Chapter 3: Ambulance Services

Transcription

1 Payment Plicies fr Healthcare Services Prvided t Injured Wrkers and Crime Victims Effective July 1, 2014 Link: Lk fr pssible updates and crrectins t these payment plicies at: Table f cntents Page Definitins Payment plicies: All ambulance services Arrival f multiple prviders Emergency air ambulance transprt Multiple patient transprtatin Prper facilities Mre inf: Related tpics CPT cdes and descriptins nly are 2013 American Medical Assciatin 3-1

2 Payment Plicies Definitins Bed cnfined criteria: The wrker is: Unable t get up frm bed withut assistance, and Unable t ambulate, and Unable t sit in a chair r wheelchair. Destinatin: Nearest place f prper treatment. HCPCS cde mdifier mentined in this chapter: GM Multiple patients n ne ambulance trip Laded miles: Miles traveled frm the pickup f the wrker(s) t their arrival at the destinatin. 3-2 CPT cdes and descriptins nly are 2013 American Medical Assciatin

3 Payment Plicies Payment plicy: All ambulance services (See definitins f laded miles and destinatin in Definitins at the beginning f this chapter.) When these services are paid Ambulance services are paid when the injury t the wrker is s serius that use f any ther methd f transprtatin is cntraindicated. Payment is based n the level f medically necessary services prvided, nt nly n the vehicle used. Hw mileage is paid The insurer pays fr mileage (grund and/r air) based nly n laded miles, which are the miles traveled frm the pickup f the wrker(s) t their arrival at the destinatin. Nte: The destinatin is defined as the nearest place f prper treatment. Vehicle and crew requirements T be eligible t be paid fr ambulance services fr wrkers, the prvider must meet the criteria fr vehicles and crews established in WAC Emergency Medical Services and Trauma Care Systems and ther requirements as established by the Washingtn State Department f Health fr emergency medical services. Links: Key sectins f this WAC are: General: WAC Licenses required, Grund ambulance vehicle requirements: WAC Grund ambulance vehicle standards, WAC Grund ambulance and aid vehicles Equipment, WAC Grund ambulance and aid vehicles-- Cmmunicatins equipment, CPT cdes and descriptins nly are 2013 American Medical Assciatin 3-3

4 Payment Plicies WAC Trauma verificatin f prehspital EMS services, Air ambulance services: WAC Air ambulance services, Persnnel: WAC Authrized care, Washingtn State Department f Health, Office f Emergency Medical Services Certificatin Requirements Guidelines. Services that can be billed HCPCS cde Descriptin Fee schedule A0425 Grund mileage, per statute mile $13.23 per mile A0426 A0427 A0428 A0429 A0430 A0431 Ambulance service, advanced life supprt, nnemergency transprt, level 1 (ALS 1) Ambulance service, advanced life supprt, level 1 (ALS 1-emergency) Ambulance service, basic life supprt, nnemergency transprt (BLS) Ambulance service, basic life supprt, emergency transprt (BLS emergency) Ambulance service, cnventinal air services, transprt, ne way (fixed wing) Ambulance service, cnventinal air services, transprt, ne way (rtary wing) $ $ $ $ $5, $6, A0433 Advanced Life Supprt, Level 2 (ALS 2) $ A0434 Specialty care transprt (SCT) $1, A0435 Fixed wing air mileage, per statute mile $32.51 A0436 Rtary wing air mileage, per statute mile $75.54 per mile A0999 Unlisted ambulance service By reprt restrictins: (1) Reviewed t determine if a mre apprpriate billing cde is available, and (2) Reviewed t determine if medically necessary. 3-4 CPT cdes and descriptins nly are 2013 American Medical Assciatin

5 Payment Plicies Payment plicy: Arrival f multiple prviders Payment limits When multiple prviders respnd t a call fr services: Only the prvider that transprts the wrker(s) is eligible t be paid fr the services prvided, and N payment is made t the ther prvider(s). CPT cdes and descriptins nly are 2013 American Medical Assciatin 3-5

6 Payment Plicies Payment plicy: Emergency air ambulance transprt Payment limits Air ambulance transprtatin services, either by helicpter r fixed wing aircraft, will be paid nly if: The wrker s medical cnditin requires immediate and rapid ambulance transprtatin that culdn t have been prvided by grund ambulance, r The pint f pickup is inaccessible by grund vehicle, r Great distances r ther bstacles are invlved in getting the wrker t the nearest place f prper treatment. 3-6 CPT cdes and descriptins nly are 2013 American Medical Assciatin

7 Payment Plicies Payment plicy: Multiple patient transprtatin Hw these services are paid The insurer pays the apprpriate base rate fr each wrker transprted by the same ambulance. When multiple wrkers are transprted in the same ambulance, the mileage will be prrated equally amng all the wrkers transprted. Requirements fr billing The prvider is respnsible fr prrating mileage billing cdes based n the number f wrkers transprted n the single ambulance trip. The prvider must use HCPCS cde mdifier GM (Multiple patients n ne ambulance trip) fr the apprpriate mileage billing cdes. CPT cdes and descriptins nly are 2013 American Medical Assciatin 3-7

8 Payment Plicies Payment plicy: Nnemergency transprt Wh may arrange fr these services Only medical prviders may arrange fr nnemergency ambulance transprtatin. Nte: Wrkers may nt arrange nnemergency ambulance transprtatin. Medical necessity requirements Nnemergency transprtatin by ambulance is apprpriate if: The wrker is bed cnfined (see bed cnfined criteria, belw), and it is dcumented that the wrker s accepted medical cnditin is such that ther methds f transprtatin are cntraindicated, r If the wrker s accepted medical cnditin, regardless f bed cnfinement, is such that transprtatin by ambulance is medically required. Nte: Bed cnfined criteria are that the wrker is: Unable t get up frm bed withut assistance, and Unable t ambulate, and Unable t sit in a chair r wheelchair. Nnemergency transprtatin may be prvided n a scheduled (repetitive r nnrepetitive) r unscheduled basis: Scheduled, nnemergency transprtatin may be repetitive (fr example, services regularly prvided fr diagnsis r treatment f the wrker s accepted medical cnditin) r nnrepetitive (fr example, single time need). Unscheduled services generally pertain t nnemergency transprtatin fr medically necessary services. Nte: The insurer reserves the right t perfrm a pst audit n any nnemergency ambulance transprtatin billing t ensure medical necessity requirements are met. 3-8 CPT cdes and descriptins nly are 2013 American Medical Assciatin

9 Payment Plicies Payment plicy: Prper facilities What makes a facility a place f prper treatment T be a place f prper treatment, the facility must be generally equipped t prvide the needed medical care fr the wrker. A facility isn t cnsidered a place f prper treatment if n bed is available when inpatient medical services are required. Payment limits The insurer pays the prvider fr ambulance services t the nearest place f prper treatment. CPT cdes and descriptins nly are 2013 American Medical Assciatin 3-9

10 Payment Plicies Links: Related tpics If yu re lking fr mre infrmatin abut Administrative rules (Washingtn state laws) fr ambulance services Becming an L&I prvider Then g here: Washingtn Administrative Cde (WAC) : L&I s website: Billing instructins and frms Chapter 2: Infrmatin fr All Prviders Fee schedules fr all healthcare prfessinal services (including ambulance services) L&I s website: Need mre help? Call L&I s Prvider Htline at CPT cdes and descriptins nly are 2013 American Medical Assciatin