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© Copyright 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 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 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 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 J.R. Henry Consulting Inc. HEALTH CARE REIMBURSEMENT Most EMS services only collect ~40% - 50% of their billed charges!
© Copyright 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 J.R. Henry Consulting Inc. Ambulance Industry Being Targeted for Fraud & Abuse
© Copyright J.R. Henry Consulting Inc.
© Copyright 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 J.R. Henry Consulting Inc.
Medicare Reimbursement Update New Anti-Fraud Regulations
© Copyright 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 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 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 J.R. Henry Consulting Inc. Corporate Compliance Programs Components –Audit/Assessment –Written Plan –Training –Monitoring –Updating –Self-Disclosure –Hotline / Reporting Mechanism
© Copyright J.R. Henry Consulting Inc. Corporate Compliance Programs Contact Page, Wolfberg and Wirth LLC at for low cost sample compliance plans and policies
© Copyright J.R. Henry Consulting Inc. Billing and Coding Issues
© Copyright J.R. Henry Consulting Inc. Medicare HCPCS Codes A0428BLS A0429BLS - E A0426ALS 1 - NE A0427ALS 1 - E A0433ALS 2 A0434 SCT A0432Paramedic Intercept –Only applicable in certain parts of New York Fee Schedule Fundamentals
© Copyright J.R. Henry Consulting Inc. Payment for Base Rate and loaded mileage ONLY! Urban vs. Rural Base Rates Rural Mileage Bonus of 25% for first 17 loaded miles Fee Schedule Fundamentals
© Copyright 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 Paramedic Assessment Coding
© Copyright 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 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 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 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 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 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 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 J.R. Henry Consulting Inc. Medicare Reimbursement Update Mileage and Signature Authorization Requirements
© Copyright 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 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 J.R. Henry Consulting Inc. Medicare Reimbursement Update Modifiers, ICD-9 and Condition Codes
© Copyright 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 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 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 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 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 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 J.R. Henry Consulting Inc. Why do I need to obtain all of this information and also the patient’s signature?
© Copyright J.R. Henry Consulting Inc. “If it isn’t documented – It didn’t happen!” Medical Record Documentation
© Copyright J.R. Henry Consulting Inc. Medical Record Documentation To some degree, Everyone has a photographic memory… Some just don't have any film!!
© Copyright 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 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 J.R. Henry Consulting Inc. New CMS Signature Rule In 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 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 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 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
© Copyright J.R. Henry Consulting Inc. THANK YOU FOR PARTICIPATING IN THIS SESSION!!! Special Thanks
J.R. Henry, EMT-P 535 Perry Highway Pittsburgh, PA (412) (412) (fax)
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