Tennessee Ambulance Services Association Conference

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1 Tennessee Ambulance Services Association Conference Nashville, TN October 7, 2014 Clinical Education Presented by Julia McKinley, RN, MAED Provider Outreach and Education

2 Disclaimers This resource is not a legal document. The presentation was prepared as a tool to assist providers and was current at the time of creation. Responsibility for correct claims submission lies with the provider of services. Reproduction of this material for profit is prohibited; providers are encouraged to share this education with staff. American Medical Association (AMA) Current Procedural Terminology (CPT ) Copyright 2013 and trademark of the AMA All Rights Reserved 2

3 Topics Medical Review (MR) Updates/Reminders Medical Review/Documentation o Medical Necessity o Beneficiary Signatures Comprehensive Error Rate Testing (CERT) CMS and Cahaba GBA Resources 3

4 Medical Review Updates / Reminders 4

5 Ambulance Review Results Medical Review : CERT Special Project: HCPCS A0427 January 2014 Part B Widespread Targeted Review Results for Ambulance Emergency Transport Error rates: o Alabama = 49% o Georgia = 54% o Tennessee = 57% Prepayment widespread targeted review will continue for identified errors: o o o o Lack of a beneficiary acknowledgement form Documentation did not support medical necessity for ambulance transport Billed date of service not included in the medical record Medical record documentation not submitted timely Part B Widespread Targeted Review Results for Ambulance Emergency Transport- HCPCS A

6 Current Prepayment Log Current Prepayment Medical Review Log September / October 2014 Review Description Ambulance Service; ALS, Emergency Ambulance Service; BLS, Non-Emergency Coding A0427 A0428 Medical Review Current Prepayment Log: 6

7 From Medical Review Frequent Documentation Errors: No beneficiary form submitted Missing signatures on a beneficiary form No valid reason documented as to why beneficiary was unable to sign Lack of documentation that paint a picture of why the patient requires transport MR - September

8 From Medical Review Frequent Documentation Errors Illegible hand writing - can not read the record/signature Reasonable and medical necessity not documented Incorrect codes submitted Electronic records with no electronic signature Medical records not received MR - September

9 Additional Documentation Request (ADR) Reminder: Submitting Requested Documentation Include ALL requested documentation outlined in ADR letter Include copy of the ADR letter with documentation Mail to address listed on the ADR letter Electronic Submission (esmd) Fax or CD Multiple ADR responses Pair each ADR request with the applicable documentation Do not submit replacement/duplicate claims if claims are pending medical review 9

10 Late Submission or No Records o Major Errors Seen o No medical records submitted o Late submission of records o What Happens if No Records? o Claims denied o Increased error rates o Prolonged probe review o Providers continue on review for no record 10

11 Timely Record Submission Prevent Error Message no records received o Timeframe for Documentation Submission o 30 calendar days from date of ADR request o After 45 th day, claim is denied Insufficient documentation 11

12 Comparative Billing Reports (CBR) Educational CBRs Provider specific request Compare specific billing practice Educational tool CBR Required Information: Provider Transaction Access Number (PTAN) or Provider Identifying Number (PIN) Report fee is $20.00 per report Separate required fee for multiple provider reports CMS Pub , Medicare Program Integrity Manual, Chapter 3, Section

13 Medical Review 13

14 The Medical Review Program Prevent improper payments in the Medicare FFS Program Data Driven Program May evaluate medical records/claims Review for compliance Program Integrity Manual (PIM) Publication Medical Review Program 14

15 Local Coverage Determination (LCD) Transportation Services: Ambulance Local Coverage Determination (LCD) The LCD contain Medical Necessity guidelines LCD Excerpt: General Information - Documentations Requirements - section (C): Beneficiary Financial Signature Requirements: Medicare requires the signature of the beneficiary, or that of his or her representative, for both the purpose of accepting assignment and submitting a claim to Medicare. Medicare does not require that the signature to authorize claim submission be obtained at the time of transport for the purpose of accepting assignment of Medicare payment for ambulance benefits. When a provider/supplier is unable to obtain the signature of the beneficiary, or that of his or her representative, at the Medicare time of transport, it may obtain this signature any time prior to submitting the claim to Medicare for payment. Refer to the Medicare Benefit Policy Manual (Pub ), Chapter 10, Section for complete details of the Beneficiary Signature Requirements. The General Information section list information to submit if medical records are requested for review. 15

16 Medical Necessity 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. In all cases, the appropriate documentation must be kept on file and, upon request, presented to Medicare. 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. The reason for the ambulance transport must be medically necessary; the transport must be to obtain a Medicare covered service, or to return from such a service. Benefit Policy Manual Necessity for the Service 16

17 Signature Requirements MLN Matters Special Edition Article 1419: Medicare Signature Requirements - Educational Resources for Health Care Professionals o Resources are related to signature requirements for Medicare-covered services Change Request (CR) 6698: Signature Requirements for Medical Review Purposes o For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author: o o Hand written (legible) Electronic signature Stamp signatures - exception o Change Request Use of Rubber Stamp o The Rehabilitation Act of 1973 o Effective June 18, 2013 Medicare Signature Requirements - Educational Resources for Health Care Professionals 17

18 Documentation: Ambulance Services Trip record to include: o Ensure records are signed o Follow CMS Beneficiary Signature Requirements o Detailed statement of the condition necessitating the ambulance o Point of pick-up (identify place and complete address) o Number of loaded miles/cost per mile/mileage charge o Minimal or base charge and charge for special items or services with an explanation o Rationale for condition (bed confined, if applicable) o Any further documentation that supports the medical necessity of ambulance transport (e.g., emergency room report) o Hospital discharge/transfer summary, if applicable Local Coverage Determination - L30022: Transportation Services - Ambulance 18

19 Documentation of Bed Confinement Non-emergency transports All three components required: o If condition is bed confinement, before and after the transport, the patient cannot: Get up from bed without assistance; AND Ambulate; AND Sit in a chair or wheelchair 19

20 From Appeals Correct Use of GY Modifier If an ambulance transport is medically necessary, do not append the GY modifier Errors of GY modifier appended incorrectly seen GY modifier will auto deny Statutorily excluded service 20

21 Comprehensive Error Rate Testing (CERT) Protect Medicare Trust Fund Measure Correct Claim Process/Payment Assess Evaluate Contractor and Provider 21

22 Part B CERT: September 2014 Type Codes Error and Regulations Ambulance Services CPT A0425 HN A0428 HN Insufficient Documentation CERT Disagree per: SSA 1833(e), 42 CFR Â (a), 42 CFR Â (d)(3) (Special rule for nonemergency ambulance services that are either unscheduled or that are scheduled on a non-repetitive basis), PUB 100-8, Chap 3 Â (Additional Documentation Requests), PUB Chapter 10 Â (necessity for the service), Â (reasonableness of the ambulance trip), and LCD Transportation Services: Ambulance (L30022), revision effective 08/01/2012. Rationale The billed transport and mileage is not reasonable and necessary. Submitted includes: Non emergency ambulance transport record for transport 1.7 loaded miles from inpatient hospital to SNF documenting alert and oriented x3, normal exam findings with the exception of lower extremity weakness, that states, Ambulance transport was not medically necessary because patient can ride safely in W/C. Patient was secured to the stretcher with three straps and transported without incident. The billed transport and mileage is not reasonable and necessary per LCD. 22

23 Help Prevent Errors? Conduct self audits CMS rules and regulations, Local Coverage Determination (LCD) and National Coverage Determination (NCD) Comply with CMS guidelines; obtain required beneficiary or representative signature Medical record/run sheet: document complete, accurate, reasonable and medically necessary services Sign documentation with a handwritten or electronic signature Submit claims correctly Correct HCPCS codes Correct modifiers Submit requested medical records timely 23

24 References CMS Ambulance Service Center: CMS Manual References: Medicare Benefit Policy Manual; Chapter 10 Section Necessity and Reasonableness Section Documentation Requirements Section 10.3 Destination Section 30.1 Categories of Ambulance Services Medicare Claims Processing Manual; Chapter 15 - Ambulance Section 20.1 Fee Schedule Section 30 General Billing Guidelines o Section 20.2 Mileage o Section 20.5 Documentation Section 30 General Billing Guidelines Quick Reference Ambulance Booklet: Requirements-Medicare-Ambulance-Transports-Educational-Tool-ICN pdf Ambulance CEUs for MLN s web-based training courses: 24

25 Questions Thank You! Provider Contact Center Alabama, Georgia and Tennessee Providers:

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