Medical Review of Ambulance Services. Provider Outreach & Education and Medical Review October 2014

Transcription

1 Medical Review of Ambulance Services Provider Outreach & Education and Medical Review October 2014

2 Before We Start Help Us Help You! CHAT Area Enter name, facility name and state do not enter in Q&A section Dial into teleconference using assigned Attendee ID number rather than just # sign Check Event Info tab for ID 10/15/2014 2

3 Workshop Protocol When entering/throughout workshop all lines muted Presentation ed 3 days before webinar Adobe PDF format (with printing instructions) Throughout workshop Questions pertinent to workshop slide addressed Address Q & A to all panelists ; not to host directly All other questions, call Part A Provider Contact Center Workshop conclusion Asking questions aloud? Use raise/lower hand feature MUTE phones never place on HOLD 10/15/2014 3

4 Continuing Education Unit (CEU) When registering, add additional attendees First and last names Attend entire workshop Take short polling survey After closing out of webinar CEU ed 3 days after presentation Earn between.5 and 1.5 CEUs No password or index number needed All providers use CEU certificate Certificate of Attendance no longer available 10/15/2014 4

5 DISCLAIMER This information release is the property of Noridian Healthcare Solutions, LLC. It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents. The information is provided as is without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and CMS. The most current edition of the information contained in this release can be found on the Noridian website at and the CMS website at The identification of an organization or product in this information does not imply any form of endorsement. CPT codes, descriptors, and other data only are copyright 2014 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. 10/15/2014 5

6 Agenda Medical Necessity Covered and Non Covered Transports Ambulance Service Levels Medical Review Errors and Findings Questions Resources 10/15/2014 6

7 Objective Assist Medicare Part A ambulance providers in better understanding ambulance transport, billing, coding and coverage Provide documentation requirements from Noridian Medical Review s findings Equip providers with helpful resources 10/15/2014 7

8 Medical Necessity

9 Medical Necessity Internet Only Manual , Chapter 10, Section states: Medical necessity is established when the patient s condition is such that use of any other method of transportation is contraindicated. In any case in which some means of transportation other than an ambulance could be used without endangering the individual s health, whether or not such other transportation is actually available, no payment may be made for ambulance services. 10/15/2014 9

10 Medical Necessity Internet Only Manual , Chapter 10, Section states: It is important to note that the presence (or absence) of a physician s order for a transport by ambulance does not necessarily prove (or disprove) whether the transport was medically necessary. The ambulance service must meet all program coverage criteria in order for payment to be made. 10/15/

11 Bed Confined Internet Only Manual , Chapter 10, Section states: Bed-confinement, by itself, is neither sufficient nor is it necessary to determine the coverage for Medicare ambulance benefits. It is simply one element of the beneficiary's condition that may be taken into account in the intermediary's/carrier's determination of whether means of transport other than an ambulance were contraindicated. 10/15/

12 Bed Confined Bed confined alone does not determine medical necessity All three must be met before and after transport, not just at the time of transport: Unable to get up from bed without assistance Unable to ambulate, and Unable to sit in a chair or wheelchair Includes wheelchair, geri chair, dialysis chair and recliner 10/15/

13 Bed Confined This is NOT synonymous with: Non-ambulatory Stretcher bound or Bedbound Bedrest Bedfast Bedridden 10/15/

14 Oxygen Oxygen administration alone does not necessarily make a trip payable Documentation needs concise explanations for why the respiratory status may be compromised and why skilled personnel are needed for monitoring patient en route 10/15/

15 Oxygen Documentation needs to show: Amount of oxygen transported with Application route of oxygen The spo2 taken by EMS (not from the hospital before EMS arrived) Respiratory rate Lung sounds 10/15/

16 Oxygen Patients with chronic respiratory problems generally have lower spo2 readings than the general population. In some cases, it is contraindicated to apply/increase oxygen to achieve a higher spo2 10/15/

17 Physician Certification Statement (PCS) Does not determine medical necessity alone Completed form does not guarantee coverage 10/15/

18 Physician Certification Statement (PCS) Not required for emergency services Non-emergency transports MAY require a written order certifying medical necessity 10/15/

19 Physician Certification Statement (PCS) Advanced certification required for repetitive scheduled transports Obtain prior to transport, but no more than 60 days before the date the service is furnished 10/15/

20 Physician Certification Statement (PCS) The signature of the person signing the PCS must be legible and include a title If unable to obtain completed PCS form within 21 days Document attempts Claim can be submitted without 10/15/

21 Physician Certification Statement (PCS) Each PCS should be personalized to each patient and match the patient s condition at time of transport. Reasons for ambulance transport on the PCS must be supported by the documentation 10/15/

22 Physician Certification Statement (PCS) An addendum should not be added to the PCS to make the ambulance trip payable 10/15/

23 Covered and Non Covered Transports

24 Basic Medicare Coverage Transportation by any other means could pose a threat to the beneficiary s survival or seriously endanger their health Based on the beneficiary s medical condition at the time of transport Medical diagnosis alone may not make trip payable 10/15/

25 Basic Medicare Coverage To the nearest appropriate facility capable of providing care needed If needed, Medicare may pay for unusual circumstances requiring further distance to another appropriate facility 10/15/

26 Basic Medicare Coverage Transport by approved ambulance service For Part A coverage, ambulance services are furnished under arrangements by participating hospitals, skilled nursing facilities, and home health agencies 10/15/

27 Return Transports Usually not reimbursed Must meet medical necessity Treated and released patients could go by other means Specialized services of ambulance crew usually not required 10/15/

28 Non Covered Transports The Medicare payment benefit for ambulance services is very restricted Providers must understand the benefit and refrain from seeking Medicare payment for services that do not conform to the limited benefit requirements 10/15/

29 Non Covered Transports Claims denied as not medically necessary are beneficiary liable for payment of the bill 10/15/

30 Non Covered Transports Invalid reasons to transport by ambulance: Non-emergency situation with no other means of transportation available Neighbors, taxis, friends, relatives Stretcher/wheelchair van service not available Family requesting ambulance services 10/15/

31 Non Covered Transports Use modifier GY (statutorily excluded; beneficiary liable) if transport by an ambulance occurred but it is known it will not meet Medicare payment benefit 10/15/

32 Advance Beneficiary Notice of Non Coverage (ABN) ABN rare for Ambulance Notice to patient of possible denial - not reasonable and necessary Protects your rights and changes financial responsibility May be used for nonemergency transports Signed and dated before rendering service Modifier GA No changes allowed to form except letterhead 10/15/

33 Extenuating Circumstances Must document extenuating circumstances that prohibit transport to the closest appropriate facility Blizzard conditions Heavy fog Extensive road construction Specialist/equipment not available Hospital on diversion Beds not available 10/15/

34 Locality: Facility Locality Service area surrounding the institution Institution provides care for the illness/injury Appropriate equipment and staff for patient s condition Unusual circumstances requiring further distance to an appropriate facility must be explained in the trip notes and remarks section of the claim 10/15/

35 Transfers: Facility Transfers Medicare does not pay for transportation from one institution to another unless: Discharging institution does not have appropriate facilities for treating the patient Admitting institution was the nearest with appropriate facilities/specialists 10/15/

36 Not covered: Facility Transfers Convenience transfers (family/patient want a different facility) Transfers for a particular provider Nursing Home (NH) to NH Skilled Nursing Facility (SNF) to SNF 10/15/

37 Transports To/From Hospice Care If the medical condition of the patient at the time of transport is related to the patient s hospice diagnosis, then the claim is to be submitted to hospice If transport is unrelated to the hospice patient s terminal condition, submit with a GW modifier 10/15/

38 Ambulance Service Levels Ground and Air Transport

39 Ground Service Level Overview (refers to both land and water) HCPCS Code Short Description Long Description A0428 BLS Basic Life Support, non-emergency transport A0429 BLS-Emergency Basic Life Support, emergency transport A0426 ALS1 Advanced Life Support, non-emergency transport, level 1 A0427 ALS1-Emergency Advanced Life Support, emergency transport, level 1 A0433 ALS2 Advanced Life Support, level 2 A0434 SCT Specialty Care Transport A0432 PI Paramedic Intercept Does not apply to Noridian providers Only in New York A0425 Ground Mileage Ground mileage, per statute mile 10/15/

40 Specialty Care Transport (SCT) Internet Only Manual , Chapter 10, Section states: SCT is the interfacility transportation of a critically injured or ill beneficiary by a ground ambulance vehicle, including the provision of medically necessary supplies and services, at a level of service beyond the scope of the EMT-Paramedic. 10/15/

41 Specialty Care Transport (SCT) Use caution to avoid confusing chronic illness with critical illness or injury Must be furnished by one or more health professionals in an appropriate specialty Emergency or critical care nursing, emergency medicine, respiratory care, cardiovascular care, or a paramedic with additional training 10/15/

42 Specialty Care Transport (SCT) Generally a transfer to a higher level of care Transfers to a lower level of care, such as rehab or subacute care, generally do not meet the critically ill or injured criteria Ground services only 10/15/

43 Specialty Care Transport (SCT) Documentation must support illness/injury severity and that the health professionals are doing interventions May not qualify for SCT by itself: nurse on board or patient on a ventilator for example 10/15/

44 Air Service Level Overview HCPCS Code Short Description Long Description A0430 A0431 Fixed wing air transport Rotary wing air transport Conventional air services, transport, one way (fixed wing) Conventional air services, transport, one way (rotary wing) A0435 Air mileage, FW Fixed wing air mileage, per statute mile A0436 Air mileage, RW Rotary wing air mileage, per statute mile 10/15/

45 Air Transport Air service coverage is furnished when medical condition required immediate and rapid ambulance transport that could not have been provided by ground The point of pickup (POP) is inaccessible by land/water, or Great distances or other obstacles are involved 10/15/

46 Air Transport Special Payment Limitations (CR 7161) If ground transport would have sufficed, Medicare will pay the ground ambulance rate 10/15/

47 Mileage Beyond Closest Facility A0888 Line item for non covered mileage Need Origin/Destination modifiers and QN modifier GY modifier Is it provider liable? Leave GY off of claim 10/15/

48 Mileage Beyond Closest Facility Example Scenario: Residence to closest appropriate hospital: 14.3 miles Patient transported to a different hospital 46.8 miles from residence Bill should look like this: A0427 QNRH, 1 unit A0425 QNRH, 14.3 units A0888 QNRHGY, 32.5 units 10/15/

49 Modifiers QM = Ambulance service provided under arrangement by a provider of services QN = Ambulance services furnished directly by a provider of services 10/15/

50 Origin/Destination Modifiers D E G H I J Diagnostic or therapeutic site (other than P or H) ASC and IDTF Residential facility, domiciliary, custodial facility, assisted living, group home Hospital-based dialysis facility (ESRD) Hospital Site of transfer (airport, helicopter pad) Non hospital-based dialysis facility (ESRD) 10/15/

51 Origin/Destination Modifiers N P R S U X Skilled nursing facility (swing bed, hospice) Physician s office (freestanding ER non hospital-based, urgent care, clinics) Residence (private only) Scene of accident or acute event (origin only) Unclassified ambulance service Intermediate stop at physician s office on way to hospital (destination only) 10/15/

52 Misuse of Modifier 22 Medical Review has noticed a trending of providers using Modifier 22 on Ambulance Claims. Modifier 22 documents work required to provide a service was substantially greater than the work typically required Modifier 22 should not be appended to an Ambulance claim 10/15/

53 Medical Review Errors and Findings

54 Error: Medical Review Errors - Return Trip to SNF/Home - Many are not medically necessary Physician or Social Services ordered the trip but medical necessity not met An order alone does not allow coverage of ambulance transport for Medicare benefit payment. The patient must meet medical necessity. Submitting a Physician Certification Statement (PCS) does not guarantee payment 10/15/

55 Error: Medical Review Errors - Return Trip to SNF/Home - PCS does not give a clear indication of why an ambulance was needed PCS or ambulance crew reference the patient s admitting/acute state rather than the current condition at discharge 10/15/

56 Error: Medical Review Errors - Medical Necessity - Documentation does not support that travel by other means would endanger the patient s health Documentation does not support necessity of traveling beyond closest appropriate facility Description of the patient on the Physician Certification Statement does not match the condition in the trip sheets 10/15/

57 Medical Review Errors - Return Trips and Medical Necessity - Solution: Clear, legible documentation EMT/Paramedics need to be descriptive of the beneficiary s condition 10/15/

58 EMT/Paramedic Documentation Relevant, clear and concise facts relating to patient s condition Do not document the Physician Certification Statement verbatim into their narrative note Justify why an ambulance was the only means of transport 10/15/

59 EMT/Paramedic Documentation If it s not documented, Medicare considers it not done Re-read report for errors or omissions while information is fresh Include the place and complete addresses of point of pickup and drop-off 10/15/

60 EMT/Paramedic Documentation Poor: Possible stroke Descriptive: Temporary LOC Numbness/tingling of arm, face, leg Facial drooping Slurred speech Loss of motor function one side of body 10/15/

61 EMT/Paramedic Documentation Poor: Required restraints Alzheimer s diagnosis (billed alone may not be payable; may need other reasons) Descriptive: Patient is violent Convulsing Harmful to self or others 10/15/

62 EMT/Paramedic Documentation Poor: Myocardial infarction (MI) Descriptive: Chest pain radiating to jaw, neck, arm Unexplained chest discomfort Nausea and vomiting Profuse sweating 10/15/

63 Clearer Documentation These explanations require further clarification and/or clearer documentation to support the need for ambulance transport: Patient cannot tolerate wheelchair BLS secondary to weakness Patient has pain 10/15/

64 Clearer Documentation (continued) Patient has dementia Patient forgetful Family requests ambulance transport Needs oxygen Needs monitoring 10/15/

65 Error: Medical Review Errors - Psychiatric Transport - Psychiatric transport does not have enough information to pay the claim Solution: Document within the trip report the reason an ambulance is required, such as suicide watch, needs restraint (with explanation of why), or overdose requiring continuous monitoring 10/15/

66 Error: Medical Review Errors - Level of Service - HCPCS for level of service billed incorrectly, examples: BLS vs ALS vs SCT Emergent vs Non-emergent Air vs Ground transport 10/15/

67 Solution: Medical Review Errors - Level of Service - Service level must reflect the level of care required to care for the patient at the time of transport Documentation must support level of service billed on claim 10/15/

68 Error: Medical Review Errors - Timeliness - ADR letters not returned within requested timeframe or not at all, thus the claim is denied without documentation 10/15/

69 Solution: Medical Review Errors - Timeliness - Providers have 30 days to submit ADR letter with an additional 15 day grace period to allow for mailing delays 10/15/

70 Error: Medical Review Errors - Mileage - Documenting fractional mileage inappropriately Mileage inconsistent throughout EMS report, trip sheets and the bill Billing miles beyond nearest facility as covered units 10/15/

71 Medical Review Errors - Mileage - Solution, per Internet Only Manual , Chapter 15, Section : Miles totaling less than 100 miles: Round up to the nearest tenth of a mile E.g miles will become 99.4 units Miles totaling less than 1 mile: Include a 0 before the decimal (e.g. 0.6) 10/15/

72 Solution: Medical Review Errors - Mileage - Miles totaling 100 miles or greater: Round up to the nearest whole number Trip miles or GPS can be used Document method 10/15/

73 Solution: Medical Review Errors - Mileage - Split mileage for miles beyond nearest facility Inappropriate miles to be billed with A0888 and use GY modifier on it, unless provider liable then leave GY off If mileage not supplied, Medicare automatically uses 0.1 unit as default Accurately document mileage throughout 10/15/

74 Determining Coverage The following details help Medical Review staff in determining the medical status and stability of the beneficiary at the time of transport: Vital signs, including oxygen saturation Glasgow coma scale Orientation status IV fluids infusing during transport Medications given/infusing during transport 10/15/

75 (continued) Determining Coverage Equipment used by the patient during transport (e.g. wound vac, ventilator, feeding tube, etc.) How did the patient get to/from the ambulance gurney Assessment (neuro status, respiratory status, etc.) 10/15/

76 Questions? Provider Contact Center Phone Numbers: JE: JF: /15/

77 Resources

78 Sign Up to Get Medicare News Now! Receive the most recent Noridian and CMS news and information s sent Tuesday/Friday Simple, quick sign up Regulation and policy updates Payment and reimbursement updates Workshop and educational event notices Noridian hours of availability and related notifications JE JF 10/15/

79 CMS Resources (This is not an all-inclusive list of available resources) Internet-Only Manuals (IOMs) IOM , Medicare Benefit Policy Manual (MBPM), Chapter 10 Ambulance Services IOM , Medicare Claims Processing Manual (MCPM), Chapter 15 Ambulance 10/15/

80 CMS Resources (This is not an all-inclusive list of available resources) Medicare Learning Network (MLN) Education/Learn/Get-Training/Get-trainingpage.html CMS Connects Provider enews National Provider Calls Announcements Events MLN Educational Products 10/15/

81 CMS Connects Provider enews 10/15/

82 CMS Resources (This is not an all-inclusive list of available resources) Ambulance Services Center Type/Ambulances-Services-Center.html Locate ambulance-specific links and other helpful links Online Ambulance Booklets Quick Reference Information: Coverage and Billing Requirements for Medicare Ambulance Transports Medicare Ambulance Transports 10/15/

83 Noridian Resources (This is not an all-inclusive list of available resources) Noridian Website: JE Ambulance page: JF Ambulance page: _center/ambulance.html 10/15/

84 Other Resources (This is not an all-inclusive list of available resources) Healthcare Common Procedure Coding System (HCPCS) Manual Social Security Act (SSA) section 1862(a)(1)(A) Code of Federal Register section Coverage of Ambulance Services 10/15/

85 Thank you for attending today!