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

2. March 2010 CA Regulations Training – AMB & DMEPOS Overview Hi! In this module, you will learn about two different fee schedules—Ambulance 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 Let’s start by discussing some general ambulance guidelines... Part I: Ambulance Guidelines  Ambulance Fee Schedule

3. March 2010 CA Regulations Training – AMB & DMEPOS 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 Let’s take a look…

4. March 2010 CA Regulations Training – AMB & DMEPOS 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 Training – AMB & DMEPOS Ambulance Services The ambulance fee schedule covers transportation services only if other means of transportation are contraindicated, or inadvisable, due to the patient’s 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 patient’s home.  To an extended care facility.

6. March 2010 CA Regulations Training – AMB & DMEPOS 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 Training – AMB & DMEPOS Supplies and Materials Let’s take a look… In addition to transportation, ambulance guidelines include reimbursement for certain supplies and materials.

8. March 2010 CA Regulations Training – AMB & DMEPOS 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

9. March 2010 CA Regulations Training – AMB & DMEPOS 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.

10. March 2010 CA Regulations Training – AMB & DMEPOS Modifiers Let’s take a look… Just like other types of service, special modifiers are associated with ambulance services.

11. March 2010 CA Regulations Training – AMB & DMEPOS 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 ambulance’s place of origin. The second digit identifies the ambulance’s destination.

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

13. March 2010 CA Regulations Training – AMB & DMEPOS 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

14. March 2010 CA Regulations Training – AMB & DMEPOS Ambulance Reimbursement For services provided in the year 2009, Medicare announced ambulance fees must be increased by an Ambulance Inflation Factor (AIF) of 1.05. To apply the new AIF, multiply the ambulance service fees in the CY 2008 Ambulance Fee Schedule by 1.05. As you can see, it is important to check the website often for updates!

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

16. March 2010 CA Regulations Training – AMB & DMEPOS 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

17. March 2010 CA Regulations Training – AMB & DMEPOS 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

18. March 2010 CA Regulations Training – AMB & DMEPOS 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 Let’s take a look…

19. March 2010 CA Regulations Training – AMB & DMEPOS 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.

20. March 2010 CA Regulations Training – AMB & DMEPOS 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? Let’s take a look…

21. March 2010 CA Regulations Training – AMB & DMEPOS 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.

22. March 2010 CA Regulations Training – AMB & DMEPOS 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.

23. March 2010 CA Regulations Training – AMB & DMEPOS 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

24. March 2010 CA Regulations Training – AMB & DMEPOS 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.

25. March 2010 CA Regulations Training – AMB & DMEPOS 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.

26. March 2010 CA Regulations Training – AMB & DMEPOS 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 let’s take a look at the reimbursement calculation for the other expenses...

27. March 2010 CA Regulations Training – AMB & DMEPOS Ambulance Reimbursement Now, let’s calculate the reimbursement for the services related to A0426. HCPCSRVUCFGPCI A04251.0 1.265 A04261.20209.651.265 All Other Reimbursements: (CF x RVU x GPCI) = Total Reimbursement ($209.65X 1.20 = $318.24 X 1.265) Now that you have learned about ambulance services and how they are reimbursed, we will discuss DMEPOS guidelines.

28. March 2010 CA Regulations Training – AMB & DMEPOS Ambulance Reimbursement Now, let’s 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.

29. March 2010 CA Regulations Training – AMB & DMEPOS Ambulance Reimbursement Using the information in the table: HCPCSRVUCFGPCIMGR A04251.0 1.0435.90 A0426234.521.201.043292.79 Mileage Reimbursement: (MGR x Mileage)(AIF) = Total Reimbursement ($5.90 X 9 miles)= $54.43(1.025) Now let’s take a look at the reimbursement calculation for the other expenses...

30. March 2010 CA Regulations Training – AMB & DMEPOS DMEPOS In Part II of this module, you will learn about DMEPOS services, how they are differentiated, and how they are reimbursed. Let’s 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

31. March 2010 CA Regulations Training – AMB & DMEPOS 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

32. March 2010 CA Regulations Training – AMB & DMEPOS DMEPOS Guidelines Reimbursement for orthotic and prosthetic services accounts for more than the device itself. Prosthetic and orthotic HCPCS 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

33. March 2010 CA Regulations Training – AMB & DMEPOS 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 provider’s scope of their practice. Items denoted by a two asterisks may be reimbursed if the item falls within the provider’s 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.

34. March 2010 CA Regulations Training – AMB & DMEPOS Modifiers Just like other types of services, DMEPOS services can have associated modifiers. Let’s take a look... Part II: DMEPOS Guidelines DMEPOS Guidelines Asterisked Items  Modifiers  DMEPOS Reimbursement  Modifiers

35. March 2010 CA Regulations Training – AMB & DMEPOS 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.

36. March 2010 CA Regulations Training – AMB & DMEPOS 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

37. March 2010 CA Regulations Training – AMB & DMEPOS DMEPOS Reimbursement Lastly, let’s take a quick look at DMEPOS reimbursement guidelines... Part II: DMEPOS Guidelines DMEPOS Guidelines Asterisked Items Modifiers  DMEPOS Reimbursement

38. March 2010 CA Regulations Training – AMB & DMEPOS 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 2010. 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://www.cms.hhs.gov/DMEPOSFeeSch ed/LSDMEPOSFEE/list.asp?filterType=n one&filterB The most current version is: D10_JanR [Zip, 2.0MB]

39. March 2010 CA Regulations Training – AMB & DMEPOS 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

40. March 2010 CA Regulations Training – AMB & DMEPOS Module 1 Quiz: U6M1: Ambulance & DMEPOS Guidelines Click on the link to go directly to the quiz. Feel free to review any of the material before you move on. Good Luck!