnosed pre-diabetic• Two tests within 12-month period (not less than six
months apart)
• Deductible and coinsurance do not apply– 100% of clinical lab fee schedule
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Diabetes Screening Tests• Coding
– Tests• 82947, 82950, 82951• Modifier TS–pre-diabetes
– Diagnosis• V77.1
• http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5895.pdf
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Diabetes Self-Management Training (DSMT)
• Medicare guidelines• Physician or qualified NPP order required • Plan of care• Provided by individual associated with
accredited DSMT program
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DSMT• Eligibility• At risk for complications from diabetes• Recently diagnosed • Previously diagnosed
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DSMT• Frequency
– Initial training: 10 hours in 12 months– Follow-up training: 2 hours in subsequent
years • ABN
– Services denied over the limited number of hours
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DSMT• Coding
– Training• G0108 Diabetes outpatient self-management training
services, individual, per 30 minutes• G0109 Diabetes outpatient self-management training
services, group session (2 or more), per 30 minutes– Diagnosis
• No specific required
• http://www.cms.hhs.gov/MLNMattersArticles/Downloads/mm5433.pdf
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DSMT• Reimbursement
– MPFS– Deductible and coinsurance apply
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Medical Nutrition Therapy (MNT)
• Physician referral• Provided by registered dietitian or nutrition
professional enrolled with Medicare• Eligibility
– Diabetic– Renal disease
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Medical Nutrition Therapy (MNT)
• Coding– Service
• 97802 – Used once a year• 97803 – All individual reassessments and
interventions after initial (97802)• 97804 – All group visits• G0270, G0271 – Additional hours of MNT beyond
number of hours typically covered
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Medical Nutrition Therapy (MNT)
• Coding– Diagnosis
• No specific required
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Medical Nutrition Therapy (MNT)
• Frequency– Initial calendar year: 3 hours– Subsequent years: 2 follow-up hours
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Medical Nutrition Therapy (MNT)
• Reimbursement– MPFS– Deductible and coinsurance apply
• ABN– Services denied over the limited number of hours
http://www.cms.hhs.gov/MLNMattersArticles/Downloads/mm5433.pdf
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Covered Diabetic Supplies• Blood glucose monitors and supplies• Therapeutic shoes• Insulin pumps• DME MAC
– www.NGSMedicare.com– www.Medicare.gov
• Resources• Publications
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Cardiovascular Screening Blood Tests
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Cardiovascular Screening Blood Tests Coverage
• Total cholesterol test• Cholesterol test for High Density
Lipoproteins (HDL)• Triglycerides test
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Cardiovascular Screening Blood Tests Coverage
• Physicians order required• Asymptomatic beneficiaries • Every 60 months
– Applies regardless of ordering pattern
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Cardiovascular Screening Blood Tests Coding
• 80061 Lipid panel (must include 82465, 83718, 84478)
• 82465 Cholesterol, serum or whole blood, total – 80061 & 82465 – L27352, A47388
• 83718 Lipoprotein, direct measurement; HDL cholesterol
• 84478 Triglycerides
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Cardiovascular Screening Blood Tests Coding
• V81.0 Special screening for ischemic heart disease
• V81.1 Special screening for hypertension
• V81.2 Special screening for other and unspecified cardiovascular conditions
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Cardiovascular Screening Blood Tests Reimbursement
• Clinical laboratory fee schedule• Part B coinsurance or deductible does not
apply
• http:/www.cms.hhs.gov/manuals/downloads/clm104c18.pdf
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Immunizations
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Pneumococcal Vaccine (PPV)
• No physician order or supervision required• State laws may require order and
supervision• Paid at 100%
– Deductible/coinsurance do not apply• Mandatory assignment on vaccine
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PPV• Frequency
– Covered once in a lifetime– Revaccination for high-risk
• No PPV in last five years
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PPV• Coding
– Vaccine • 90732 Pneumococcal polysaccharide
vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use
– Administration • G0009 Administration of pneumococcal
vaccine
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PPV• Coding
– Diagnosis• V03.82 Need for prophylactic vaccination and
inoculation against bacterial diseases; other specified vaccinations against single bacterial diseases; streptococcus pneumonia (pneumococcus)
• V06.6 Need for prophylactic and inoculation against combinations of diseases, streptococcus pneumonia pneumococcus and influenza
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Hepatitis B Vaccine (HBV)• Covered for beneficiaries at high or
intermediate risk for hepatitis B virus • Physician order and supervision required• Mandatory assignment on vaccine
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Hepatitis B Vaccine• Coding
– Vaccine• 90740, 90743, 90744, 90746, 90747 (as
appropriate) – Administration
• G0010– Diagnosis
• V05.3
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Hepatitis B Vaccine• Payment at 80% of approved• Medicare Part B deductible and
coinsurance apply
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ABN and the Hepatitis B Vaccine
• ABN required– Patient not at intermediate or high-risk of
contracting HBV
www.cms.hhs.gov/MLNProducts/downloads/qr_immun_bill.pdf - 2010-03-08
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Coverage Influenza • One vaccination per influenza season for
all beneficiaries• More than one per season if reasonable
and medically necessary• H1N1 vaccine covered as additional
preventive immunization service• No physician order or supervision needed
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Influenza CPT/HCPCS Codes
90655 Split virus, preservative-free, for children 6-35 months of age, intramuscular use
90656 Split virus, preservative-free, for individuals 3 years and above, for intramuscular use
90657 Split virus, 6-35 month’s dosage for intramuscular or jet injection use
90658 Split virus, 3 years and above dosage, for intramuscular or jet injection use
90660 Influenza virus vaccine, live, for intranasal useG9142 H1N1 vaccine (effective 9/1/09) – not required
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Administration and Diagnosis Codes
• Administration HCPCS codes:– G0008 for influenza virus vaccine seasonal
administration– G9141 for H1N1 virus vaccine administration
(effective 9/1/09)
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Administration and Diagnosis Codes
• Diagnosis codes:– V04.81 for seasonal and H1N1– V06.6 on claims for influenza vaccine and
pneumococcal polysaccharide vaccine (PPV) when purpose of visit was to receive both
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Medicare Payment – H1N1• Medicare pays for administration but not
vaccine itself– Vaccine will be furnished at no cost to all
providers– Administration reimbursed at same rate as
seasonal vaccine administration
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ABN and the Influenza Virus Vaccine
• ABN required– Patient requests additional influenza
vaccination in same flu season– Medical necessity not justified
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Resources• The Guide to Medicare Preventive Services for
Physicians, Providers, Suppliers and Other Health Care Professionals: http://www.cms.hhs.gov/MLNProducts/downloads/mps_guide_web-061305.pdf
• Quick Reference Chart: http://www.cms.hhs.gov/MLNProducts/downloads/MPS_QuickReferenceChart_1.pdf
• The Medicare Learning Network (MLN) Preventive Services Educational Products Web page: http://www.cms.hhs.gov/MLNProducts/35_PreventiveServices.asp
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Resources• CMS Manuals
– http://www.cms.gov/Manuals/IOM/list.asp– Benefit Policy Manual (100-02)
• Chapter 15– Claims Processing (100-04)
• Chapter 18• Chapter 32
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Best Resources for Updates and Policy Changes
• www.NGSMedicare.com– Sign in as Part B Provider
• Subscribe to Part B Listerve– Select New and Pubications– Select Listserve
• Medicare Monthly Review (MMR)– Quick Links– Select Medicare Monthly Review
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Training Opportunities
• www.NGSMedicare.com– Sign in as Part B Provider– Calendar of Events, Part B
• Medicare Part B Basics 101– May 17 – Gilbertsville– May 19 – Frankfort– July 6 – Somerset– July 9 - Ashland
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Medicare University Self-Reporting Instructions
• Event Number = 10120OBDRM1• Topic = KY Health Department Training
Screening and Preventive Services • Medicare University Credits (MUCs) = 2• # of Sessions = 1• Catalog Number = AA-C-????
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Medicare University Credit Self-Reporting Instructions
To earn MUCs, you must self-report your attendance after this training event has ended:•Go to www.MedicareUniversity.com or•Go to www.NGSMedicare.com, select your business type and region, then select Go
– On the upper-right side of the page, select the Medicare University logo
– You will be redirected to an informational page about Medicare University
– Look toward the middle of the page (just above the Click & Learn; Come & Learn; and About MU sections) for Enter the Medicare University CBT Online System and link; Select this link and you will be redirected to the Medicare University log on screen
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Medicare University Credit Self-Reporting Instructions– Log on to the National Government Services Medicare University
site via the log on screen at www.MedicareUniversity.com – Note: You will be prompted to enter your Medicare University log on ID
and password. If you don’t already have one, you may obtain one at this point
– Select Course Catalog from the left side menu– Select the Details button for the course entitled “KY Health
Department Training Screening & Preventive Services”– To locate and self-report today’s training event either look for the name
of the event or look for the Catalog ID number provided for this event– A new window will open providing the event description and information;
select the Enroll button (the screen will then refresh)
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Medicare University Credit Self-Reporting Instructions– Next, select Curriculum List from the left side menu; locate the
self-reporting course you just enrolled in and select the Go button next to it
– A new page will open; select the Launch button on the new page and the course will load in a new window
– Enter the training event number (10120OBDRM1) and select the Submit button
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Thank You!