Illinois State Ambulance Association (ISAA) Henson.pdfas an EMT-Intermediate or an EMT-Paramedic by the state or local authority where the services are being furnished to perform one

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Jurisdiction 6 – Part B

Illinois State Ambulance Association (ISAA)

September 22, 2016


J6 Provider Outreach and Education Consultant

Carolyn S Henson CPC,CAC,CACO,CPC-I

AAPC I-10 Instructor

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Today’s Presenter

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Disclaimer

National Government Services, Inc. has produced this material as an informational reference for providers furnishing services in our contract jurisdiction. National Government Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare Program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare Program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the CMS website at https://www.cms.gov.

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No Recording

Attendees/providers are never permitted to record (tape record or any other method) our educational events

This applies to our webinars, teleconferences, live events and any other type of National Government Services educational events

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Acronyms

Acronyms used in this presentation can be viewed on the NGSMedicare.com website. On the Welcome page, click on Provider Resources > Acronyms.

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Objectives

To be a Partner with our Ambulance Provider Community

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Agenda

Medical Review Prepayment Review Results

Change Request 9761

Appeals

Duplicate Claims

Prior Authorization for Repetitive Scheduled Non-emergent Ambulance Prior Authorization Model

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Probe Update

A0425/A0428 modifier G or J

IL– Ambulance transport services to and from dialysis facilities

Medical documentation will be reviewed for evidence to support that the procedure code billed is documented and the level of service is appropriate.

Claims error rate 58.06%

Errors include: •Documentation did not clearly support other means of transportation were contraindicated.

•Documentation did not include a valid PCS (Physician Certification Statement)

•Insufficient documentation

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Primary Problems Identified:

1. Support Other Means of Transportation were Contraindicated

If the beneficiary is transported by wheelchair van for other appointments, he/she should be able to be transported to or from dialysis by wheelchair van also. The record needs to clearly state the reason a beneficiary is unable to sit in a wheelchair for transport

2. Valid Physician Certification Statement (PCS)

The PCS must be obtained no more than 60 days before the ambulance service is furnished and must be signed by the attending physician. Only a physician’s signature is acceptable on the PCS for medically necessary scheduled, repetitive transports. (Reference 42 CFR Section 410.40 (d) (2) and Section 410.40 (d) (3)). Information on the PCS should include a specific explanation as to why the beneficiary is unable to be transported by other means

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Primary Problems Identified:

3. Insufficient documentation

Mileage was denied if the documentation sent for review did not include a run sheet showing the mileage associated with the transport. The trip sheet/run sheet should also include a description of the beneficiary’s condition and functional status or physical assessment at time of transport

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Ambulance Staffing Requirements CR9761

Revise (1) 42 CFR 410.41(b) and the definition of Basic Life Support (BLS) in 42 CFR 414.605, to require that all Medicare covered ambulance transports be staffed by at least two people who meet both the requirements of state and local laws where the services are being furnished, and the current Medicare requirements, (2) 42 CFR 410.41(b) and the definition of Basic Life Support (BLS) in 42 CFR 414.605 to clarify that for BLS vehicles, one of the staff members must be certified at a minimum as an EMT-Basic, and (3) the definition of Basic Life Support (BLS) in 42 CFR 414.605 to delete the last sentence, which sets forth examples of certain state law provisions. CMS is updating the Medicare Benefit Policy Manual to incorporate these revisions

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Internet only manual (IOM) 100-02 Medicare Benefit

Policy Manual Chapter 10 Ambulance Services

10.1 - Vehicle Requirements Basic Life Support

Basic Life Support (BLS) ambulances must be staffed by at least two people, who meet the requirements of state and local laws where the services are being furnished and where, at least one of whom must (1) be certified at a minimum as an emergency medical technician-basic (EMT-basic) by the state or local authority where the services are being furnished and (2) be legally authorized to operate all lifesaving and life-sustaining equipment on board the vehicle

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10.2 - Vehicle Requirements Advanced Life Support

Advanced Life Support (ALS) vehicles must be staffed by at least two people, who meet the requirements of state and local laws where the services are being furnished and where at least one of whom must (1) meet the vehicle staff requirements for BLS vehicles and (2) be certified as an EMT-Intermediate or an EMT-Paramedic by the state or local authority where the services are being furnished to perform one or more ALS services

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30.1 - Definition of Ambulance Services

All ground and air ambulance transportation services must meet all requirements regarding medical reasonableness and necessity as outlined in the applicable statute, regulations and manual provisions

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30.1.1 - Ground Ambulance Services

The ambulance vehicle must be staffed by at least two people who meet the requirements of the state and local laws where the services are being furnished, and at least one of the staff members must be certified at a minimum as an emergency medical technician-basic (EMT-Basic) by the state or local authority where the services are being furnished and be legally authorized to operate all lifesaving and life-sustaining equipment on board the vehicle. These laws may vary from state to state or within a state

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Advanced Life Support, Level 1 (ALS1)

ALS1 is the transportation by ground ambulance vehicle (as defined in section 10.1) and the provision of medically necessary supplies and services (as defined in section 10.2) including the provision of an ALS assessment by ALS personnel or at least one ALS intervention

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ALS Assessment

An ALS assessment is 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

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ALS Personnel

ALS personnel are individuals trained to the level of the emergency medical technician-intermediate (EMT-Intermediate) or paramedic

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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. The nature of an ambulance’s response (whether emergency or not) does not independently establish or support medical necessity for an ambulance transport. Rather, Medicare coverage always depends on, among other things, whether the service(s) furnished is actually medically reasonable and necessary based on the patient’s condition at the time of transport

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In The Case of an Appropriately Dispatched ALS Emergency Service

If the ALS crew completes an ALS Assessment, the services provided by the ambulance transportation service provider or supplier may be covered at the ALS emergency level, regardless of whether the patient required ALS intervention services during the transport, provided that ambulance transportation itself was medically reasonable and necessary

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ALS Intervention

An ALS intervention is a procedure that is in accordance with state and local laws, required to be done by an emergency medical technician-intermediate (EMT-Intermediate or EMT-Paramedic)

You may not consider a procedure that is within the scope of practice of an EMT-Basic to be an ALS intervention

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ALS Intervention Possible Examples

Peripheral venous puncture

Blood drawing

Administration of IV fluids

Administration of IV medication

Monitoring IN solutions with medication

Remember each state has a different scope of practice for EMS providers, check state EMS laws and keep a list of current ALS interventions

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Advanced Life Support, Level 2 (ALS 2)

Advanced Life Support, Level 2 (ALS2)

ALS2 is the transportation by ground ambulance vehicle and the provision of medically necessary supplies and services including at least three separate administrations of one or more medications by intravenous (IV) push/bolus or by continuous infusion (excluding crystalloid fluids) or ground ambulance transport, medically necessary supplies and services, and the provision of at least one of the following ALS2 procedures

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Advanced Life Support, Level 2 (ALS 2) Procedures

Manual defibrillation/cardioversion

Endotracheal intubation

Central venous line

Cardiac pacing

Chest decompression

Surgical airway

Intraosseous line

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Application Example

Crystalloid fluids include but are not necessarily limited to 5 percent Dextrose in water (often referred to as D5W), Saline and Lactated Ringer’s. To qualify for the ALS2 level of payment, medications must be administered intravenously. Medications that are administered by other means, for example: intramuscularly, subcutaneously, orally, sublingually, or nebulized do not support payment at the ALS2 level rate

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Application Example

The IV medications are administered in standard doses as directed by local protocol or online medical direction (Specialty Societies). It is not appropriate to administer a medication in divided doses in order to meet the ALS2 level of payment. For example, if the local protocol for the treatment of supraventricular tachycardia (SVT) calls for a 6 mg dose of adenosine, the administration of three 2 mg doses in order to qualify for the ALS 2 level is not acceptable

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Application Example

The administration of an intravenous drug by infusion qualifies as one intravenous dose. For example, if a patient is being treated for atrial fibrillation in order to slow the ventricular rate with diltiazem and the patient requires two boluses of the drug followed by an infusion of diltiazem, then the infusion would be counted as the third intravenous administration and the transport would be billed as an ALS 2 level of service

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Application Example

The criterion of multiple administrations of the same drug requires that a suitable quantity of the drug be administered and that there be a suitable amount of time between administrations, and that both are in accordance with standard medical practice guidelines. Endotracheal (ET) intubation (which includes intubating and/or monitoring/maintaining an ET tube inserted prior to transport) is a service that qualifies for the ALS2 level of payment. Therefore, it is not necessary to consider medications administered by ET tube to determine whether the ALS2 rate is payable

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Specialty Care Transport (SCT)

Specialty Care Transport (SCT) is the Inter-facility 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 an EMT-Paramedic with additional training

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Inter-Facility is one in Which the Origin and Destination are One of the Following:

A hospital or Skilled Nursing Facility (SNF) that participates in the Medicare program, or

A hospital-based facility that meets Medicare’s requirements for provider-based status

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Duplicate Claim Submission

Same Provider

Same Beneficiary

Same Service/Item

Same Date of Service

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Claims NOT Finalized Cannot be Touched

Payment floor for electronically submitted claims is 14 days

Payment floor for paper claims is 29 days

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MA 130 Return/Reject / NO Appeal Rights

MA130 The only time it is appropriate to submit another claim/same service for consideration

Information was missing that is required to process the original claim / Rejected as unprocessable / Not a valid claim

MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.

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MA 01 Appeal Rights

MA01 Alert: If you do not agree with what we approved for these services, you may appeal our decision. To make sure that we are fair to you, we require another individual that did not process your initial claim to conduct the appeal. However, in order to be eligible for an appeal, you must write to us within 120 days of the date you received this notice, unless you have a good reason for being late.

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MA01 Appeal Rights

Services that have been processed for payment or denial (MA01) should not be refiled as a new claim to correct submission errors. A reopening or redetermination should be submitted for any correction for a service after the initial claim has been submitted for payment or denial

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Reopenings

Should be submitted to correct minor, uncomplicated, provider or carrier clerical errors

Online using NGSConnex

https://connex.ngsmedicare.com/home/start.swe?SWECmd=Start&SWEHo=connex.ngsmedicare.com

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Telephone Reopening Unit (TRU)

Jurisdiction 6

Illinois

877-867-3418, Press 1

Minnesota

877-867-3418, Press 2

Wisconsin

877-867-3418, Press 3

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Ambulance Documentation Not Included With Appeals

NGS must know why the patient was being transported , what medical need caused the transport, where they were coming from and being transported to, as well as why they could not have traveled by any other means

Reason for the Transport

Medical Necessity & Reasonableness

Transports from Hospital to Hospital must Include the Complete Name of the Hospital

No acronyms

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Redeterminations

IL, MN, WI

National Government Services, Inc.Attn: AppealsP.O. Box 6475Indianapolis, IN 46206-6475

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Repetitive Scheduled Non-emergent Ambulance Prior Authorization ModelThank you for your question. Last year, Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Section 515 expands the ambulance prior authorization model to all states as early as January 1, 2017 if the program meets certain requirements. We are currently collecting data to determine if all requirements specified in MACRA can be met. There is no anticipated implementation date at this time. CMS will continue to update the website (http://go.cms.gov/PAAmbulance) as information becomes available.

Thank you.

The Ambulance Prior Authorization Team

[email protected]

Tue 8/30/2016 4:01 PM

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E = Residential, domiciliary, custodial facility;

G = Hospital based ESRD facility;

J = Freestanding ESRD facility;

N = Skilled nursing facility;

P = Physician’s office;

R = Residence;

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Covered Destinations Specific to DialysisOrigin & Destination Modifiers ESRD


Basic life support (BLS) – Includes the provision of medically necessary supplies and services and BLS ambulance transportation as defined by the State where the transport is provided

A0426 - Ambulance service, Advanced Life Support (ALS), non-emergency transport, Level 1

A0428 - Ambulance service, Basic Life Support (BLS), non-emergency transport

A0425 - Mileage

*CMS Internet-Only Manuals (IOMs),The Medicare Benefit Policy Manual, Chapter 10, Section 30.1.1, “Ground Ambulance Service”

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Basic Life Support A0426, A0428

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Physician Certification Statement (PCS)

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Special rule: Nonemergency, Scheduled, Repetitive Ambulance Transports

Obtain a written order

Must be the Beneficiary’s attending physician

No earlier than 60 days before Date of Service (DOS)

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No particular form or format is required

Documentation– Patient’s name

– Date of service

– Patient diagnosis

– How and why patient is transported

– Severity of illness or injury

Exceptions– Pt. was residing at home – or in a facility and was not under

the direct care of a physician at the time of transport

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Physician Certification Statements


Physician Certification Statement (PCS)Repetitive Scheduled Non-emergent

For a Repetitive Scheduled Non-Emergent Ambulance Transport the patient’s attending physician is the ONLY person that may sign the PCS.

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A covered destination

The services were performed by qualified personnel

The transport was medically necessary and

reasonable (patient’s condition)

A physician certification statement / when necessary

Legible signatures with legible credentials

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Your Documentation Should Demonstrate:


CERT A/B MAC Outreach & Education Task Force

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The goal of the A/B MAC Outreach & Education Task Force is to ensure consistent communication and education to reduce the Medicare Part A and Part B error rates. A joint collaboration of the A/B MACs to communicate national issues of

concern regarding improper payments to the Medicare Program.

Partnership to educate Medicare providers on widespread topics affecting most providers and complement ongoing efforts of CMS, the MLN and the MACs individual error-reduction activities within its jurisdictions

Disclaimer: The CERT A/B MAC Outreach & Education Task Force is independent from the CMS CERT team and CERT contractors, which are responsible for calculation of the Medicare fee-for-service improper payment rate.

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CMS works closely with the CERT A/B MAC Task Force and the CERT DME MAC Outreach & Education Task Force CMS has a web page dedicated to education developed by the CERT

A/B MAC Outreach & Education Task Force

• https://www.cms.gov/Medicare/Medicare-Contracting/FFSProvCustSvcGen/CERT-Outreach-and-Education-Task-Force.html

NGS CERT Task Force Web Page Go to our website, https://www.NGSMedicare.com; in the About Me

drop down box, select your provider type and applicable state, click on Next, accept the Attestation. Choose the Medical Policy & Review tab, then choose CERT, the CERT Task Force link is located to the right of the web page.

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Email Updates

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Thank You!

Follow-up email

Questions?

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Documents

Illinois State Ambulance Association (ISAA) Henson.pdfas an EMT-Intermediate or an EMT-Paramedic by the state or local authority where the services are being furnished to perform one