Ambulance Basics
Part B Coverage Guidelines
Presented by:
Medicare Part B Provider Outreach and Education (POE) November 2015
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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 http://www.noridianmedicare.com and the CMS website at
http://www.cms.gov
The identification of an organization or product in this information does not imply any form of endorsement.
Acronyms
Acronym Description
ALS Advanced Life Support BLS Basic Life Support
CFR Code of Federal Regulations EMS Emergency Medical Services
HCPCS Healthcare Common Procedure Coding System
IOM Internet Only Manual
OIG Office of Inspector General
SNF CB Skilled Nursing Facility Consolidated Billing
Agenda
• Ambulance Coverage Guidelines
• Vehicle and Staffing Requirements
• Origin/Destinations
• Mileage
• Billing Requirements
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
Part B Ambulance Coverage
If patient can travel by other means safely…..
Ambulance transport is non-covered
7 November 2015
Transportation Benefit Only
• Services covered only if other means of
transportation would endanger the
beneficiary’s health
• 42 CFR §410.10
• IOM 100-02, Chapter 10
– Sections 10.2, 10.3 & 10.4Transportation 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
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
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 100-02, Chapter 10, Section 10.2.3
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
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
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.
Vehicle & Facility
Requirements
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 100-02, Chapter 10, §10.1
Staffing Requirements
November 2015BLS
2 People 1 + EMTALS
2 people 1 + EMT Intermediate or EMT -Paramedic 17• Enroll with CMS 855B - provide certification requirements
• Each crew member has certified training with pertinent state/local licenses and permits for the vehicle/equipment
Transport Categories
• 7 ground/water ambulance
Ground Transport• 2 air ambulance
Rotary Wing• IOM 100-2, Chapter 10 §30.1.1
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
Does Not Determine ALS2 Level
• Medications
– Oral, Injections, Nebulized
• Crystalloid fluids
• 5% dextrose in water
• Saline
• Lactated Ringer’s
• Oxygen
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
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
Origin/Destination Modifiers
Mod Description
D Diagnostic / therapeutic site (other than P / H), ASC and IDTF
E Residential, nursing home, assisted living, domiciliary, custodial facility
G Hospital-based dialysis facility (ESRD) H Hospital
Origin/Destination Modifiers
2Mod Description
N Skilled nursing facility (swing bed, rehabilitation, hospice)
P Physician’s office (includes freestanding ER facility - non-hospital based)
R Residence (private only)
S Scene of accident or acute event U Unclassified ambulance service
X Intermediate stop at physician’s office on way to hospital (destination only)
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
Hospice Patients
• Hospice related = bill hospice
• Unrelated to hospice = bill Part B
– Append “GW” modifier020215 020215 41 A0428 RH GW 1 1 020215 020215 41 A0425 RH GW 1 25
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
Auto Denial
-Origin/Destination Modifiers
• https://med.noridianmedicare.com/web/jeb/cert-reviews/mr/ambulance-automated-prepayment-edits 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 2015 29Death Pronouncement (Ground/Air)
Time of deathpronouncement
Medicare payment decision
Before dispatch None
After dispatch
Before patient loading Before/after arrival POP
Appropriate base rate (depending if air/ground) No mileage or rural
adjustment
Death Pronouncement (Ground)
2• 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 2015 31
Pronounced dead after ambulance called/
before pick-up
Mileage
• Only
local
ambulance transportation
– Covered to nearest appropriate facility – Document exceptions• Comments field (NTE-02) or Item 19
– IOM 100-02, Chapter 10 §10.3
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)
Mileage Beyond Closest Facility
• A0888 - 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
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
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
CMS 1500/Electronic Equivalent
November 2015 39
• 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)
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
Special Edition (SE) 1029
A. Use CMS Medical Conditions List
– http://www.cms.gov/manuals/downloads/ 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
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
Capture Employee’s Signatures
• Typed name
• Employment dates
• Position/Credentials
• Signature
• Initials
• Retain with internal
Compliance Manual
November 2015EMPLOYEE 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
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 refusedtransport”
• Denied “Patient Responsibility” (PR)
• Per CR 7489 – January 2012
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 non-emergency transports BEFORE transport
• Notice to patient of possible denial
• Protects provider rights; changing financial responsibility • https://www.noridianme dicare.com/partb/forms/ docs /cms-r-131.pdf November 2015 45
• 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
Noncovered Modifiers
Modifier Description
GA
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
FYI: Beneficiary's Ambulance
Handbook Excerpt
"If the ambulance company believes that
Medicare won't pay for your
non-emergency 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
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)
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 fromhospital to long term acute care facility/SNF) – A0427 (higher level of care not supported) – A0428 (downcoded-notes not supported)
CMS Resources
• http://www.cms.gov/manuals
– IOM Benefit Policy Manual 100-02 • Chapter 10 Ambulance Services
– IOM Claims Processing Manual 100-04 • Chapter 15 Ambulance
• http://www.cms.gov/medlearn/matters
– Articles based on various CMS MLN articles
•
https://www.cms.gov/Center/Provider-Type/Ambulances-Services-Center.html
Ambulance Services Booklet
November 2015
•http://www.cms.gov/MLNProducts/downloads/MLNCatalog.pdf
Ambulance Fee Schedule
• 5 page booklet • November 2014 • http://www.cms.gov/O utreach-and- Education/Medicare- Learning-Network-MLN/MLNProducts/D ownloads/AmbulanceCEU Reminder
• Attend entire workshop to earn CEU(s)
• Take short polling survey
– Pops up after closing out of webinar
• CEU emailed 3 days after presentation
– Earn 1.0 CEU today– No password/index number needed for AAPC
• PDF presentation emailed again with CEU
• Q/A posted after 30 business days
Thank you!
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