EMS Reimbursement Issues and Trends

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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
© Copyright 2011 - J.R. Henry Consulting Inc.
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!
© Copyright 2011 - J.R. Henry Consulting Inc.
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”
© Copyright 2011 - J.R. Henry Consulting Inc.
HEALTH CARE REIMBURSEMENT
Most EMS services
only collect
~40% - 50% of their
billed charges!
© Copyright 2011 - J.R. Henry Consulting Inc.
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
© Copyright 2011 - J.R. Henry Consulting Inc.
Ambulance Industry
Being Targeted for Fraud & Abuse
© Copyright 2011 - J.R. Henry Consulting Inc.
© Copyright 2011 - J.R. Henry Consulting Inc.
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
© Copyright 2011 - J.R. Henry Consulting Inc.
© Copyright 2011 - J.R. Henry Consulting Inc.
Medicare Reimbursement Update
New Anti-Fraud Regulations
© Copyright 2011 - J.R. Henry Consulting Inc.
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
© Copyright 2011 - J.R. Henry Consulting Inc.
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
© Copyright 2011 - J.R. Henry Consulting Inc.
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
© Copyright 2011 - J.R. Henry Consulting Inc.
Corporate Compliance Programs
• Components
– Audit/Assessment
– Written Plan
– Training
– Monitoring
– Updating
– Self-Disclosure
– Hotline / Reporting Mechanism
© Copyright 2011 - J.R. Henry Consulting Inc.
Corporate Compliance Programs
Contact Page, Wolfberg and
Wirth LLC at
www.pwwemslaw.com
for low cost sample compliance
plans and policies
© Copyright 2011 - J.R. Henry Consulting Inc.
Billing and Coding Issues
© Copyright 2011 - J.R. Henry Consulting Inc.
Fee Schedule Fundamentals
Medicare HCPCS Codes
•
•
•
•
•
•
•
A0428
A0429
A0426
A0427
A0433
A0434
A0432
BLS
BLS - E
ALS 1 - NE
ALS 1 - E
ALS 2
SCT
Paramedic Intercept
– Only applicable in certain parts of New
York
© Copyright 2011 - J.R. Henry Consulting Inc.
Fee Schedule Fundamentals
Payment for Base Rate and loaded
mileage ONLY!
Urban vs. Rural Base Rates
Rural Mileage Bonus of 25% for
first 17 loaded miles
© Copyright 2011 - J.R. Henry Consulting Inc.
OTHER PAYER INFORMATION
• Medicaid – SC Dept. of Public Assistance
– SC has a fixed payment system
• $ 117 – $136 BLS
- $ 140 – $170 ALS
• $ 2.60 per mile
• Commercial Insurance Payers
– HMO’s , PPO’s and Indemnity Companies
– Medicare fee schedule definitions and rates often
used as the basis of payments
© Copyright 2011 - J.R. Henry Consulting Inc.
OTHER PAYERS
Alternative Medical Transportation (WCV)
and
pre-hospital prevention programs are
typically not included in commercial
Insurance coverage's
© Copyright 2011 - J.R. Henry Consulting Inc.
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
© Copyright 2011 - J.R. Henry Consulting Inc.
Fee Schedule Fundamentals
Who can sign the PCS?
• Attending Physician
– MD required for repetitive
patients
Effective on
1/31/00
•
•
•
•
•
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.
© Copyright 2011 - J.R. Henry Consulting Inc.
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?”
© Copyright 2011 - J.R. Henry Consulting Inc.
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?
© Copyright 2011 - J.R. Henry Consulting Inc.
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
© Copyright 2011 - J.R. Henry Consulting Inc.
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
© Copyright 2011 - J.R. Henry Consulting Inc.
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.
© Copyright 2011 - J.R. Henry Consulting Inc.
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
© Copyright 2011 - J.R. Henry Consulting Inc.
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.
© Copyright 2011 - J.R. Henry Consulting Inc.
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.
© Copyright 2011 - J.R. Henry Consulting Inc.
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 (EMT-Basic).”
© Copyright 2011 - J.R. Henry Consulting Inc.
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
© Copyright 2011 - J.R. Henry Consulting Inc.
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!
© Copyright 2011 - J.R. Henry Consulting Inc.
Paramedic Assessment Coding
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.
© Copyright 2011 - J.R. Henry Consulting Inc.
Paramedic Assessment Coding
“ 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.
© Copyright 2011 - J.R. Henry Consulting Inc.
“ 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.”
© Copyright 2011 - J.R. Henry Consulting Inc.
Paramedic Assessment Coding
• 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
© Copyright 2011 - J.R. Henry Consulting Inc.
Paramedic Assessment Coding
• 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
© Copyright 2011 - J.R. Henry Consulting Inc.
Paramedic Assessment Coding
• 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 !!!!
© Copyright 2011 - J.R. Henry Consulting Inc.
Paramedic Assessment Coding
• 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!
© Copyright 2011 - J.R. Henry Consulting Inc.
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:
© Copyright 2011 - J.R. Henry Consulting Inc.
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
© Copyright 2011 - J.R. Henry Consulting Inc.
ALS 2 Coding
ALS 2: Non-Qualifying
Medications / Solutions
•
Aspirin (ASA)
• Oxygen
• Crystalloids, Hypotonic, Isotonic, hypertonic
solutions (e.g: Dextrose, Saline, Ringers Lactate)
© Copyright 2011 - J.R. Henry Consulting Inc.
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.
© Copyright 2011 - J.R. Henry Consulting Inc.
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.
© Copyright 2011 - J.R. Henry Consulting Inc.
Medicare Reimbursement Update
Mileage and Signature
Authorization Requirements
© Copyright 2011 - J.R. Henry Consulting Inc.
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
© Copyright 2011 - J.R. Henry Consulting Inc.
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!
© Copyright 2011 - J.R. Henry Consulting Inc.
Medicare Reimbursement Update
Modifiers, ICD-9 and Condition
Codes
© Copyright 2011 - J.R. Henry Consulting Inc.
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
© Copyright 2011 - J.R. Henry Consulting Inc.
pad)
Modifiers
J = Freestanding ESRD facility;
N = Skilled nursing facility;
P = Physician’s office;
R = Residence;
S = Scene of accident or acute event;
© Copyright 2011 - J.R. Henry Consulting Inc.
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
© Copyright 2011 - J.R. Henry Consulting Inc.
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
© Copyright 2011 - J.R. Henry Consulting Inc.
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
© Copyright 2011 - J.R. Henry Consulting Inc.
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.
© Copyright 2011 - J.R. Henry Consulting Inc.
Why do I need to obtain all of this
information and also the patient’s
signature?
© Copyright 2011 - J.R. Henry Consulting Inc.
Medical Record Documentation
“If it isn’t documented –
It didn’t happen!”
© Copyright 2011 - J.R. Henry Consulting Inc.
Medical Record Documentation
To some degree, Everyone has a
photographic memory…
Some just don't have any film!!
© Copyright 2011 - J.R. Henry Consulting Inc.
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.
© Copyright 2011 - J.R. Henry Consulting Inc.
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
© Copyright 2011 - J.R. Henry Consulting Inc.
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
© Copyright 2011 - J.R. Henry Consulting Inc.
New CMS Signature Rule
• 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.
© Copyright 2011 - J.R. Henry Consulting Inc.
New CMS Signature Rule
• 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.
© Copyright 2011 - J.R. Henry Consulting Inc.
New CMS Signature Rule
• 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
© Copyright 2011 - J.R. Henry Consulting Inc.
Special Thanks
THANK YOU FOR PARTICIPATING
IN THIS SESSION!!!
© Copyright 2011 - J.R. Henry Consulting Inc.
J.R. Henry, EMT-P
535 Perry Highway
Pittsburgh, PA 15229
(412) 736-4163
(412) 291-3434 (fax)
[email protected]
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