1. Provided by Coventry Health Care® ©2010 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. California Medical Bill Reviewer Re-Certification Unit 6: Other Fee Schedules Module 1: Ambulance & DMEPOS Guidelines

2. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 2 Overview Hi! In this module, you will learn about two different fee schedulesAmbulance and DMEPOS. You will learn about ambulances services, the crew requirements, ambulance modifiers, and how these services are reimbursed. Then, you will learn about the DMEPOS fee schedule and the guidelines for reimbursement. Part I: Ambulance Guidelines Ambulance Fee Schedule Crew Requirements Ambulance Services Supplies & Materials Modifiers Ambulance Reimbursement Lets start by discussing some general ambulance guidelines... Part I: Ambulance Guidelines Ambulance Fee Schedule

3. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 3 Ambulance Fee Schedule Just like medical legal services, ambulance services are covered in a separate fee schedule. Ambulance guidelines include reimbursement for: Transportation Services Supplies & Materials Lets take a look…

4. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 4 Vehicle & Crew Requirements The ambulance must be designed and equipped for transporting the sick, or injured, and include patient care equipment. The ambulance crew must have two members, one of which has medical training equivalent to the standard and advanced Red Cross training. Patient care equipment includes: Stretchers Clean linens First aid supplies Oxygen equipment Lifesaving equipment required by state and local authorities.

5. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 5 Ambulance Services The ambulance fee schedule covers transportation services only if other means of transportation are contraindicated, or inadvisable, due to the patients medical condition. Transportation services must be provided only to local facilities, unless necessary services are not available locally. Transportation may also be provided: From one hospital to another. To the patients home. To an extended care facility.

6. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 6 Air Ambulance Services In addition to ground ambulance services, air ambulance services are included in the ambulance fee schedule. Air ambulance services are covered when: The point of pick-up is inaccessible by land vehicle. The distances and/or other obstacles impede getting the patient to the nearest hospital with appropriate facilities.

7. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 7 Supplies and Materials Some types of supplies are considered part of general ambulance services, and are included in the charge for the trip. Reusable devices, not separately reimbursed include devices such as: Back boards Neck boards Inflatable leg and arm splints

8. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 8 Supplies and Materials In contrast, a separate reasonable charge may be recognized for non-reusable items and disposable supplies. Separate charges may be allowed for supplies, such as: Oxygen Gauze IV Tubing...that are required for patient care during the trip.

9. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 9 Modifiers For ambulance services, one-digit modifiers are combined to form a two-digit modifier. Please refer to the state reference guide for a list of modifiers. The first digit of the modifier identifies the ambulances place of origin. The second digit identifies the ambulances destination. Just like other types of service, special modifiers are associated with ambulance services.

10. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 10 Ambulance Reimbursement Now that you understand the basics of ambulance services, lets look at how these services are reimbursed... Part I: Ambulance Guidelines Ambulance Fee Schedule Crew Requirements Ambulance Services Supplies & Materials Modifiers Ambulance Reimbursement

11. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 11 Ambulance Reimbursement Reimbursement is consistent across all providers of ambulance services. The maximum reasonable fee for ambulance services shall not exceed 120% of the applicable fee as set forth in the CMS' Ambulance Fee Schedule. Providers of ambulance services include: Hospitals Private companies Fire departments

12. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 12 Ambulance Reimbursement For services provided in the year 2007, Medicare announced ambulance fees must be increased by an Ambulance Inflation Factor (AIF) of 1.025. To apply the new AIF, multiply the ambulance service fees in the CY 2007 Ambulance Fee Schedule by 1.025. As you can see, it is important to check the website often for updates!

13. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 13 Ambulance Reimbursement The ambulance fee schedule amount is determined by the zip code of the point of pick-up, not the providers address. Zip codes are divided into nine Medicare localities: 03 05 06 07 09 17 18 26 99

14. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 14 Zip Code Localities Within each of the nine localities, certain zip codes may be a rural area, which will have a different mileage rate than urban zip code areas in that same locality. A zip code table lists the locality of the zip code and indicates whether it is a rural or urban area. Different Mileage Rates

15. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 15 Zip Code Localities The zip code table is located at the following link: National Breakout of the Geographic Area Definitions by Zip Code Remember, for a specific zip code, the table indicates the: Locality Rural Indicator, if applicable

16. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 16 Zip Code Localities Each locality has several different associated values that you need to be familiar with. These different values include: Geographic Practice Cost Index (GPCI) Conversion Factor (CF) Mileage Ground Rate (MGR) Relative Value Unit (RVU) for each HCPCS code Lets take a look…

17. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 17 Ambulance Reimbursement You should be familiar with conversion factors and relative value units from your earlier studies of reimbursement calculations. However, you may not be familiar with the GPCI and MGR. Geographic Practice Cost Index (GPCI): Mileage Ground Rate (MGR) : A factor used to adjust for geographic differences in the cost of maintaining a medical practice. The reimbursement rate per mile for ground ambulance services.

18. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 18 Ambulance Reimbursement There are different reimbursement calculations for mileage and other types of service. Mileage Reimbursement: (MGR x Mileage)(AIF) = Total Reimbursement All Other Reimbursements: (RVU x CF x GPCI)(AIF) = Total Reimbursement Suppose an ambulance picks up an injured worker in the 95605 zip code area and travels nine miles to the nearest facility. How should the services be reimbursed? Lets take a look…

19. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 19 Ambulance Reimbursement 1. The first step is to identify the zip code locality from the zip code table. 2. For zip code 95605, the locality is 99. After identifying the zip code locality, reimbursement values can be calculated.

20. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 20 Ambulance Reimbursement Ambulance reimbursement information is available at the following website: http://www.dir.ca.gov/dwc/FeeSchedules/AMBULANCE_FeeSched ule/OMFS_Ambulance.pdf There, you will find tables listed by state that provide information specific to different localities.

21. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 21 Ambulance Reimbursement From the table you can get information for the following: Carrier # Locality HCPCS Code Conversion Factor Relative Value Unit GPCI Urban Mileage Rates Rural Mileage Rates

22. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 22 Ambulance Reimbursement For the example we are working with, suppose the bill shows HCPCS codes: A0425: Ground mileage, per statute mile. A0426: Ambulance service, advanced life support, non-emergency transport, level 1.

23. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 23 Ambulance Reimbursement From the zip code table we found that 95605 corresponds to Locality 99 and an urban area, because the rural indicator is blank. Zip CodeCarrierLocality Rural Indicator 956053114099 HCPCSRVUCFGPCIMGR A04251.0 1.2656.87 A04261.20209.651.265333.58 Then, by locating the correct locality on the table in the fee schedule, we found the information in the table below.

24. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 24 Ambulance Reimbursement Using the information in the table: HCPCSRVUCFGPCIMGR A04251.0 1.2656.87 A04261.20209.651.265333.58 Mileage Reimbursement: (MGR x Mileage)(AIF) = Total Reimbursement ($6.87 X 9 miles)= $63.37(1.025) Now lets take a look at the reimbursement calculation for the other expenses...

25. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 25 Ambulance Reimbursement Now, lets calculate the reimbursement for the services related to A0426. HCPCSRVUCFGPCIMGR A04251.0 1.2656.87 A0426209.651.201.265333.58 All Other Reimbursements: (RVU x CF x GPCI)(AIF) = Total Reimbursement ($209.65X 1.20= $326.19(1.025)X 1.265) Now that you have learned about ambulance services and how they are reimbursed, we will discuss DMEPOS guidelines.

26. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 26 DMEPOS Here, you will learn about DMEPOS services, how they are differentiated, and how they are reimbursed. Lets start by taking a look at some general guidelines... Part II: DMEPOS Guidelines DMEPOS Guidelines Asterisked Items Modifiers DMEPOS Reimbursement Part II: DMEPOS Guidelines DMEPOS Guidelines

27. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 27 DMEPOS Guidelines The DMEPOS Fee Schedule provides reimbursement guidelines for durable medical equipment, prosthetics, orthotics, and supplies. Prosthetics and orthotics are appliances or supplies that: Restore function Immobilize joints Protect joints Provide pain relief Correct & prevent deformity Replace body parts

28. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 28 DMEPOS Guidelines Reimbursement for orthotic and prosthetic services accounts for more than the device itself. Prosthetic and orthotic codes have a L or X prefix attached to a four digit numeric code. Reimbursement accounts for: Evaluation & consultation Construction Delivery Training on the proper use of the device

29. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 29 Asterisked Items Prosthetic and orthotic supplies can be designated by a single asterisk or a pair of asterisks in the fee schedule. One AsteriskTwo Asterisks Items denoted by a single asterisk in the Maximum Reimbursement list may be billed by a provider only if the item falls within the providers scope of their practice. Items denoted by a two asterisks may be reimbursed if the item falls within the providers scope of their practice, and if the pharmacy or pharmacist is certified by the NARD Health Support & Appliances Program. NARD stands for National Association of Retail Druggists.

30. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 30 Modifiers Just like other types of services, DMEPOS services can have associated modifiers. Lets take a look... Part II: DMEPOS Guidelines DMEPOS Guidelines Asterisked Items Modifiers DMEPOS Reimbursement Modifiers

31. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 31 Modifiers The DMEPOS reimbursement guidelines include three two-digit modifier supply codes. 51: This modifier indicates a medical supply company with certified orthotic personnel accredited by an organization recognized by the National Organization for Competency Assurance. 52: This modifier indicates a medical supply company with certified prosthetic personnel accredited by an organization recognized by the National Organization for Competency Assurance. 53: This modifier indicates a medical supply company with certified orthotic and prosthetic personnel accredited by an organization recognized by the National Organization for Competency Assurance.

32. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 32 Modifiers In addition to the modifier supply codes, there are two digit alphabetical modifiers. Most commonly these modifiers include: NU: Purchase, New RR: Rented UE: Purchased, Used KM: Replacement

33. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 33 DMEPOS Reimbursement Lastly, lets take a quick look at DMEPOS reimbursement guidelines... Part II: DMEPOS Guidelines DMEPOS Guidelines Asterisked Items Modifiers DMEPOS Reimbursement

34. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 34 DMEPOS Reimbursement The maximum reasonable fees for durable medical equipment, prosthetics, orthotics, and supplies should not exceed 120% of the applicable California fees set forth in the Medicare calendar year 2007. It is important to realize that the DMEPOS fee schedule is updated quarterly. Therefore, it is important to check for updates! To check for updates, you can find the DMEPOS fee schedule at: http://cms.hhs.gov/DMEPOSFeeSc hed/LSDMEPOSFEE/list.asp The most current version is: D07 JAN C.zip

35. March 2010 CA Regulations RefresherTraining – AMB & DMEPOS 35 Summary Ambulance Guidelines Ambulance Crew Requirements, Services, Supplies & Materials Ambulance Modifiers & Reimbursement Guidelines DMEPOS Guidelines DMEPOS Modifiers & Reimbursement Guidelines Asterisked Items in the DMEPOS Guidelines