EMS Reimbursement Issues and Trends

EMS Billing and Coding

Key Issues

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Disclaimer

• The information contained in this presentation is not intended and should not be construed as legal advice or direction.

• The consultant plans to share knowledge and practical experience with the attendees.

• The consultant does not provide legal advice and strongly advises attendees to seek professional legal advice from an attorney before implementing any material change in their operational polices, procedures or any other matter which is governed by law or regulation

© Copyright 2011 - J.R. Henry Consulting Inc.

Agenda and Topics

• Welcome and Introductions

• E.M.S. Issues and Trends

• Reimbursement Issues

• Compliance Issues

• Questions and Answers


Winds of Change

… coming soon to a neighborhood near you!

 Declining payments per trip:

 Medicare Fee Schedule

Below our average costs!

No longer covers the “Cost of Readiness”

 Health Care Reform

 Rising Deductibles

 New Co-payment Requirements

 Medicaid Rates still well below our costs!


Winds of Change

… coming soon to a neighborhood near you!

 Ever-increasing Labor and System Costs

 Expensive New Technologies and Meds

 Limited Subsidy:

Have we have spoiled our local communities???

Who pays for the “Cost of Readiness”


HEALTH CARE REIMBURSEMENT

Most EMS services only collect

~40% - 50% of their billed charges!


E.M.S. Subsidy

• Municipal subsidy levels vary widely from community to community

– None

– Partial

• Indirect expenses such as volunteer workers compensation premiums, fuel expenses, building / utility costs

• Direct - Annual donation or subsidy

• Dedicated % of Real Estate Tax

• Annual amount based upon budget request


Ambulance Industry

Being Targeted for Fraud & Abuse



FEDERAL INITIATIVES

CMS is mandating renewed Carrier emphasis on compliance in these core areas:

• Signature Authorizations

• Physician Certifications

• Repetitive Transports

• Medical Necessity

• Up coding of Claims

Office of Inspector General (OIG) Compliance

Guidelines for Ambulance and Billing Companies



Medicare Reimbursement Update

New Anti-Fraud Regulations


PPACA INITIATIVES

Effective March 25, 2011

CMS new authority to investigate suspected fraud

New rules now give CMS the ability to suspend Medicare payments based upon

“creditable” allegation of fraud

18 month cap on suspensions

Except when “good cause: exists


PPACA INITIATIVES

Revalidation is now required for all providers and suppliers at least every 5 years – with a fee!!!

Screening Measures vary on type of health care organization

Limited, Moderate and High

Database checks, credentialing, license verifications, etc.

CMS can show up “unannounced” to inspect

States can implement higher standards for

Medicaid and CHIP providers


Corporate Compliance Programs

• Why Have One?

– Promotes prevention, detection and resolution of problems

– Self-Disclosure can usually keep the issues at the carrier level

– Careful monitoring can identify under / over payments

– Increased organizational efficiency

– Reduced likelihood of negative audit outcome

– Mitigating factor in criminal sentencing per

DOJ sentencing guidelines



• Components

– Audit/Assessment

– Written Plan

– Training

– Monitoring

– Updating

– Self-Disclosure

– Hotline / Reporting Mechanism



Contact Page, Wolfberg and

Wirth LLC at www.pwwemslaw.com for low cost sample compliance plans and policies


Billing and Coding Issues


Fee Schedule Fundamentals

Medicare HCPCS Codes

• A0428 BLS

• A0429 BLS - E

• A0426 ALS 1 - NE

• A0427 ALS 1 - E

• A0433 ALS 2

• A0434 SCT

• A0432 Paramedic Intercept

– Only applicable in certain parts of New

York



Payment for Base Rate and loaded mileage ONLY!

Urban vs. Rural Base Rates

Rural Mileage Bonus of 25% for first 17 loaded miles


OTHER PAYER INFORMATION

• Medicaid – SC Dept. of Public Assistance

– SC has a fixed payment system

• $ 117 – $136 BLS

• $ 2.60 per mile

- $ 140 – $170 ALS

• Commercial Insurance Payers

– HMO’s , PPO’s and Indemnity Companies

– Medicare fee schedule definitions and rates often used as the basis of payments


OTHER PAYERS

Alternative Medical Transportation (WCV) and pre-hospital prevention programs are typically not included in commercial

Insurance coverage's


Medical Necessity

• Emergencies

• Non-Emergency Transports

– Physician’s Certification Statement (PCS)

Required

– Medical Necessity

– Patient could have been safely transported by other means

– Non-covered destinations



Who can sign the PCS?

Effective on

1/31/00

• Attending Physician

– MD required for repetitive patients

• Physician’s Assistant

• Nurse Practitioner

• Clinical Nurse Specialist

• Registered Nurse

• Discharge Planner

*

Employed by the hospital, facility or attending physician where the beneficiary is being treated, with knowledge of the beneficiary’s condition at the time the transport was ordered or service was furnished.


Two Essential Questions for Billing Purposes

“What was the nature of the call at the time of dispatch?”

“Why did the patient need to be transported by ambulance at this particular time?”


Non-Emergency Transports

• Describe the patient's condition at the time of transport – not just the past medical history!

• Did we transport to the nearest appropriate facility?

• What is the reason for transfer to other facility?

• What tests or other treatments were or will be performed?


Hospital-to-Hospital Transfers

•

Transported To / For?

• Transport to the nearest facility for care of symptoms, complaints or both.

• Transports for the care of a specialist or for availability of specialized equipment

Patient transferred to rehabilitation facility

Non-covered services typically include:

• Transports for the benefit of a preferred physician or nearness of family members


Other Issues

• Multiple Arrivals

– Paramedic Level First Responders

– Could encourage more ALS first responders

– Two-Tiered ALS Systems

– Only transporting unit may bill Medicare!

– Can BLS bill without a contract with ALS?

• Yes, BLS only!

– ALS /BLS payment “split” or flat rate amount should be established between the providers

– Since ALS vs. BLS payment differential is shrinking, many are considered flat fee rather than percentagebased or “split” contracts


Other Issues

• Multiple Patients

– If two patients are transported simultaneously, for each Medicare beneficiary, will allow 75 percent of the payment allowance for the base rate

– If three or more patients are transported simultaneously, then the payment allowance for the Medicare beneficiary (or each of them) is equal to 60 percent of the base rate

– However, a single payment allowance for mileage would continue to be prorated by the number of patients onboard.


Medicare Fee Schedule Issues

• Paramedic Assessment

• Emergency Vs. Non-Emergency

• Mileage Rounding Rules (next whole mile)

• Rural Mileage Adjustment of 1-17

• New regulations will require tenths of miles

– no rounding until miles >100


Definitions

Emergency Response - Emergency response is a

BLS or ALS1 level of service that 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.


Definitions

Advanced life support, level 1 (ALS1) means transportation by ground ambulance vehicle, medically necessary supplies and services and either an ALS assessment by

ALS personnel or the provision of at least one ALS intervention.


Definitions

• Advanced life support (ALS) Intervention

“a procedure that is, in accordance with

State and local laws, beyond the scope of practice of an emergency medical technician-basic (EMTBasic).”


Emergency Dispatched Calls

• Documentation of Dispatch Information

– Response Priority

– Patient's reported condition at “time of dispatch”

• Documentation if a Paramedic

Assessment was performed by an ALS crew, if applicable


Paramedic Assessment Coding

• Dispatch Information is critical

• National accepted EMD protocols or locally developed (Medical Director)

• Emergency calls which are dispatched

ALS (without ALS on scene intervention and BLS transport) can be billed as ALS 1-E transports!



Advanced Life Support Assessment:

– 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.



“ The determination to respond emergently with an ALS ambulance must be in accordance with the local 911 or equivalent service dispatch protocol.

“ If the call came in directly to the ambulance provider/supplier, then the provider's/supplier's dispatch protocol must meet, at a minimum, the standards of the dispatch protocol of the local 911 or equivalent service.


“ In areas that do not have a local 911 or equivalent service, then the protocol must meet, at a minimum, the standards of a dispatch protocol in another similar jurisdiction within the State or, if there is no similar jurisdiction within the State, then the standards of any other dispatch protocol within the State.

“ Where the dispatch was inconsistent with this standard of protocol, including where no protocol was used, the beneficiary's condition (for example, symptoms) at the scene determines the appropriate level of payment.”



• If call comes in directly to you, then your dispatch protocol must meet, at a minimum, the standards of the dispatch protocol “of the local 911 or equivalent service”

• If no local 911 or equivalent service, then protocol must meet, at a minimum, the standards of a dispatch protocol in another similar jurisdiction within the state, or if no similar jurisdiction, then the standards of any dispatch protocol in the state



• If dispatch was inconsistent with the standard of protocol including where no dispatch protocol was used, then condition at the scene determines the level of payment

– Medicare Claims Processing Manual, 100-4,

Chapter 15, Sec. 10.3



• CMS understands that dispatch protocols may vary widely!

• Are your billers familiar with and understand the dispatch protocols?

• Have your dispatch protocols reviewed and approved by your Medical Director?

• Key area for future reviews by CMS /

Carriers !!!!



• Don’t be afraid to bill all aspects - If the definitions are met!

• Problem with this level of service being

“counterintuitive” to how we did it before!

• Monitor carefully: quality assurance, audits, etc.

• Understand and have input into the dispatch protocol at the county level!


ALS 2 Coding

Advanced life support, level 2 (ALS2) means either transportation by ground ambulance vehicle, medically necessary supplies and services, and the administration of at least three medications by intravenous push/bolus or by continuous infusion excluding crystalloid, hypotonic, isotonic, and hypertonic solutions (Dextrose, Normal Saline,

Ringer's Lactate); or transportation, medically necessary supplies and services, and the provision of at least one of the following ALS procedures:


ALS 2 Coding

ALS 2 ADVANCED SKILLS (Con’t)

• Manual defibrillation/cardioversion

• Endotracheal intubation

• Central venous line

• Cardiac pacing

• Chest decompression

• Surgical airway

• Intraosseous line


ALS 2 Coding

ALS 2: Non-Qualifying

Medications / Solutions

• Aspirin (ASA)

• Oxygen

•

Crystalloids, Hypotonic, Isotonic, hypertonic solutions (e.g: Dextrose, Saline, Ringers Lactate)


SCT Coding

Specialty Care Transport (SCT):

“ hospital-to-hospital 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.


SCT Coding

Note:

“Additional training” means the specific additional training that a State requires a paramedic to complete in order to qualify to furnish specialty care to a critically ill or Injured patient during an SCT.



Mileage and Signature

Authorization Requirements


Fractional Mileage Issues

• Medicare implemented a new policy on 1/1/2011

• Affects Medicare HMO beneficiaries also

• Record odometer readings in tenths of miles

• Use actual odometer or trip odometer for loaded miles

• Can use Mapquest and other software products

– Maintain thorough documentation with each claim


Fractional Mileage Issues

• What about Non-Medicare Payors?

– What are the Medicaid mileage policies in your state???

– Commercial insurance companies???

• Do they permit fractional mileage?

• Can they process you claim with fractional mileage

• Use conventional rounding, when necessary!



Modifiers, ICD-9 and Condition

Codes


Modifiers

D = Diagnostic or therapeutic site other than

P or H when these are used as origin codes;

E = Residential, domiciliary, custodial facility;

G = Hospital based ESRD facility;

H = Hospital;

I = Site of transfer (e.g. airport or helicopter pad) © Copyright 2011 - J.R. Henry Consulting Inc.

Modifiers

J = Freestanding ESRD facility;

N = Skilled nursing facility;

P = Physician’s office;

R = Residence;

S = Scene of accident or acute event;


Modifiers

GM = Multiple Patient on One Ambulance

Trip;

QL = Patient pronounced dead after ambulance was called;

GY = Non-covered services or mileage;

Check CMS Claims and Billing Policy

Manuals for additional modifiers


ICD- 9 Codes

• Ambulance payments are not based upon the ICD-9 code

BUT; at least one code is still mandated

• EMS personnel care not permitted to issue a diagnose patients!

• Attempt to find most appropriate ICD-9 code based upon the patient’s chief complaint or relevant medical condition


Condition Codes

• Condition Codes implemented in January,

2005

BUT; Not in the manner most of us thought!

• Condition codes were supposed to:

– Eliminate the need for ICD-9 Codes

– Stipulate level of service (ALS/BLS) for each condition


CMS Change Request 3619, January 4, 2005

“The Ambulance Medical Conditions List is intended primarily as an educational guideline …”

“…The ambulance medical condition codes crosswalk to ICD-9-CM codes…

“Use of the ICD-9-CM codes in the crosswalk will not guarantee payment of the claim or payment for a certain level of service.

Also, neither the presence nor absence of a code affects whether the claim would be paid or denied.


Why do I need to obtain all of this information and also the patient’s signature?


Medical Record Documentation

“If it isn’t documented –

It didn’t happen!”


Medical Record Documentation

To some degree, Everyone has a photographic memory…

Some just don't have any film!!


These are actual notes from patient charts...

•

The patient has no past history of suicides.

• Patient had waffles for breakfast and anorexia for lunch.

• She is numb from her toes down.

• Occasional, constant, infrequent headaches.


Other Required Documentation

• Signature Authorization Form:

– Billing Authorization and Release of Records

– ABN or Waivers

• Insurance and Patient Information:

– Name, Date, SS #, Primary and Secondary Insurance,

Group Number, Responsible Party, Etc.

• Hospital or Facility Insurance Records:

– Face Sheet

– Patient’s Medical Records

– List of procedures or tests performed


New CMS Signature Rule

• In 2006 - CMS implemented a new signature rule!

• Beneficiary Signature Exception was limited to emergency ambulance services (patient unable to sign

• The exception has been expanded to also cover non-emergency ambulance transports.

• CMS requires a secondary form of verification which included the receiving hospital’s face sheet when patient is unable to sign



• CMS has revised the definition of acceptable "secondary forms of verification" to include not only records from a receiving hospital, but also records from other types of receiving facilities.



• CMS has also agreed that "verification forms" do not need to be signed by a representative of the receiving facility, provided that the documentation you received is an official record of that hospital or other facility, and

• that it documents the patient's name and the date and time they were received by that facility.

• This final rule eliminates confusion and clarifies that all secondary forms of verification can be unsigned.



• New rules stress legibility of the signature of the patient and any authorized signers!

• Stamped signatures are not permitted

• Must be legible or printed!

• Signature logs and attestation statements are permitted

• Review CMS Transmittal #327

• Sample form at www.pwwemslaw.com


Special Thanks

THANK YOU FOR PARTICIPATING

IN THIS SESSION!!!


J.R. Henry, EMT-P

535 Perry Highway

Pittsburgh, PA 15229

(412) 736-4163 (412) 291-3434 (fax) jrhenry@emsconsult.org

EMS Reimbursement Issues and Trends

EMS Billing and Coding

Key Issues

Disclaimer

Agenda and Topics

Winds of Change

Winds of Change

Most EMS services only collect

~40% - 50% of their billed charges!

Contact Page, Wolfberg and

Wirth LLC at www.pwwemslaw.com for low cost sample compliance plans and policies

Billing and Coding Issues

Payment for Base Rate and loaded mileage ONLY!

Urban vs. Rural Base Rates

Rural Mileage Bonus of 25% for first 17 loaded miles

Medical Necessity

Modifiers

Modifiers

Modifiers

ICD- 9 Codes

Condition Codes

Why do I need to obtain all of this information and also the patient’s signature?

“If it isn’t documented –

It didn’t happen!”

Special Thanks

Related documents

Products

Support

EMS Reimbursement Issues and Trends

EMS Billing and Coding

Key Issues

Disclaimer

Agenda and Topics

Winds of Change

Winds of Change

Most EMS services only collect

~40% - 50% of their billed charges!

Contact Page, Wolfberg and

Wirth LLC at www.pwwemslaw.com for low cost sample compliance plans and policies

Billing and Coding Issues

Payment for Base Rate and loaded mileage ONLY!

Urban vs. Rural Base Rates

Rural Mileage Bonus of 25% for first 17 loaded miles

Medical Necessity

Modifiers

Modifiers

Modifiers

ICD- 9 Codes

Condition Codes

Why do I need to obtain all of this information and also the patient’s signature?

“If it isn’t documented –

It didn’t happen!”

Special Thanks

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