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EMS Billing and Coding Key Issues
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© Copyright 2011 - J.R. Henry Consulting Inc.
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.
• Welcome and Introductions
• E.M.S. Issues and Trends
• Reimbursement Issues
• Compliance Issues
• Questions and Answers
Agenda and Topics
© 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.
• 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
E.M.S. Subsidy
© 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.
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
FEDERAL INITIATIVES
© 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.
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
© Copyright 2011 - J.R. Henry Consulting Inc.
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
PPACA INITIATIVES
© 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.
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
Fee Schedule Fundamentals
© Copyright 2011 - J.R. Henry Consulting Inc.
Payment for Base Rate and loaded Payment for Base Rate and loaded mileage ONLY!mileage ONLY!
Urban vs. Rural Base Rates
Rural Mileage Bonus of 25% for first 17 loaded miles
Fee Schedule Fundamentals
© 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.
Who can sign the PCS?• 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.
Effective on 1/31/00
Fee Schedule Fundamentals
© Copyright 2011 - J.R. Henry Consulting Inc.
“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?”
Two Essential Questions for Billing Purposes
© 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.
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
Hospital-to-Hospital Transfers
© Copyright 2011 - J.R. Henry Consulting Inc.
• 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 percentage-based or “split” contracts
Other Issues
© Copyright 2011 - J.R. Henry Consulting Inc.
• 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.
Other Issues
© 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.
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.
Paramedic Assessment Coding
© Copyright 2011 - J.R. Henry Consulting Inc.
“ 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.
Paramedic Assessment Coding
© 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.
• 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
Paramedic Assessment Coding
© Copyright 2011 - J.R. Henry Consulting Inc.
• 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
Paramedic Assessment Coding
© Copyright 2011 - J.R. Henry Consulting Inc.
• 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 !!!!
Paramedic Assessment Coding
© Copyright 2011 - J.R. Henry Consulting Inc.
• 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!
Paramedic Assessment Coding
© 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 ADVANCED SKILLS (Con’t)
• Manual defibrillation/cardioversion
• Endotracheal intubation
• Central venous line
• Cardiac pacing
• Chest decompression
• Surgical airway
• Intraosseous line
ALS 2 Coding
© Copyright 2011 - J.R. Henry Consulting Inc.
ALS 2: Non-Qualifying
Medications / Solutions
• Aspirin (ASA)
• Oxygen
• Crystalloids, Hypotonic, Isotonic, hypertonic
solutions (e.g: Dextrose, Saline, Ringers Lactate)
ALS 2 Coding
© Copyright 2011 - J.R. Henry Consulting Inc.
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
© Copyright 2011 - J.R. Henry Consulting Inc.
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.
SCT Coding
© Copyright 2011 - J.R. Henry Consulting Inc.
Medicare Reimbursement Update
Mileage and Signature Authorization Requirements
© Copyright 2011 - J.R. Henry Consulting Inc.
• 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
© Copyright 2011 - J.R. Henry Consulting Inc.
• 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!
Fractional Mileage Issues
© 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 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;
© 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.
““If it isn’t documented –If it isn’t documented –
It didn’t happen!”It didn’t happen!”
Medical Record Documentation
© 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.
• 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
Other Required Documentation
© 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.
THANK YOU FOR PARTICIPATING IN THIS SESSION!!!
Special Thanks
J.R. Henry, EMT-P535 Perry Highway
Pittsburgh, PA 15229(412) 736-4163 (412) 291-3434 (fax)