Ambulance Basics Part B Coverage Guidelines. Presented by: Medicare Part B Provider Outreach and Education (POE) November 2015

Ambulance Basics

Part B Coverage Guidelines

Presented by:

Medicare Part B Provider Outreach and Education (POE) November 2015

DISCLAIMER

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 & 10.4

Transportation 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 2015

BLS

2 People 1 + EMT

ALS

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

2

Mod 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” modifier

020215 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 29

Death Pronouncement (Ground/Air)

Time of death

pronouncement

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 2015

EMPLOYEE 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 refused

transport”

• 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 from

hospital 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/Ambulance

CEU 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!

WATCH OUR WEBSITE FOR FUTURE WORKSHOPS!