Ambulance Basics Part B Coverage Guidelines. Presented by: Medicare Part B Provider Outreach and Education (POE) November 2015

Transcription

1 Ambulance Basics Part B Coverage Guidelines Presented by: Medicare Part B Provider Outreach and Education (POE) November 2015

2 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 2015 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.

3 Acronyms Acronym ALS BLS CFR EMS HCPCS IOM OIG SNF CB Description Advanced Life Support Basic Life Support Code of Federal Regulations Emergency Medical Services Healthcare Common Procedure Coding System Internet Only Manual Office of Inspector General Skilled Nursing Facility Consolidated Billing November

4 Agenda Ambulance Coverage Guidelines Vehicle and Staffing Requirements Origin/Destinations Mileage Billing Requirements Noteworthy & Resources November

5 Objective Provide Ambulance suppliers with a better understanding of basic Medicare Part B coverage guidelines Reduce ambulance billing errors and paid error rates No documentation questions/information No documentation/review findings in presentation Will send in next 3 days CEU, both Basics and Documentation PDF November

6 Ambulance Coverage Guidelines

7 Part B Ambulance Coverage If patient can travel by other means safely.. Ambulance transport is non-covered November

8 Transportation Benefit Only Services covered only if other means of transportation would endanger the beneficiary s health 42 CFR IOM , Chapter 10 Sections 10.2, 10.3 & 10.4 Medical Necessity Requirements November

9 Transportation Benefit If no transport, no need to bill Medicare Bill patient for services provided Their financial liability No Advance Beneficiary Notice of Non- Coverage (ABN) needed May use for non-emergent voluntarily November

10 Dialysis Transports Not guaranteed benefit; patient must meet to ambulance transport medical necessity Could have traveled by other means? OIG report Although a dialysis facility is a covered destination, transports to/from do not usually meet medical coverage requirements 2013 report Ambulance was paid $800,000 for fraudulent billed routine, non-emergency transports; not medically necessary monies recouped November

11 Bed Confinement All 3 must be met for bed confinement Unable to get up from bed without assistance; and Unable to ambulate; and Unable to sit in a chair or wheelchair Bed confined (by itself), may not warrant transport; need medical condition requiring monitoring by EMT/Paramedic Not synonymous with bedrest, non-ambulatory, bedridden, etc. IOM , Chapter 10, Section November

12 Dementia or Alzheimer s Diagnosis alone doesn t warrant coverage Must meet all coverage criteria Other transportation contraindicated Past behavior doesn t warrant current transport Document condition at time of transport November

13 Oxygen Oxygen administration alone does not necessarily allow transport; what is Application route Sp02 taken by EMT/Paramedic Respiratory rate and lung sounds Documentation needs concise explanations why respiratory status may be compromised Why skilled personnel needed for monitoring patient enroute November

14 Services Not in U.S. Upon point of entry into the U.S. Patient-loaded Ambulance mileage in connection with (and during), a foreign inpatient hospital stay may be covered Medicare B News #253, April 15, 2009 Shipboard Services not Provided Within the U.S. CR 6327 November

15 Vehicle & Facility Requirements

16 Vehicle Requirements Designed for response to Medical emergencies Patients with acute medical conditions Comply with State and local laws Licensing and certification Minimum equipment requirements IOM , Chapter 10, 10.1 November

17 Staffing Requirements BLS 2 People 1 + EMT ALS 2 people 1 + EMT Intermediate or EMT - Paramedic Enroll with CMS 855B - provide certification requirements Each crew member has certified training with pertinent state/local licenses and permits for the vehicle/equipment November

18 Transport Categories 7 ground/water ambulance 2 air ambulance Ground Transport Rotary Wing IOM 100-2, Chapter November

19 Service Levels Overview Ground refers to both land and water Seven levels of service A0428 BLS (Basic Life Support) A0429 BLS Emergency A0426 ALS1 (Advanced Life Support) A0427 ALS1 Emergency A0433 ALS2 (3 separate medications by IV) A0434 SCT (Specialty Care Transport) PI (Paramedic Intercept) does not apply to Noridian providers only New York November

20 Does Not Determine ALS2 Level Medications Oral, Injections, Nebulized Crystalloid fluids 5% dextrose in water Saline Lactated Ringer s Oxygen Aspirin November

21 Air Ambulance A0430 Fixed Wing / A0431 Rotary Wing Patient s condition necessitates Rapid transport Great distance or obstacles Inaccessible by land or water vehicle Covered destinations Hospital Site of transfer, ending at hospital November

22 Origin/Destination

23 Covered Destinations Medicare covers ambulance transports to Hospital Critical Access Hospital (CAH) Transports ONLY COVERED if patient s health is in danger if other transportation used Skilled Nursing Facility (SNF) Beneficiary s home Dialysis facility Physician s office temporarily enroute November

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

25 Origin/Destination Modifiers 2 Mod Description N P R S U X Skilled nursing facility (swing bed, rehabilitation, hospice) Physician s office (includes freestanding ER facility - non-hospital based) Residence (private only) Scene of accident or acute event Unclassified ambulance service Intermediate stop at physician s office on way to hospital (destination only) November

26 Multiple Patient Transports Not all transported have to be Medicare patients Bill full trip charge and Medicare will calculate Bill Origin/Destination/GM modifier E.g. A0428 RH GM 2 patients = 75% each of base rate 3 patients = 60% each of base rate Bill patient loaded mileage Origin/Destination modifier with GM E.g. A0425 RH GM Mileage split for each November

27 Hospice Patients Hospice related = bill hospice Unrelated to hospice = bill Part B Append GW modifier A0428 RH GW A0425 RH GW 1 25 November

28 Bill Part B or SNF? Bill SNF per Consolidated Billing (CB): Same day SNF to SNF transfer (Part A stay) Physician s office round trip Independent Diagnostic Testing Facility (IDTF) Cancer Treatment Center Radiation Therapy Center Wound Care Center CR8408 denies SNF- SNF when beneficiary in Part A stay Bill Part B: SNF admission SNF discharge to home for home health (HHA) plan of care SNF-SNF, not in Part A stay End Stage Renal Disease (ESRD) facility Outpatient hospital: Cardiac catheterization CT/MRI scans Angiography Lymphatic/venous Radiology therapy PEG tubes (insertion, removal, replacement) November

29 Auto Denial - Origin/Destination Modifiers DD SD XE JI IN HP DR ES SS ED XD GG NI NN IP ER GS XS GD DE HG GJ PN JP IR HS GX HD EE JG IJ SN NP PR IS HX ID IE PG JJ XN PP RR JS IX JD PE SG PJ DP RP SR NS JX PD RE XG SJ EP SP XR PS PX RD SE GI XJ GP XP DS RS XX November

30 Death Pronouncement (Ground/Air) Time of death pronouncement Before dispatch After dispatch Before patient loading Before/after arrival POP After pickup prior to or upon arrival at receiving facility Medicare payment decision None Appropriate base rate (depending if air/ground) No mileage or rural adjustment Medically necessary level of service furnished November

31 Death Pronouncement (Ground) 2 Pronounced dead after ambulance called/ before pick-up Appropriate HCPCS base rate billed A0428 (BLS; non-emergency transport) Origin/Destination modifiers Append QL modifier Bill without mileage or rural adjustments Vehicle dispatch DOS to point of pickup Need time of death & time of call November

32 Mileage

33 Mileage Only local ambulance transportation Covered to nearest appropriate facility Document exceptions Comments field (NTE-02) or Item 19 IOM , Chapter November

34 Mileage (Patient Loaded) If mileage not indicated, defaults "0.1" Ground/Water (A0425) Mileage 100 miles Rounded up nearest tenth of a mile (E.g. 99.9) Mileage 100 miles Round up nearest mile (E.g. 299) Air (round up nearest mile) A0435 Fixed Wing A0436 Rotary Wing November

35 Mileage Beyond Closest Facility A line item for noncovered mileage E.g. Family would like patient to be closer Need Origin/Destination modifiers GY modifier Is Ambulance liable? Leave GY off claim E.g. A0888HHGY Patient liability November

36 Extenuating Circumstances Document extenuating circumstances that may prohibit transport to closest facility Blizzard conditions Heavy fog Extensive road construction Specialist/equipment not available at closest hospital Hospital on diversion (no beds, weather, not taking patients) November

37 Billing Requirements

38 General Billing Overview HCPCS must reflect type of service the beneficiary received, not vehicle used Must accept assignment Check goes to your office (not the patient) Accept Medicare s allowable payment ONLY bill patient unmet Part B deductible, Part B coinsurance and non-covered charges Cannot unbundle non-covered supplies/costs Ambulance has own fee schedule November

39 CMS 1500/Electronic Equivalent Item 19 = continue to give brief narratives Blood pressure, pulse, chest pain, dizziness, etc. Item 21 = up to 12 diagnoses Even though EMTs/Paramedics don t diagnose, use condition codes and ICD-10 Item 24A = to/from date of service Item 24B = place of service 41 (ground) or 42 (air) Item 24E = link only one diagnosis from 21 Item 24F = charges Item 24G = base rate number of services (always 1) Miles = patient loaded miles November

40 CMS-1500 Item 32 Ambulance suppliers required to submit both origination and destination information Originating site information entered in Item 32 Recommended providers list name of facility, city, state and ZIP code Street address not required If not enough space for destination information in Item 32, utilize Item 19 narrative Origin/destination modifiers identify type of facility for beneficiary transport Beyond closest facility, briefly identify why Item 19 narrative or electronic equivalent November

41 Special Edition (SE) 1029 A. Use CMS Medical Conditions List clm104c15.pdf B. Use ICD-10 diagnosis code provided by treating physician or practitioner Effective 10/1/15, new diagnoses implemented making ICD-9 obsolete November

42 Paper Claim Submission Claims received by Noridian as of 10/1/2015, ICD- 9/ICD-10 indicator will be required If indicator is left blank, claim will deny Resubmit claim with indicator 9 for ICD-9 codes or a 0 (zero) for ICD-10 diagnoses Enter the ICD indicator as a single digit between the vertical, dotted lines November

43 Capture Employee s Signatures Typed name Employment dates Position/Credentials Signature Initials Retain with internal Compliance Manual EMPLOYEE SIGNATURE LOG Name: Emmett M. Turner Employed: From: 02/01/2004 To: 10/01/2015 Position: Emergency Medical Technician Signature & Initials: Emmett M. Turner EMT November

44 No Transport/Refused Transport Billing Medicare for denial, use A0998 Append modifier RR or SS with GY Comments field (NTE-02) or Item 19 Enter No transport or Patient refused transport Denied Patient Responsibility (PR) Per CR 7489 January 2012 Instructions to Accept and Process All Ambulance Transportation Healthcare Common Procedure Coding System (HCPCS) Codes November

45 Advance Beneficiary Notice of Non- Coverage (ABN) Never use under patient duress or emergency ABN rare for Ambulance Official form CMS-R-131 (03/11 current) Signed before transport Original=office file Copy=beneficiary Not needed for statutorily excluded items/services CR 7821 May be used for nonemergency transports BEFORE transport Notice to patient of possible denial Protects provider rights; changing financial responsibility dicare.com/partb/forms/ docs /cms-r-131.pdf November

46 Green EMT/Paramedic fills out Medicare does not pay Convenience of physician or family To physician s office Mileage beyond nearest facility When other transportation could have been used without endangering your health Blue Patient or guardian must fill out November

47 Noncovered Modifiers Modifier GA Description ABN rarely used in Ambulance Non-emergency situation only Never under patient duress GY Service statutorily excluded or does not meet definition of Medicare benefit (non transport) Return trips November

48 FYI: Beneficiary's Ambulance Handbook Excerpt "If the ambulance company believes that Medicare won't pay for your nonemergency ambulance service, they might ask you to sign an Advance Beneficiary Notice (ABN). If you sign the ABN, you are responsible for paying for the cost of the trip, if Medicare doesn't pay." November

49 Ambulance Common Errors Selecting incorrect HCPCS code ALS vs. BLS Origin and destination modifiers Not all combinations covered Enter origin/destination modifiers on all lines Pattern of inappropriate modifiers to receive payment may result in fraud referral Billing H (hospital), when actually transported to freestanding IDTF (D) November

50 MR Claim Review Medical Review found 52.88% of claims contained errors after reviewing trip reports A0425 (mileage overbilled per MapQuest, etc.) A0426 (critically ill/injured unsupported from hospital to long term acute care facility/snf) A0427 (higher level of care not supported) A0428 (downcoded-notes not supported) A0434 (SCT did not support higher care level) November

51 Noteworthy & Resources

52 CMS Resources IOM Benefit Policy Manual Chapter 10 Ambulance Services IOM Claims Processing Manual Chapter 15 Ambulance Articles based on various CMS MLN articles Type/Ambulances-Services-Center.html Fee Schedule, open door forums, articles, etc. November

53 Ambulance Services Booklet November

54 Ambulance Fee Schedule 5 page booklet November utreach-and- Education/Medicare- Learning-Network- MLN/MLNProducts/D ownloads/ambulance FeeSched_508.pdf November

55 CEU Reminder Attend entire workshop to earn CEU(s) Take short polling survey Pops up after closing out of webinar CEU ed 3 days after presentation Earn 1.0 CEU today No password/index number needed for AAPC PDF presentation ed again with CEU Q/A posted after 30 business days November

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