Medical Review Ambulance Presentation. Part B

Transcription

1 Medical Review Ambulance Presentation Part B

2 DISCLAIMER This information release is the property of Noridian Healthcare Solutions, LLC (Noridian). 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. July

3 AGENDA Medical Necessity PCS Provider Signatures Covered vs. Non Covered Transports Service Level Overview Modifiers Challenges and Solutions Medical Reviews and Findings Resources July

4 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. July

5 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. July

6 Oxygen Oxygen administration alone does not necessarily make trip payable Other allowable transport reasons: Syncope Acute Dyspnea not chronic Possible pulmonary embolus Extreme shortness of breath July

7 Physician Certification Statement (PCS) Part B non-emergency transports require written order or PCS Certifying medical necessity Obtain PRIOR to transport, no sooner than 60 days Required for repetitive scheduled trips Form does not guarantee coverage Unable to obtain signed form from physician for nonrepetitive transports within 21 days? Complete PCS form, submit claim and document attempts made to physician s office 42 C.F.R July

8 Physician Certification Statement (PCS) The signature of the person signing the PCS must be legible and include a title. Each PCS should be personalized with the information from each beneficiary. Medical Review often sees certifications with bed confined, when on the trip report the beneficiary is sitting in a chair. Information must match the actual patient condition. Nothing should be added to cert to try to make an ambulance trip payable. July

9 Provider Signature Requriements Signature Guidelines for Medical Review Purposes article. Medicare B News #263 dated July, 2010 CR Ambulance must adhere to the provider signature requirements; same as all Medicare providers. Medical Review sees incomplete signatures on documentation, or no signatures by EMT and/or Paramedic on the trip reports. The ambulance crew should also include their credentials. July

10 Return Transports Return Ambulance Transports: Usually not reimbursed Must meet medical necessity Specialized services of ambulance crew usually not required Treated/released; could go by other means Many are routine scheduled dialysis trips Use modifier GY (statutorily excluded; beneficiary liable) July

11 Non Covered Transports The Medicare payment benefit for ambulance services is very restricted Ambulance suppliers must understand the benefit and refrain from seeking Medicare payment for services that do not conform to the limited benefit requirements July

12 Non Covered Transports (2) Medicare covers ambulance services only if furnished to a beneficiary whose medical condition at the time of transport is such that transportation by other means would endanger the patient s health A patient whose condition permits transport in any type of vehicle other than an ambulance does not qualify for Medicare payment. as stated in regulation July

13 Non-Covered Transports Invalid reasons to transport by ambulance: Non-emergency situation - no other means of transportation available Cabulance/Stretch car not available Patient could have transported home by Taxi Friend Neighbor Relative Bus, etc. July

14 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. July

15 Bed Confined (2) Bed confined does not determine medical necessity by itself All three must be met: Unable to get up from bed Unable to ambulate Unable to sit in a chair Including Geri chair/wheelchair/dialysis chair/recliner July

16 Bed Confined (3) NOT synonymous with bed confined: Non-ambulatory Stretcher bound Bed rest Bed fast Bed confined before and after the transport, not just at the time of the trip July

17 Facility Transfers Medicare doesn t pay for transportation from one institution to another unless: Discharging institution does not have appropriate facilities for treating patient Admitting institution was the nearest with appropriate facilities/specialists Not covered: Convenience transfers (family/patient wants closer facility) or for a particular provider. Skilled Nursing Facility (SNF) to SNF Nursing Home (NH) to NH July

18 Transporting to/from Hospice Care If the medical condition of the patient at the time of transport is related to the patients Hospice diagnosis, then the claim must be submitted to Hospice. If unrelated, submit with a GW modifier. July

19 Physician s Office Modifier P should be used for Physician s Office and not Modifiers H or D. To: Not covered, unless an emergency stop, to stabilize patient on way to hospital Bill with destination modifier (X) From: Ambulance reimbursed for emergency transports to hospital (e.g. severe dehydration) July

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

21 Specialty Care Transport (SCT) Intrafacility (hospital/hospital or hospital/snf) Generally for a higher level of care Critically injured/ill Defined as: A patient who is experiencing an acute lifethreatening episode or who is believed to be in imminent danger of such an episode. A critically ill/injured patient is medically unstable and, if not treated, likely to decline Use caution in confusing chronic illnesses with critically ill or injured Beyond scope of paramedic/above paramedic expertise level Ground services only (A0434) Documentation must support illness/injury severity May not qualify for SCT by itself: Nurse on board, Patient on ventilator July

22 Specialty Care Transport (SCT) IOM , Chapter 10, Section Transfers that are intrafacility (same parent company) would be Part A Coverage. Intra-campus transfers (between different departments of the same hospital even when located in separate buildings would be Part A. Transfers to a lower level of care such as rehab or subacute care generally do not meet the critically ill or injured criteria. July

23 Origin/Destination Modifiers D - Diagnostic/therapeutic site (other than P/H) ASC and IDTF E - Residential facility, domiciliary, custodial facility, assisted living G - Hospital-based dialysis facility (ESRD) H - Hospital I - Site of transfer (airport, helicopter pad) J - Non hospital-based dialysis facility (ESRD) N - Skilled nursing facility (swing bed) P - Physician s office (freestanding ER nonhospital based, urgent care, clinics) July

24 Origin/Destination Modifiers R Residence (private only) S Scene of accident or acute event (origin only) U Unclassified ambulance service X Intermediate stop at physician s office on way to hospital (destination only) July

25 Origin/Destination Modifiers Make sure to use the appropriate modifiers for the origin and destination. R is for private residence only E is for facilities such as a group home or assisted living. Do not use H or D for a physician s office. Do not use H for a facility such as outpatient Radiation or an outpatient dialysis unit. July

26 Automated Prepayment Ambulance Edits Effective August 25, 2014 Noridian will implement automated prepayment edits to deny claims billed by ambulance suppliers with certain modifier combinations.

27 Modifier Combinations DD IG XN DS ED JG DP ES GD PG EP GS HD SG GP HS ID XG HP IS JD GI IP JS PD II JP NS RD JI NP PS SD NI PP RS

28 Modifier Combinations cont XD GJ RP SS DE IJ SP XS EE JJ XP GX IE PJ DR HX PE SJ ER IX RE XJ IR JX SE IN PR PX XE NN RR XX GG PN SR HG SN XR July

29 Rationale for auto denial of modifier combinations Per IOM , chapter 10, section 20: Payment may be made for expenses incurred by a patient for ambulance services for transports between the following points: From patient's residence (or other place where need arose) to hospital or Skilled Nursing Facility (SNF). Skilled nursing facility to a hospital or hospital to a skilled nursing facility. Hospital to hospital or SNF to SNF.

30 Denied modifier combinations From a hospital or SNF to patient's residence. Round trip for hospital or participating SNF inpatients to the nearest hospital or nonhospital treatment facility. Condition met if the reasonable and necessary diagnostic or therapeutic service required by patient s condition is not available at the institution where the beneficiary is an inpatient.

31 Noncovered Modifiers Modifier GA: ABN rarely used in ambulance, this would be for non emergency situations, never under patient duress. GY: Service statutorily excluded or does not meet the definition of Medicare benefit. This would be for many return trips. If the patient is capable of being transported by other means, the GY modifier is appropriate and must be billed. July

32 Medical Review Errors Return trip to SNF/Home Noridian sees many return transports from hospital to SNF/Home not medically necessary Physician, RN, or Social Services ordered trips Cert often does not give clear indication of why ambulance needed Confusing because patient is liable for the bill July

33 Challenges and Solutions Challenge Psychiatric transport does not have information to pay the initial claim Solution Reason for transport must be documented within the trip report Suicide watch Needs restraints Overdose requiring monitoring. July

34 Mental Health Transports Transport is court ordered for a mental health hold. Bill the ambulance transport to the ordering court, not to Medicare July

35 Challenges and Solutions Challenge Ventilator dependent patient Transported for return to their home May require suctioning BLS or ALS Solution Medicare considers this scenario as BLS non-emergent July

36 Medical Review Findings July

37 JF Ground Ambulance Specific Review tb/coverage/ July

38 JE /jeb/cert-review/mr/notificationsfindings July

39 Medical Review Errors Level of Service errors ALS vs. BLS Emergent vs. Non-Emergent Documentation must support billed level Other billing errors: Billing mileage past the nearest appropriate facility. Mileage needs to be split and inappropriate miles billed with A0888 ADS/ADR letters not returned within 45 days, the claim is denied July

40 Medical Review Errors Services not Reasonable and Necessary Documentation does not support travel by other means endangering patient s health Trip to hospital necessary, return trip was not Documentation does not support necessity of traveling beyond closest available facility Description of the beneficiary on the PCS does not match the patient's condition in the trip report. July

41 Medical Review Findings Often the PCS and the trip report do not match EMT/Paramedics need to be descriptive of the beneficiaries condition -do not use dementia, instead describe the patient's condition: uncooperative, hitting out, impulsive, trying to crawl off the gurney, picking at oxygen Scheduled repetitive transports (usually dialysis), PCS submitted is not guarantee of payment Does the patient need assistance by a skilled clinician, or by a friend or family member July

42 Medical Review Findings The following details help the Medical Review staff in determining the patient s medical status and stability at the time of transport: Vital signs, including Oxygen Saturations Glasgow Coma Scale IV fluids infusing during transport Medications infusing during transport Equipment used by the patient during transport (i.e. wound vac, ventilator, feeding tube, etc) How did the patient get to/from the ambulance gurney Assessment (neuro status, respiratory status, etc.) July

43 Medical Review Findings Documentation needs to clearly identify why the patient needed an ambulance and the skilled personnel during transport. Common explanations found during review of trip sheets include, but are not limited to: Patient cannot tolerate wheelchair BLS secondary to weakness Patient unable to support self in wheelchair Patient has dementia Patient has pain Needs monitoring Needs oxygen Patient forgetful Cabulance not available Family requests ambulance transport July

44 Medical Review Findings The fact that supplemental oxygen is needed for transport is not indicative of skilled transportation. Documentation needs to show the amount of oxygen the patient is transported with, the application route of oxygen, the SPo2 taken by the EMS, (not a SPo2 reading from the hospital before EMS arrived), lung sounds, and respiratory rate. There needs to be a concise explanation why the patients respiratory status may be compromised and why skilled personnel are needed to monitor the patient en route. Documentation must support why the patient cannot manage their own respiratory status. Persons with chronic respiratory problems generally have a lower SPo2 reading than the rest of the population. In some cases, it is contraindicated to apply oxygen to achieve a higher SPo2. Transport only for oxygen administration is not a valid reason for skilled transport. July

45 Examples of Medical Review Claims July

46 Example of return trip claim that does not meet the ambulance benefit 80 year old female, s/p general weakness/pneumonia C/o general discomfort, not short of breath Vital signs are stable, oxygen at 2 Liters, saturation level is 98% Lungs are clear Patient is in no distress Transferred to a wheelchair at nursing home July

47 Example of return trip claim that does not meet the ambulance benefit 84 y/o male returning to residence after dialysis. PCS noted bed confined and confusion Trip report notes alert oriented x4, GCS of 15, no confusion Vital signs are stable Patient is found in the dialysis chair: not bed confined. July

48 Example of return trip claim that does not meet the ambulance benefit Return to residence after X-rays to rule out a back fracture. Alert ox3, GCS is 15, Vital signs are stable. Patient is having no pain. No special positioning. No mention that patient is medicated for pain. Lifted to the gurney. Left in care of family. July

49 Example of return trip claim that does not meet SCT Criteria 76 year old female to the nursing home after dialysis. Cert notes patient is on the respirator Trip report notes, alert ox2, GCS is 13, vital signs are stable, oxygen saturation is 98%. The patient has clear lungs, has a trach with 2L oxygen. No vent settings given. This claim was corrected coded to A0428. July

50 Example of return trip claim that does not meet SCT Criteria 70 year old male from Dialysis to Nursing Home Cert notes patient is on respirator Trip report notes alert ox3, GCS is 15, vital signs are stable, oxygen saturation is 98% Patient has a trach, long term ventilator patient. Patients respiratory status is stable This claim was correct coded to A0428 July

51 Resources Need to add some resources July

52 What Questions Do You Have? July

53 THANK YOU