Your instructor Levels of Service National Academy of Ambulance Coding Steve Wirth Founding Partner, Page, Wolfberg & Wirth LLC Over 30 years experience as an EMT, Paramedic, Flight Medic, EMS Instructor, Fire Officer, and EMS Administrator MS in Health Services Administration and active EMS educator at the college level Two-term Commissioner for the Commission on Accreditation of Ambulance Services Author of numerous articles on EMS, Fire Service, Public Safety and Ambulance Reimbursement. Member of JEMS editorial board Co-author of some of the industry s leading publications and contributing author to some of the industry s bestknown textbooks Currently active as an EMT and fire/rescue officer for a busy suburban fire department. Board member of PA Fire & Emergency Services Institute Disclaimer This information is presented for educational purposes only. This educational program does not constitute legal or consulting advice, and should not be relied upon as such. Nothing in this program is intended to provide specific instructions on the coding or submission of any particular claim for payment or reimbursement by any payor, public or private. User agrees to release NAAC and its employees, contractors, agents, officers and directors from any and all liability, including but not limited to liability arising out of any billing and/or coding decisions. By enrolling in the National Academy of Ambulance Coding and/or taking or completing any courses and/or lessons from NAAC, and/or obtaining certification as a Certified Ambulance Coder, the user agrees to these terms and conditions. All materials are Copyright, National Academy of Ambulance Coding. Any distribution of these materials in any form - electronic, video graphic, photographic, audio, digital, and/or paper or any other form - is prohibited without the express written permission of the National Academy of Ambulance Coding. Registered enrollees may print these materials and/or save an electronic copy, for their own use in completing their Certified Ambulance Coder course work. Lesson Objectives Upon completion of this lesson, the participant will: Understand the different modes of ambulance transportation List and describe the levels of service that are billable for each mode of transport Describe the Health Care Common Procedure Coding System (HCPCS) that is used when submitting ambulance claims for payment Lesson Objectives (cont d) Upon completion of this lesson, the participant will: Understand the difference between HCPCS codes and ICD-9 codes Understand the distinction between emergency and non-emergency ambulance claims Recognize that payors other than Medicare may use different level of service definitions and have different charge codes Levels of Service - Overview The focus of this lesson is on the levels of service according to the Medicare Ambulance Fee Schedule regulations Many other payors such as Medicaid and other insurers have adopted these definitions and payment codes Page 1
Modes of Medical Transportation Ground Ambulance Land Based Water Based Air Ambulance Fixed Wing Rotary Wing Ground Levels of Service Ground Ambulance Basic Life Support (BLS) Advanced Life Support (ALS) Ground Levels of Service Basic Life Support (BLS) BLS Non-emergency or BLS-NE BLS Emergency or BLS-E Ground Levels of Service Advanced Life Support (ALS) ALS 1 Non-emergency or ALS-1 NE ALS 1 Emergency or ALS-1 E ALS 2 Specialty Care Transport (SCT) or Critical Care Transport Paramedic Intercept (PI) HCPCS Codes Healthcare Common Procedure Coding System (HCPCS) HCPCS codes are a common set of codes recognized by Medicare, Medicaid and Commercial Insurers Medical transportation has a short list of HCPCS codes Purpose of HCPCS Codes Provides a standardized coding system for describing specific items and services provided in the delivery of health care Necessary for Medicare, Medicaid, and other health insurance programs to ensure that insurance claims are processed in an orderly and consistent manner Since implementation of the Health Insurance Portability and Acountability Act of 1996 (HIPAA) use of the HCPCS became mandatory Page 2
Ground Transportation HCPCS BLS-NE A0428 BLS-E A0429 ALS-1 NE A0426 ALS-1 E A0427 ALS-2 A0433 SCT A0434 PI A0432 Ground Mileage A0425 Ground Transportation HCPCS Usually, only two (2) HCPCS codes will be used on a claim: Base Rate Level of Service BLS-E, BLS-NE, ALS-1E, ALS-1NE, ALS-2, etc. AND Patient Loaded Mileage Air Transportation HCPCS Base Rates Fixed Wing A0430 Rotary Wing A0431 Mileage Fixed Wing Mileage A0435 Rotary Wing Mileage A0436 HCPCS vs. ICD-9 Codes Some medical services paid by Medicare rely on ICD-9 codes (diagnosis codes) to determine the level of payment made to the provider of service For ambulance service, Medicare uses the HCPCS codes to determine level of payment and ICD-9 codes are used to support medical necessity for the level of service The Total Picture ALL requirements for billing must be met: The correct level of service must be determined and the proper HCPCS codes used Must meet crew and vehicle requirements Medical necessity must be met Must be transported to a covered destination Personnel Certification Levels Emergency Medical Technician (EMT) EMT Basic (EMT-B) EMT Intermediate (EMT-I) EMT Paramedic (EMT-P) Need to look to EMS law of each state to determine what skills personnel in each category of certification are permitted to perform Page 3
Personnel BLS personnel are individuals trained to the level of EMT - Basic ALS personnel are individuals trained to the level of EMT Intermediate or EMT - Paramedic Basic Life Support (BLS) Basic life support (BLS) is transportation by ground ambulance vehicle and the provision of medically necessary supplies and services, including BLS ambulance services as defined by the State. The ambulance must be staffed by an individual who is qualified in accordance with State and local laws as an emergency medical technician-basic (EMT- Basic) Basic Life Support (BLS) BLS Emergency (A0429) requires an emergency response of an ambulance BLS Non-Emergency (A0428) has a stricter medical necessity requirement and generally requires a signed physician order (Physician Certification Statement) certifying that these requirements are met Covered in more detail in CAC lesson on Beneficiary Signatures and Forms Advanced Life Support ALS 1 Advanced life support, level 1 (ALS1) is the transportation by ground ambulance vehicle and the provision of medically necessary supplies and services including the provision of an ALS assessment or at least one ALS intervention Advanced Life Support ALS 1 ALS 1 Non-Emergency usually scheduled or unscheduled nonemergency patient transports between facilities of seriously ill or injured patients ALS 1 Emergency requires that there be an emergency response of an ambulance and ALS level of service ALS Assessment An advanced life support (ALS) assessment is an assessment performed by an ALS crew as part of an emergency response that was necessary because the patient's reported condition at the time of dispatch was such that only an ALS crew was qualified to perform the assessment. An ALS assessment does not necessarily result in a determination that the patient requires an ALS level of service Page 4
ALS Assessments Summary of requirements to utilize the ALS assessment rule: 911 or 911-type dispatch ALS-level dispatch required Immediate response Paramedic assessment performed Other coverage requirements satisfied (i.e., there is a medically necessary transport to a covered destination) ALS Intervention An advanced life support (ALS) intervention is a procedure that is, in accordance with State and local laws, beyond the scope of authority of an emergency medical technician-basic (EMT-Basic) The intervention must be medically necessary to qualify as an intervention for payment of an ALS level of service ALS Intervention Possible examples: Peripheral venous puncture Blood drawing Administration of IV fluids Medications administered Monitoring IV solutions with medication Remember! Each state has a different scope of practice for EMS providers. Need to check state EMS law and keep a list of current ALS interventions ALS Intervention In states where an EMT Basic can perform ALS type procedures, (e.g., IV establishment), then that procedure would NOT fit the definition of an ALS intervention You may not consider a procedure that is within the scope of practice of an EMT- Basic to be an ALS intervention ALS Intervention Special note: An unsuccessful attempt to perform an ALS intervention (e.g., IV start) may qualify the transport for billing at the ALS level provided that the intervention was reasonable and necessary had it been successful Joint ALS BLS Situations When there is a joint response and transport with a BLS staffed ambulance and an ALS crew that arrives by nontransport vehicle, the call may in some situations be billed as an ALS level of service and the reimbursement split between the BLS and ALS service as long as all program requirements are met Joint billing agreement is required Page 5
ALS 2 or Advanced life support, level 2 (ALS2) is the transportation by ground ambulance vehicle and the provision of medically necessary supplies and services including either: (1) at least three separate administrations of one or more medications by intravenous push/bolus or by continuous infusion (excluding crystalloid fluids) (2) the provision of at least one of the following ALS procedures: ALS 2 Procedures Manual defibrillation/cardioversion; Endotracheal intubation; Central venous line; Cardiac pacing; Chest decompression; Surgical airway; or Intraosseous line. ALS 2 Notes Common question - Aspirin and oxygen are not medications for purposes of the three medication rule, as they are not administered IV Can be three (3) IV administrations of the same medication, so long as each is a full dose, administered in accordance with accepted clinical practice ALS 2 Notes Fractional administration of a single dose of an IV medication would not qualify under the three medication rule Example: Protocol calls for administration of 30 mg of a particular drug as a single dose. If paramedic gives 3 separate doses of 10 mg each dose over 15 minutes it would not qualify for ALS 2 ALS 2 Level of Service Can be either a non-emergency ambulance transport or emergency response Typical examples: 911 response, cardiac arrest with intubated patient or multiple (3 or more) IV medications Interfacility transport to higher level of care with patient with multiple IVs and (3 or more) IV medications Specialty Care Transport (SCT) Specialty care transport (SCT) is 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. SCT is necessary when a beneficiary s condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area, for example, emergency or critical care nursing, emergency medicine, respiratory care, cardiovascular care, or a paramedic with additional training (as defined by their State) Page 6
Specialty Care Transport (SCT) Interfacility transport Typically hospital-to-hospital or skilled nursing facility-to-hospital Critically ill or injured patient Nurse, respiratory therapist, or a paramedic with additional level of training (in accordance with state protocol) was required due to patient condition. Not just that the nurse was the only person available to ride along! Specialty Care Transport (SCT) Practical pointer: It is rare that this level of service is billable to Medicare. An example of a potentially billable SCT: Transfer of a critically ill cardiac patient on a ventilator with a CCRN attending to the patient for a transport to a medical center for complex cardiac surgery not available at the current facility, and where paramedics are not permitted under their state scope of practice to operate a ventilator Paramedic Intercept (PI) Paramedic Intercept services are ALS services provided by an entity that does not provide the ambulance transport in areas where volunteer ambulance services that provide the ambulance transport are not permitted by law to bill for their services This is a very limited Medicare benefit, currently applicable only in certain areas of the State of New York Paramedic Intercept (PI) Paramedic Intercept level of service (A0432) may be payable separate from the ambulance transport, subject to the following: The intercept service(s) is: Furnished in a rural area; Furnished under a contract with one or more volunteer ambulance services; and Medically necessary based on the condition of the beneficiary receiving the ambulance service. Paramedic Intercept (PI) In addition, the volunteer ambulance service involved must: Meet the program s certification requirements for furnishing ambulance services; Furnish services only at the BLS level at the time of the intercept; and Be prohibited by State law from billing anyone for any service. Paramedic Intercept (PI) Finally, the entity furnishing the ALS paramedic intercept service must: Meet the program s certification requirements for furnishing ALS services; and Bill all recipients who receive ALS paramedic intercept services from the entity, regardless of whether or not those recipients are Medicare beneficiaries. Page 7
Paramedic Intercept (PI) Practical pointer: It is very rare that this level of service is used It is primarily only available in certain areas of New York State where volunteer ambulances services are prohibited by state law to bill for services This is different than the joint BLS-ALS response discussed earlier Emergency Response An emergency response is when a BLS or ALS 1 level of service has been provided in immediate response to a 911 call or the equivalent. An immediate response is one in which the ambulance provider/supplier begins as quickly as possible to take the steps necessary to respond to the call. Emergency Response If it was reasonable for the dispatcher to issue an emergency dispatch in light of accepted, standard dispatch protocol, based on the information available to the dispatcher at the time of the call, the response meets the Medicare definition of an emergency response. Emergency Response Has nothing to do with whether lights and sirens were used by the ambulance The increased payment is to reimburse the ambulance service for the additional expense involved in maintaining a state of readiness to respond immediately Medicare Q & A Air: Rotary and Fixed Wing Rotary wing air ambulance (RW) means transportation by a helicopter that is certified as an ambulance and such services and supplies as may be medically necessary Fixed wing air ambulance (FW) means transportation by a fixed wing aircraft that is certified as a fixed wing air ambulance and such services and supplies as may be medically necessary Medical Transport Bills The ambulance Base Rate is an allinclusive charge Supplies and services are included in the base rate (bundled) The only additional charge is for loaded mileage Transport with the patient onboard the ambulance, typically from the scene or point of pickup to the receiving hospital Page 8
Ambulance HCPCS Coding Two HCPCS codes for each claim One code for the all-inclusive service or the base charge A0428, A0429, A0426, A0427, etc. One code for patient loaded mileage A0425 Air Transportation HCPCS Two HCPCS Codes for each Claim One for the all-inclusive service or base charge One for the patient loaded mileage Fixed Wing Base Rate Fixed Wing Mileage Rotary Wing Base Rate Rotary Wing Mileage A0430 A0435 A0431 A0436 Additional Types of Transport Wheelchair Van Transport Stretcher Van Transport Mileage (WC / SV) A0130 T2005 S0209 These services are not covered by Medicare You cannot bill Medicare for any transport other than a ground or air ambulance transport They may be covered by Medicaid or commercial insurers Another Useful Code HCPCS code A0998 Ambulance Response and Treatment, No Transport This is not a Medicare benefit May be useful to request Medicare denial May also be useful in billing commercial carriers, direct pays, etc. in a nontransport situation Treatment Without Transport Ambulance provider may bill patient Medicare provides a transportation benefit only No transportation, no benefit No need to bill Medicare unless patient wants a denial Some commercial insurers will pay Treatment Without Transport Usually a response to a 9-1-1 emergency call Ambulance responds to the call and cares for the patient (e.g., diabetic patient) The patient improves and refuses transport Page 9
Non-Covered Mileage A0888 Used when billing Medicare to indicate mileage beyond closest appropriate facility For Medicare, this is Non-Covered, but is billable to the Patient Note: When billed, should include Denial Modifier GY, which will be discussed in CAC Lesson on Modifiers Some Medicare contractors prefer use of A0425 GY for non-covered mileage Other Payors Medicaid and other payors may have different level of service definitions than the Medicare Fee Schedule definitions Example: Medicaid may not recognize an ALS assessment without an ALS intervention to bill for the ALS level of service Need to check Medicaid requirements in your state Check rules for commercial and other payors Other Payors Some states pay for wheelchair van transport where Medicare does not Medical necessity requirements may differ between Medicare, Medicaid and other payors Summary Two General Modes of Transport Ground Air Ambulance Billers use a very limited set of HCPCS Codes to communicate level of service to Medicare and other payors Summary There are specific levels of service for which you may bill, provided all program requirements are met Important to know the distinctions between the levels of service and which HCPCS code to use Payors other than Medicare may rely on the Medicare definitions for level of service, but others may not Levels of Service National Academy of Ambulance Coding Page 10