Texas EMS Alliance Presents: EMS Evolution...
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7/19/2015 1 Texas EMS Alliance Presents: EMS Evolution 2015 August 4, 2015 Disclaimer • All Current Procedural Terminology (CPT) only copyright 2014 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable Federal Acquisition Regulation/ Defense Federal Acquisition Regulation (FARS/DFARS) Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. • The information enclosed was current at the time it was presented. Medicare policy changes frequently; links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. • Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. • Novitas Solutions 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 guide. • This presentation is a general summary that explains certain aspects of the Medicare program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. • Novitas Solutions does not permit videotaping or audio recording of training events.
Transcript of Texas EMS Alliance Presents: EMS Evolution...
7/19/2015
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Texas EMS Alliance Presents:
EMS Evolution 2015
August 4, 2015
Disclaimer
• All Current Procedural Terminology (CPT) only copyright 2014 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable Federal Acquisition Regulation/ Defense Federal Acquisition Regulation (FARS/DFARS) Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
• The information enclosed was current at the time it was presented. Medicare policy changes frequently; links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations.
• Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.
• Novitas Solutions 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 guide.
• This presentation is a general summary that explains certain aspects of the Medicare program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings.
• Novitas Solutions does not permit videotaping or audio recording of training events.
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Agenda
• Updates and Reminders
• Draft Ambulance Local Coverage Determination (LCD) Policy
• Frequently Asked Questions (FAQs)
• Comprehensive Error Rate Testing Program (CERT)
• Office of Inspector General (OIG)
• Documentation Requirements
• Physician Certification Statement (PCS) Requirements
• 2017 Prior Authorization Process
• Enrollment and Revalidation
• Self-Service Options
Acronym List
Acronym Definition
CERT Comprehensive Error Rate Testing
CMS Centers for Medicare & Medicaid Services
CARC Claims Adjustment Reason Code
CPT Current Procedural Terminology
HCPCS Healthcare Common Procedure Coding System
GPS Global Positioning System
MREP Medicare Remit Easy Print
RARC Remittance Advice Remark Codes
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Updates and Reminders
Medicare Administrative Contractor
(MAC) Satisfaction Indicator (MSI)
• Your opinion is important to us!
• Share your experience with the services we provide
• Quick 10 minute survey
• CFI Group is conducting the survey on behalf of CMS
• Technical difficulties, contact CFI support at o [email protected]
• Links to surveys o https://cfigroup.qualtrics.com/SE/?SID=SV_3UBxriB8
PrHOZEN&MAC_BRNC=7
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Novitas Website
Improvements
• Based on your feedback we continue to
improve our website
• Recent website improvements
o Content pages now include ‘Last Updated’
date
o Continued cleanup of outdated documents
o Quick access rolling banner spotlighting
Medicare news
Website Satisfaction
Surveys
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Novitas Home Page
Customized Content
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Novitas Solutions Home
Page
What is Novitasphere?
• Novitasphere is our free web-based Portal that will allow providers access to Eligibility, Claim Information and Remittance Advice, Claim Submission with File Status, Electronic Remittance Advice (ERA), Claim Correction, and MailBox
• Novitasphere is available to the Jurisdiction H and Jurisdiction L Part B Provider Community
• Visit the Learning Management System to Register for all of demonstrations being offered for Novitasphere
• More Information on Novitasphere can be located on our website www.novitas-solutions.com or by accessing the link below o http://www.novitas-
solutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00081055
• Novitasphere will soon be available for Billing Services and Clearinghouses that service Part B practitioners! o Coming September 2015
o Stay tuned for EDI Mailing List Messages regarding testing and enrollment
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Novitasphere Registration
• Step 1: Determine who the Provider Office Approver, or primary person from your office, who will be responsible for accessing the application
• Step 2: Complete the Electronic Data Interchange (EDI) Portal Enrollment form (8292PJH) found in the Enrollment section of the Novitasphere Center of our website o Fax the completed form to 1-877-439-5479
• Step 3: Once the EDI enrollment form is approved, you will receive instructions to apply for a User ID for the Provider Office Approver, and the required next steps to set up access for your organization and End Users
Eligibility Information
• Eligibility o Part A Eligibility Effective and Termination
Dates
o Part B Eligibility Effective and Termination Dates
o Part B Total Deductible Remaining for Calendar year
o Occupational Therapy amount applied to the capitation limit
o Physical/Speech Therapy amount applied to the capitation limit
• Medicare Advantage Plan (MAP) o Contract Name and Number
o Type of Medicare Advantage Plan
o The Bill Option code of the Plan type
o Effective and Termination Dates
o Plan Address and Telephone Number
• Medicare Secondary Payer (MSP) o The reason Medicare is secondary
o Effective and Termination Dates
o Name of Insurance Company and Address
• Hospice/Home Health o Insurer Name and Address
o Home Health Episode Start and End Dates
o Home Health Episode termination date
o Provider NPI Number of the Home Health Facility
• Preventive Services o Number of Smoking Sessions remaining for
the beneficiary.
o Next Available Smoking Cessation Date
o Preventive Service Procedure Code
o The date the beneficiary is eligible for the associated procedure code
o Calendar Year
o Deductible Applied for the Calendar Year
o Deductible Remaining for the Calendar Year
o Coinsurance Remaining for the Calendar Year
• Inpatient o Date of earliest and latest billing activity for
the spell of illness
o Hospital Information
o Skilled Nursing Facility Information
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Novitasphere Claim
Correction Feature
• Save your office valuable time with this great Novitasphere feature!
• It’s free, quick, easy, and secure to do on-line with no need to call our Claim Correction line!
• The following common clerical errors can be corrected on finalized claims through the Novitasphere Claim Correction feature o Number of services or units
o Diagnosis code (Primary)
o Eligible modifiers
o Procedure code
o Date of service
o Place of service
o Billed amount
• Novitasphere Claims Correction Guide o http://novitas-
solutions.com/cs/idcplg?IdcService=GET_FILE&RevisionSelectionMethod=LatestReleased&dDocName=00086496&allowInterrupt=1
Novitasphere Portal
Home Page
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Novitasphere Help Desk
1-855-880-8424
Increasing Your Bottom Line:
How Much Does Rework Cost Your
Organization?
• Campaign began May 2015
• Focus on cost savings for providers by reducing the need for reopening requests
• Website page dedicated to the campaign o http://www.novitas-
solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00092539
• Long term initiative with new articles added frequently
• Periodic webinars will be conducted
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Ambulance Inflation Factor
for 2015
• Change Request # 8895 o Effective: January 1, 2015
o Implementation: January 5, 2015
• Key Points o The ambulance inflation factor for 2015 is 1.5 percent
o Deductible and coinsurance requirements apply to payments under the Ambulance Fee Schedule http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/AmbulanceFeeSchedule/index.html
• References o http://www.cms.gov/Outreach-and-Education/Medicare-
Learning-Network-MLN/MLNMattersArticles/Downloads/MM8895.pdf
Medicare Access and CHIP
Reauthorization Act of 2015
• Effective for dates of service on and after April 1, 2015
• Extended the Medicare ground ambulance bonus payments until December 31, 2017
• The Medicare fee schedule amount for ground ambulance services will continue to be increased by:
o 3% for transports originating in rural area;
o 2% for transports originating in urban areas; and
o 22.6% for transports originating in super-rural area
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Medicare Access and CHIP
Reauthorization Act of 2015 (Cont.)
• National Expansion of Prior Authorization
for Repetitive scheduled non-emergent
Ambulance transports
• Effective January 1, 2017, for all states
• Reference
o https://www.congress.gov/bill/114th-
congress/house-bill/2/text
Upcoming Change to the
Establishment of Medicare Effective
Dates
• Change Request # 9065
o Effective: May 28, 2015
o Implementation: May 28, 2015
• Key Points
o CMS is limiting the ability of ambulance suppliers to “backbill” for services performed prior to enrollment
o Specifically, the effective date of Medicare billing privileges will be the later of The date the supplier filed an enrollment application that was
subsequently approved, or
The date the supplier first began furnishing services at a new practice location
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Upcoming Change to the
Establishment of Medicare
Effective Dates (Cont.)
• The date of filing for paper enrollment applications
is the date of receipt by the Medicare Administrative Contractor (MAC)
• The date of filing for Internet-based Provider Enrollment, Chain and Ownership System (PECOS) applications is the date the MAC received an electronic version of the enrollment application and a signed certification statement submitted via paper or electronically
Upcoming Change to the
Establishment of Medicare
Effective Dates (Cont.)
• An ambulance supplier may retrospectively bill for services when it has met all program requirements, including state licensure requirements, and the services were provided at the enrolled practice location for up to o 30 days prior to their effective date , if circumstances precluded
enrollment in advance of providing services to Medicare beneficiaries, or
o 90 days prior to their effective date if a Presidentially-declared disaster under the Robert T. Stafford Disaster Relief and Emergency Assistance Act precluded enrollment in advance of providing services to Medicare beneficiaries
• Reference o http://www.cms.gov/Regulations-and-
Guidance/Guidance/Transmittals/Downloads/R582PI.pdf
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Extension of Provider Enrollment
Moratoria for Part B Ambulance
Suppliers
• Special Edition Article SE1425
• Effective January 29, 2015
• Key Points o The temporary moratoria on new Part B ambulance suppliers are being extended for
an additional 6 months in certain geographic locations
o Locations City
– Houston, TX
Counties – Harris
– Brazoria
– Chambers
– Fort Bend
– Galveston
– Liberty
– Montgomery
– Waller
• References o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNMattersArticles/downloads/SE1425.pdf
Mandatory Payment Reductions
— “Sequestration”
• Medicare Fee-for-Service claims with dates of service or date of discharge on or after April 1, 2013
• 2% reduction to Medicare payment will continue until March 31, 2016
• Payment adjustments shall be applied to all claims after determining the Medicare payment including application of the current fee schedule, coinsurance, any applicable deductible, and any Medicare Secondary Payment adjustments
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ICD-10 Implementation
• Are you prepared?
o October 1, 2015, is the compliance date for
health care providers, health plans, and health
care clearinghouses to transition to ICD-10
• Where can I find more information on the
ICD-10 Implementation?
o http://www.novitas-
solutions.com/webcenter/portal/MedicareJH/page
byid?contentId=00003602
Special Edition Article SE1239
ICD-10 Implementation
• Updated ICD-10 Implementation
• Provides updated information about the implementation of the ICD-10 and ICD-10-PCS code sets to help you better understand and prepare for the change from ICD-9 to ICD-10 o Date of Service for Part B Professional Billing
o Date of Discharge specific for Part A Institutional Billing
• Reference o http://www.cms.gov/Outreach-and-
Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1239.pdf
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ICD-10 Implementation
Claim Submission
• ICD-9 codes will no longer be accepted for claims ON or AFTER the implementation of the new revision
• ICD-10 codes will not be recognized/accepted for claims BEFORE implementation o Date of service for Part B professional claims
o Date of discharge/through dates for on Part A institutional claims
• Claims cannot contain BOTH ICD-9 codes and ICD-10 codes o Institutional Claims - Return to Provider (RTP)
o Professional/Supplier Claims - Return as Unprocessable
Updates to International Classification
of Diseases, 10th Edition (ICD-10)
Local Coverage Determinations
• Special Edition Article SE1421
• Key Points
o Advises how to access ICD-10 Local Coverage
Determinations (LCDs) in the CMS Medicare
Coverage Database (MCD)
• Reference
o http://www.cms.gov/Outreach-and-
Education/Medicare-Learning-Network-
MLN/MLNMattersArticles/Downloads/SE1421.pdf
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New Timeframe for Response to
Additional Documentation Requests
(ADR)
• Change Request # 8583 o Effective : April 1, 2015
o Implementation: April 6, 2015
• Key Points o Prepayment review providers and suppliers have 45
calendar days to respond to an ADR letter
o Failure to respond within 45 days of a pre-payment review ADR will result in denial of the claim(s) related to the ADR
• Reference o http://www.cms.gov/Outreach-and-Education/Medicare-
Learning-Network-MLN/MLNMattersArticles/Downloads/MM8583.pdf
How to Correctly Submit
Documentation for Additional
Documentation Requests (ADR)
• Novitas Solutions’ Medical Review Department
has noticed an increase in the improper submission of documentation in response to an Additional Documentation Request (ADR)
• Multiple occurrences have been identified of providers submitting redetermination forms in response to an ADR
• Redetermination forms should never be used to submit documentation or records requested by an ADR but should only be utilized if you disagree with the initial claim determination
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How to Correctly Submit
Documentation for Additional
Documentation Requests (ADR)
• The process whereby a contractor requests additional
documentation after claim receipt is known as "development“
• When a coverage or coding determination cannot be made based upon the information on the claim and its attachments (e.g., due to a medical review of the service/claim), contractors may solicit for more information by issuing an ADR
• Novitas Solutions specifies in the development letter or ADR, a description of the type of documentation that is needed to make the coverage or coding determination, along with the date of service o Make sure you review the ADR letter carefully as the ADR letter may
request multiple types of documentation
• Reference o http://www.novitas-
solutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00093969
Upcoming Focus of Provider
Specific Reviews-Medical Review
Part B-JH
• A0427- Ambulance service, advanced life
support, emergency transport, level 1
(ALS1- Emergency)
• Reference
o http://www.novitas-
solutions.com/webcenter/spaces/MedicareJH/
page/pagebyid?contentId=00083013
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Informational Unsolicited Response
(IUR) or Reject for Ambulance SNF
to SNF Transfer
• Change Request # 8408
o Effective: April 1, 2014
o Implementation: April 7, 2014
• Key Point o Implementing system changes to reject ambulance claims
when suppliers are billing ambulance claims for Skilled Nursing Facility (SNF) to SNF transfer separately under Part B
o This resulted in an overpayment for a transport between two SNFs when a beneficiary is in a Part A covered SNF stay
• Reference o http://www.cms.gov/Outreach-and-Education/Medicare-
Learning-Network-MLN/MLNMattersArticles/downloads/MM8408.pdf
Contractors Requirements
for CR 8408
• If the ambulance transport date falls within the dates of an SNF Part A stay, the contractor is required to view the claim that was submitted by the SNF to see what the discharge status is o If the SNF filed their claim with a discharge status of “03” (03 -
Discharged/Transferred to a Skilled Nursing Facility (SNF) with Medicare Certification in Anticipation of Skilled Care) and the ambulance claim paid, an overpayment has occurred. If the Ambulance claim is in process and the SNF filed their claim with a discharge status of 03, the ambulance claim will deny
o The CR did not direct the contractors to review the modifiers submitted by the Ambulance supplier. For complete details refer to the CR 8408 Recoupment and Denial Message will be: N390-This service/report cannot be
billed separately
• If the Ambulance supplier disagrees with the overpayment or claim denial a redetermination will need to be submitted by following the Appeals guidelines from the Novitas Website o http://www.novitas-solutions.com/webcenter/spaces/Appeals_JH
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Issues Identified with the
Implementation of CR 8408
• If the SNF files their claim with the
incorrect “discharge status code” this could cause the claim to deny in error or an overpayment to occur in error
o Example Patient in a SNF Part A stay is being transported to
a hospital and is admitted.
If the SNF files their claim with a “Status Code of 03” this indicates to Medicare the patient is being transferred to another SNF
Resource for Discharge
Status Codes
• Special Edition Article SE 0801 Revised
• Key Points
o Clarification of Patient Discharge Status Codes and Hospital
Transfer Policies
• Reference
o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-MLN/MLNMattersArticles/downloads/SE0801.pdf
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Draft Ambulance LCD (Ground
Ambulance) ( DL32606 )
CMS National Policy
• Medicare coverage for ambulance transportation is limited by the Centers for Medicare & Medicaid Services (CMS) national policy in accordance with federal law o Medicare covers ambulance services only if furnished to a
beneficiary whose medical condition at the time of transport is such that transportation by other means would endanger the patient’s health
o A patient whose condition permits transport in any type of vehicle other than an ambulance does not qualify for Medicare payment
o Medicare payment for ambulance transportation depends on the patient’s condition at the actual time of the transport regardless of the patient’s diagnosis
o To be deemed medically necessary for payment, the patient must require both the transportation and the level of service provided
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CMS National Policy
(Cont.)
• Medicare covers both emergency ambulance transportation and non-emergency ambulance transportation based on Medical Necessity o Ambulance transportation is covered when the patient’s
condition requires the vehicle itself and/or the specialized services of the trained ambulance personnel
o A requirement of coverage is that the needed services of the ambulance personnel were provided and clear clinical documentation validates their medical need and their provision in the record of the service (usually the run sheet)
• Actual transportation of the beneficiary occurs
• Services must be reasonable and necessary
• Transportation is to the closest appropriate facility
Proposed Changes
• Coverage Guideline
o Coverage Indications, Limitations, and/or
Medical Necessity
Compliance with the provisions in this policy may
be monitored and addressed through prepayment
and/or post payment data analysis and subsequent
medical review audits
Emergency Ambulance Service
– Added CMS application guidelines
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Proposed Changes (Cont.)
• Codes that Support Medical Necessity
o Removed the ICD-9/ICD-10 approved tables
1 and 2
Due to the large number of possible covered
diagnosis codes, the Contractor is not providing a
comprehensive list of covered diagnosis codes for
HCPCS codes A0425, A0426, A0427, A0428,
A0429, A0433 and A0434
Current Procedural Terminology (CPT) only copyright 2014 American Medical Association. All rights reserved.
Proposed Changes (Cont.)
• All ambulance transports require dual diagnosis codes as
described below
• Providers should report the most appropriate ICD-9-CM code that adequately describes the patient's medical condition (for example: stroke, coma, trauma, etc.) at the time of transport as the primary diagnosis o In addition, a secondary diagnosis, must be reported
• Additionally, the KX modifier must be reported on the claim for the service to be considered for coverage o Reporting of the KX modifier is an attestation from the provider
that the services are reasonable and necessary and that there is documentation of medical necessity in the patient's record
o The KX modifier should not be reported if the patient's condition does not require an ambulance
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Proposed Changes (Cont.)
• Group 1 Codes o V46.11 Dependence on Respirator, Status
Note: Use code V46.11 to denote ventilator dependency transport ONLY
o V46.9 Unspecified Machine Dependence Note: Use code V46.9 to denote the need for continuous IV
fluids, 'active airway management' or the need for multiple machine devices
o V49.84 Bed Confinement Status Note: Use code V49.87 to denote patient safety: danger to self
and others - monitoring other and unspecified reactive psychosis
o V49.87 Physical Restraints Status
o V71.9 Observation for Unspecified Suspected Condition Note: Use code V71.9 to denote the need for continuous clinical
assessment throughout the transport
Proposed Changes (Cont.)
• ICD-9 Codes that DO NOT Support
Medical Necessity
o V68.81 Referral of patient without
examination or treatment
Note: V68.61 should be reported for those patients
who were transported by ambulance but did NOT
require the services of an ambulance crew
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Proposed Documentation
Requirements
• All documentation must be maintained in the patient's medical record and made available to the contractor upon request
• Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s))
• The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient
• The submitted records must support the use of the selected diagnoses
• The submitted CPT/HCPCS code must describe the service performed
Mileage Documentation
• Documentation supporting the number of loaded miles billed o See FAQ for Ambulance posted on Novitas
website
o Documentation may include odometer reading, trip odometer reading, GPS system, navigation computer, mapping programs and will need to be available if requested
o Reference http://www.novitas-
solutions.com/webcenter/portal/FAQs_JH
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Comment Period
• Newly developed Local Coverage Determinations (LCDs) and those with significant revisions are posted for “comment” for 45 days on the Novitas Website o Ambulance policy was posted on January 15, 2015
o Comment period ended March 5, 2015
• All comments are considered as the LCD is finalized
• Once finalized, a synopsis of the LCD is published
• Approximately 45 days after it is finalized, the LCD becomes effective
Comment Period Ends
• When Comment Period Ends
o Novitas will provide a minimum comment period of 45 calendar days
o A contractor has the discretion but is not required to accept comments submitted after the end of the comment period
o Comment period ended March 5, 2015
o Medical Directors are working on finalizing the policy
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Frequently Asked Questions
(FAQs)
Appropriate Facility
• What is does Medicare consider an
appropriate facility?
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Ambulance Coverage
Destinations
• Only to the following destinations o Hospital
o Critical Access Hospital (CAH)
o Skilled Nursing Facility (SNF)
o Beneficiary’s home.
o Dialysis facility for End Stage Renal Disease (ESRD) patient who requires dialysis
• Covered to the nearest appropriate facility
• Mileage to the nearest appropriate facility covered
Appropriate Facilities
• The term “appropriate facilities” means that the institution is generally equipped to provide the needed hospital or skilled nursing care for the illness or injury involved
• In the case of a hospital, it also means that a physician or a physician specialist is available to provide the necessary care required to treat the patient’s condition
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Origin and Destination
Modifiers Modifier Description
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 dialysis facility
H Hospital
I Site of transfer between modes of ambulance transport
J Non-hospital-based dialysis facility
N Skilled Nursing Facility
P Physician’s office
R Residence
S Scene of accident
X Intermediate stop at physician’s office on way to hospital (destination code only)
• First position equals the origin; Second position equals destination o Example: HN = Hospital (origin) to Skilled Nursing Facility (destination)
• Must be a provider based off campus facility to qualify for the H origin/destination otherwise if not provider based then it is a P origin/destination and not covered
• Refer to 42 CFR 413.65 to determine if the Free Standing Emergency Facility is provider based or not o http://www.gpo.gov/fdsys/pkg/CFR-2011-title42-
vol2/pdf/CFR-2011-title42-vol2-sec413-65.pdf
• Reference o This information was provided during the CMS
Ambulance Open Door Forum on April 21, 2015
Free Standing Emergency
Facility
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Separately Payable Ambulance
Transport Under Part B Benefits
Versus Part A
• Transportation of a beneficiary from his
home, an accident scene or any other point
of origin is covered under the Part B benefits
as an ambulance service only to the nearest
hospital, CAH, or SNF that is capable of
furnishing the required level and type of care
for the beneficiary’s illness or injury and only
if medical necessity and other program
coverage criteria are met
Separately Payable Ambulance Transport
Under Part B Benefits Versus Part A
(Cont.)
• Medicare-covered ambulance services are paid either as separately
billed services, in which case the entity furnishing the ambulance service bills under the Part B benefit of the program, or as a packaged service, in which case the entity furnishing the ambulance service must seek payment from the provider who is responsible for the beneficiary’s care
• If either the origin or the destination of the ambulance transport is the beneficiary’s home, then ambulance transport is paid separately by the Medicare Part B benefit and the entity that furnishes the ambulance transport may bill its Medicare contractor directly
• If both the origin and destination of the ambulance transport are providers, e.g., a hospital, CAH, SNF, then responsibility for payment for the ambulance transport is determined in accordance with the following sequential criteria on the next slide
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Determining who to bill
Part A or Part B
• These criteria must be applied in
sequence
• Criterion 1
o Provider Numbers
If the Medicare-assigned provider numbers of the
two providers are different, the ambulance service
is separately billable to the program
If the provider number of both providers is the
same, consider criterion 2, “campus”
Determining who to bill
Part A or Part B (Cont.)
• Criterion 2
o Campus Following criterion 1, if the campuses of the two providers
(sharing the same provider numbers) are the same, the transport is not separately billable to the program
In this case, the provider is responsible for payment
If the campuses of the two providers are different, consider criterion 3, “patient status.”
– “Campus” means the physical area immediately adjacent to the provider’s main buildings, other areas and structures that are not strictly contiguous to the main buildings, but are located within 250 yards of the main buildings, and any of the other areas determined on an individual case basis by the CMS regional office to be part of the provider’s campus
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Determining who to bill Part
A or Part B (Cont.)
• Criterion 3
o Patient Status, Inpatient vs. Outpatient
Following criteria 1 and 2, if the patient is an inpatient
at both providers (i.e., inpatient status both at the origin
and at the destination, providers sharing the same
provider number but located on different campuses),
the transport is not separately billable
In this case the provider is responsible for payment. All
other combinations (i.e., outpatient-to-inpatient,
inpatient-to-outpatient, outpatient-to-outpatient) are
separately billable to the program
Determining who to bill
Part A or Part B (Cont.)
• In the case where the point of origin is not a provider, Part A coverage is not available because, at the time the beneficiary is being transported, the beneficiary is not an inpatient of any provider paid under Part A of the program and ambulance services are excluded from the three-day preadmission payment window
• The transfer, i.e., the discharge of a beneficiary from one provider with a subsequent admission to another provider, is also payable as a Part B ambulance transport benefit
• This includes an outpatient transfer from a remote, off-campus Emergency Room (ER) department to becoming an inpatient or outpatient at the main campus hospital, even if the ER is owned and operated by the hospital
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Determining who to bill
Part A or Part B (Cont.) • Once a beneficiary is admitted to a hospital, CAH or SNF, it may be necessary to
transport the beneficiary to another hospital or other site temporarily for specialized care while the beneficiary maintains inpatient status with the original provider
• This movement of the patient is considered “patient transportation” and is covered as an inpatient hospital or CAH service and as an SNF service when the SNF is furnishing it as a covered SNF service and payment is made under Part A for that service. (If the beneficiary is a resident of an SNF and must be transported by ambulance to receive dialysis or certain other high-end outpatient hospital services, the ambulance transport may be separately payable under the Part B benefit)
• Because the service is covered and payable as a beneficiary transportation service under Part A, the service cannot be classified and paid for as an ambulance service under the Part B benefit
• This includes intracampus transfers between different departments of the same hospital, even where the departments are located in separate buildings. Such intracampus transfers are not separately payable under the Part B ambulance benefit. Such costs are accounted for in the same manner as the costs of such a transfer within a single building
Reference
• CMS IOM 100-02 Chapter 10, Section
10.3.3.
o http://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/bp1
02c10.pdf
7/19/2015
33
Paramedic Intercept
• Does Medicare pay for Paramedic
Intercept?
Paramedic Intercept
Coverage
• A0432 – Paramedic Intercept (PI) – rural area transport furnished by a volunteer ambulance company, which is prohibited by state law from billing third-party payers
• Based on the definition of paramedic intercept, suppliers/providers are not meeting the definition when billing the paramedic code
• Oklahoma and Texas do not prohibit a volunteer ambulance company from billing a third-party payer
• Coverage o Presently, only the state of New York meets the Medicare requirements
for paramedic intercept. Contractors will deny all other states
• Reference o CMS IOM 100-04 Chapter 15
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c15.pdf
Current Procedural Terminology (CPT) only copyright 2014 American Medical Association. All rights reserved.
7/19/2015
34
Joint Responses
• In situations where a Basic Life Support (BLS) entity provides the transport of the beneficiary and an Advanced Life Support (ALS) entity provides a service that meets the fee schedule definition of an ALS intervention (e.g., ALS assessment, paramedic intercept services, etc.), the BLS supplier may bill Medicare the ALS rate provided that a written agreement between the BLS and ALS entities exists
• Providers/suppliers must provide a copy of the agreement or other such evidence (e.g., signed attestation) as determined by their intermediary or carrier upon request
• Contractors must refer any issues that cannot be resolved to the regional office
• Reference o CMS IOM 100-02 Chapter 10 Section 10.5
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c10.pdf
Specialty Care Transport
(SCT)
• What are the guidelines on billing for SCT
transports?
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35
Specialty Care Transport
(SCT) – A0434
• SCT is the interfacility transportation of a critically injured or ill
beneficiary by ground vehicle, including the provision of medically necessary supplies and services beyond the scope of the Emergency Medical Technician (EMT) paramedic
• SCT is necessary when a patient’s condition requires ongoing care that must be provided by one or more health professionals in an appropriate specialty area
• Example o Emergency or critical care nursing, emergency medicine,
respiratory care, cardiovascular care or a paramedic with additional training
Current Procedural Terminology (CPT) only copyright 2014 American Medical Association. All rights reserved.
Specialty Care Transport
(SCT) Cont.
• The EMT-Paramedic level of care is set by each state
• Care above that level that is medically necessary and is furnished at a level of service above the EMT-Paramedic level of care is considered SCT
• That is to say, if EMT-Paramedics without specialty care certification or qualification are permitted to furnish a given service in a state, that service does not qualify for SCT
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36
Specialty Care Transport
(SCT) Cont.
• The phrase “EMT-Paramedic with additional training” recognizes that a state may permit a person who is not only certified as an EMT-Paramedic, but who also has successfully completed additional education as determined by the state in furnishing higher-level medical services required by critically ill or critically injured patients, to furnish a level of service that otherwise would require a health professional in an appropriate specialty care area (e.g., a nurse) to provide
• “Additional training” means the specific additional training that a state requires a paramedic to complete to qualify to furnish specialty care to a critically ill or injured patient during an SCT
Specialty Care Transport
(SCT)
• CMS considers a “facility” to include only an SNF or hospital that participates in the Medicare program or a hospital-based facility that meets CMS’ requirement for provider-based status
• Medicare hospitals include, but are not limited to, rehabilitation hospitals, cancer hospitals, children’s hospitals, psychiatric hospitals, Critical Access Hospitals (CAHs), inpatient acute-care hospitals and Sole Community Hospitals (SCHs)
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37
Transport that does not meet
Medicare Requirements
• How do I file a claim that does not meet
medical necessity to get a denial?
Coding Not Medically
Necessary Transports
• Transports Not Medically Necessary
o Use modifier GY to report ambulance services
for patients whose conditions do not meet the
requirements for coverage or for whom
ambulance transportation is non-covered
o Definition
GY - Item or service is statutorily excluded or does
not meet the definition of any Medicare benefit
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38
Mileage
• Does Novitas have a limited number of
miles that they will allow?
Revised Modification to the
Medically Unlikely Edit (MUE)
Program
• Change Request # 8853
o Effective: January 1, 2015
o Implementation: January 5, 2015
• Key Points
o New data field to the MUE edit table termed “MUE adjudication indicator” or “MAI”
o MUEs for codes with a MAI of “1” will continue to be adjudicated as a claim line
edit
o MUEs for codes with a MAI of “2” are absolute date of service edit. These are “per
day edits based on policy”
o MUEs for codes with a MAI of “3” are date of service edits. These are “per day
edits based on clinical benchmarks”
• Reference
o http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNMattersArticles/Downloads/MM8853.pdf
7/19/2015
39
Mileage Documentation
• What type of documentation is acceptable
for ambulance mileage?
Mileage Documentation
(Cont.) • There are several ways to capture and document loaded ambulance
mileage
• Per the Federal Register http://edocket.access.gpo.gov/2010/pdf/2010-27969.pdf, pages 73471 – 73575, CMS indicated mileage can be documented in a number of different ways including o Odometer reading
o Trip odometer readings
o GPS systems,
o Navigation computers
o Mapping programs (e.g., MapQuest)
• These are all acceptable forms of documentation and must be kept in the patient’s record and made available to Medicare upon request
• Note: The complete name and address of the origin and destination should be documented in the trip report completed by the Ambulance supplier
• Reference o Novitas FAQ
http://www.novitas-solutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00083573
7/19/2015
40
Treatment- No Transport
• Can I bill Medicare if we only treated the
patient and did not transport the patient?
Aid Calls
• The Medicare ambulance benefit is a transportation benefit o If no transport of a Medicare beneficiary occurs,
then there is no Medicare-covered service
• This policy applies to situations in which the beneficiary refuses to be transported, even if medical services are provided prior to loading the beneficiary onto the ambulance (e.g., BLS or ALS assessment) o Medicare does not cover aid calls; however, you
may bill the patient
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41
Aid Calls
• To file a claim, use A0998 – Ambulance response no treatment, no transport o This code may be reported to Medicare for a denial if
the patient is not being transported in the ambulance
o To receive a proper denial, the GY modifier will need to be submitted with the procedure code
o Due to the description of the code, the origin and destination modifiers do not apply
o For facility-based ambulance provider billing refer to MM7489 for the proper revenue codes https://www.cms.gov/Outreach-and-Education/Medicare-
Learning-Network-MLN/MLNMattersArticles/downloads/MM7489.pdf
Current Procedural Terminology (CPT) only copyright 2014 American Medical Association. All rights reserved.
Advanced Beneficiary Notice
(ABN) for Ambulance
• Is the ABN required for Ambulance
transports that are not medically
necessary?
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42
The Medicare Ambulance Benefit &
Statutory Bass for Denial of Claims
• Limitation of Liability o In the case of ambulance services, the limitation
of liability provision is not applicable to ambulance services partially denied because the trip exceeded covered limits, the statutory vehicle and crew requirements were not met or the patient’s condition did not contraindicate use of another method of transportation Such denials are based on Section 1861(s)(7) of the
Social Security Act and not Section 1862(a)(1)(A)
These denials do not require an Advance Beneficiary Notice of Noncoverage (ABN)
Advanced Beneficiary Notice
(ABN) for Ambulance Services
• An ABN may be needed and may be used for nonemergency transports in the following situations o A transport by air ambulance when the transporting entity has a
reasonable basis to believe that the transport can be done safely and effectively by ground ambulance transportation
o A level of care downgrade, e.g., from Advance Life Support (ALS)-2 to ALS-1, or from ALS to Basic Life Support, when the transport at the lower level of care is a covered transport
o A transport from a residence to a hospital for a service that can be performed more economically in the beneficiary’s home
o A transport of a skilled nursing facility patient to a hospital or to another SNF for a service that can be performed more economically in the first SNF
• Reference o http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/AmbulanceFeeSchedule/downloads/ambabn71603.pdf
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Time Limit
• Can a claim be allowed after the time
limited has passed?
Timely Filing
• Timely filing requirements amended to one
calendar year after the date of service
• Centers for Medicare & Medicaid Services
Claims Processing Manual, Chapter 1 Section 70 o www.cms.gov/Regulations-and-Guidance/Guidance/
Manuals/downloads/clm104c01.pdf
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44
Tips on receiving
payment after time limit
• Initial Claim Submission
o In order for a claim to be considered after the claim submission time limit, a remark/comment should be submitted in the narrative field indicating why the timely filing was not met. Example: MA plan retracted their payment due to Hospice Entitlement.
• If a denial has been received o Submit a New Claim
A new claim may be resubmitted indicating in the narrative field why the timely filing was not met.
o Submit a Reopening Providers may request a reopening using the appropriate form
– http://www.novitas-solutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00008291
In order for a reopening to be considered, a reason for the delay in the timely filing must be provided
Date of Service
• What date of service should be used to file
a claim, the date of dispatch or the date
the ambulance departs from the point of
pickup?
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45
Date of Service
• Date of Service (DOS) Definition o The DOS of an ambulance service is the date the loaded
ambulance vehicle departs the point of pickup
o In the case of a ground transport, if the beneficiary is pronounced dead after the vehicle is dispatched but before the (now deceased) beneficiary is loaded into the vehicle, the DOS is the date of the vehicle’s dispatch
o In the case of an air transport, if the beneficiary is pronounced dead after the aircraft takes off to pick up the beneficiary, the DOS is the date of the vehicle’s takeoff
• Reference o Change Request # 6372
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM6372.pdf
Psychiatric Behavioral
• What documentation is required for
psychiatric transports?
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46
Psychiatric Behavioral
Documentation
• The assessment must demonstrate the patient o Is expressing active signs and/or symptoms of an uncontrolled
psychiatric condition or acute substance withdrawal
o Is a threat to self or others requiring restraint (chemical or physical)
o Requires monitoring and/or intervention of trained medical personnel during transport for patient and crew safety
o Transport is required by state law/court order
• Examples of Symptoms and Findings Necessary (and Documented) for Coverage o Includes disorientation, suicidal ideations, attempts and gestures,
homicidal behavior, hallucinations, violent or disruptive behavior, sign/symptoms or DTs, drug withdrawal signs/symptoms, severe anxiety, acute episode or exacerbation of paranoia. Refer to definition of restraints in the CFR, Section 482.13(e)
o For behavioral or cognitive risk such that patient requires attendant to assure patient does not try to exit the ambulance prematurely, see CFR, Section 482.13(f)(2) for definition
Liability
• Can Medicare be billed due to a liability
issue?
7/19/2015
47
Auto/No-Fault/Liability
• Medicare is secondary to all accident related claims
• Providers submit to auto/no-fault/liability insurance prior to Medicare
• Conditional payments can be made if insurer does not pay timely (120 days)
• Liability insurance includes but is not limited to o Homeowners liability insurance
o Automobile
o Product liability
o Malpractice liability
o Uninsured motorist
o Underinsured motorist
Comprehensive Error Rate Testing
(CERT)
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48
Comprehensive Error
Rate Testing (CERT) • What is it?
o A program developed by Centers for Medicare & Medicaid Services (CMS) to randomly audit claims monthly to determine if they processed correctly
• Why does it matter? o To protect the Medicare trust fund and determine error rates nationally
and regionally
• Who is involved? o You. A request for medical records from AdvanceMed alerts you that
one of your claims has been selected as part of the monthly random sample
• How does it work? o A letter will be sent to your office requesting the medical documentation.
You need to comply in a timely manner with the request
• JH o http://http://www.novitas-solutions.com/webcenter/portal/CERT_JH
Part B Ambulance Errors
• Insufficient/Inadequate Documentation
o A0429 – Patient was found dead at the scene.
Husband indicated that the patient died two
hours ago, prior to calling the ambulance
Current Procedural Terminology (CPT) only copyright 2014 American Medical Association. All rights reserved
7/19/2015
49
Pronouncement of Death
• Medicare payment depends on the time the beneficiary is pronounced dead o Before dispatch
No payment.
o After dispatch, before loaded or after arrival Pay BLS service or air base rate
No mileage
Use QL modifier
Do not use origin and destination modifiers, only QL
o Pronounced dead after being loaded into ambulance Usual rules of payment
• Note: Pronouncement must be made by authorized person
Part B Ambulance Errors
• Insufficient/Inadequate Documentation
o A0429 – Received EMS report documenting a
beneficiary who is complaining of generalized
weakness
Current Procedural Terminology (CPT) only copyright 2014 American Medical Association. All rights reserved
7/19/2015
50
Generalized Weakness
• Generalized weakness is not a covered
condition for ambulance transfers
• Documentation should describe specific
signs and symptoms that require an
ambulance transfer
Part B Ambulance Errors
• Insufficient/Inadequate Documentation
o A0429 and A0425 – Documentation showed
the patient indicated that she was doing
laundry two hours ago and now her
osteoarthritis was acting up
o Run sheet indicated that the patient was in no
distress and the patient walked to the
stretcher
Current Procedural Terminology (CPT) only copyright 2014 American Medical Association. All rights reserved
7/19/2015
51
Ambulance Policy
• Ambulance Policy o Medicare covers ambulance services only if
furnished to a beneficiary whose medical condition at the time of transport is such that transportation by other means would endanger the patient’s health
o A patient whose condition permits transport in any type of vehicle other than an ambulance does not qualify for Medicare payment
o To be deemed medically necessary for payment, the patient must require both the transportation and the level of service provided
Part B Ambulance Errors
• Insufficient/Inadequate Documentation
o A0428 – Missing physician’s certification for
the repetitive transport to dialysis facility
Current Procedural Terminology (CPT) only copyright 2014 American Medical Association. All rights reserved
7/19/2015
52
Requirements for
Non-Emergency Scheduled
• Requirements for Non-Emergency Scheduled, Repetitive Transports o The Physician Certification Statement (PCS) must be
signed and dated by the attending physician prior to the transport Signature of the medical professional completing the PCS
must also be legible (or accompanied by a typed or printed name) and include credentials
o The PCS must be dated no earlier than 60 days in advance of the transport for those patients who require repetitive transports
o For repetitive services, the PCS may include the expected length of time ambulance transport would be required but may not exceed 60 days
Part B Ambulance Errors
• Insufficient/Inadequate Documentation
o A0428 – Missing physician’s certification
statement for non-repetitive transport
Current Procedural Terminology (CPT) only copyright 2014 American Medical Association. All rights reserved
7/19/2015
53
Requirements for
Non-Emergency Non-Scheduled
• Requirements for Non-Emergency Non-Scheduled or Scheduled on a Non-Repetitive Basis Transport o Before submitting the claim, a certification must
be signed by the attending physician within 48 hours after the transport
o If unable to get the attending physician to sign within 48 hours, either a Physician Assistant (PA), Nurse Practitioner (NP), Clinical Nurse Specialist (CNS), Registered Nurse (RN) or discharge planner employed by the facility with knowledge of the patient’s condition can sign the form
Part B Ambulance Errors
• Insufficient/Inadequate Documentation
o A0429 and A0425 – Documentation did justify
the transport due to medical necessity,
however; the transport record does not
contain signature – no attestation provided
Current Procedural Terminology (CPT) only copyright 2014 American Medical Association. All rights reserved
7/19/2015
54
Signature Guidelines for
Medical Review Purposes
• Medicare requires that services provided/ordered be authenticated by the author o The method used shall be a handwritten or an electronic signature
o Stamped signatures are not acceptable
• These guidelines impact the ambulance trip/run sheets and the Physician Certification Statements (PCSs)
• Signature of the medical professional completing the PCS must be o Legible (or accompanied by a type or printed name) and include credentials
o Dated at the time they are completed
• All signature requirements are effective for Comprehensive Error Rate Testing (CERT)
• All signature requirements for Affiliated Contractors (AC), Medicare Administrative Contractors (MACs), PSCs and Zone Program Integrity Contractors (ZPICs) are applicable for reviews conducted
• Reference o SE1419 http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNMattersArticles/Downloads/SE1419.pdf
Signature Guidelines for Medical
Review Purposes (Cont.)
• Trip/Run Sheet Signature Requirements
o Must contain the date and legible signature of
the observer and their credentials
o Can print their name under the signature
o Can submit a signature log
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Part B Ambulance Errors
• Insufficient/Inadequate Documentation
o A0425 – Number of miles billed to Medicare
11. Received a comprehensive report
showing total loaded miles of 11.3
Current Procedural Terminology (CPT) only copyright 2014 American Medical Association. All rights reserved
Ground Mileage
• Ground Mileage, Per Statute Mile – A0425 o Mileage can be allowed to the nearest appropriate
facility when the ambulance transfer is covered
o Only the actual number of “loaded” miles from the point of pickup to the point of destination can be reported as mileage
o Miles must be reported as fractional units For options on collecting fractional miles
– Novitas FAQ
» http://www.novitas-solutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00083573
– Federal Register
» http://edocket.access.gpo.gov/2010/pdf/2010-27969.pdf
Current Procedural Terminology (CPT) only copyright 2014 American Medical Association. All rights reserved.
7/19/2015
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Non-Covered Ground
Mileage
• Non-Covered Mileage – A0888
o Miles traveled beyond closest appropriate
facility
o In situations when a beneficiary wishes to be
transported to a facility that is not the closest
appropriate facility, Medicare does not cover
the additional mileage
Current Procedural Terminology (CPT) only copyright 2014 American Medical Association. All rights reserved.
2015 OIG Work Plan
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57
2015 OIG Work Plan
• https://oig.hhs.gov/reports-and-
publications/archives/workplan/2015/FY15
-Work-Plan.pdf
OIG Review of Ambulance
Services
• Questionable billing, medical necessity, and level of transport o OIG will examine Medicare claims data to assess
the extent of questionable billing for ambulance services, such as Transports that potentially never occurred or potentially
were medically unnecessary transports to dialysis facilities
Determining whether Medicare payments for ambulance services were made in accordance with Medicare requirements
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OIG Review of Ambulance
Services (Cont.)
• Prior OIG work found that Medicare made inappropriate payments for advanced life support emergency transports o Medicare pays for emergency and nonemergency
ambulance services when a beneficiary’s medical condition at the time of transport is such that other means of transportation are contraindicated (i.e., would endanger the beneficiary)
• Medicare pays for different levels of ambulance service, including Basic Life Support and Advanced Life Support as well as specialty care transport
OIG Review of Ambulance
Services (Cont.)
• Portfolio report on Medicare Part B payments o OIG will analyze and synthesize OIG evaluations,
audits, investigations, and compliance guidance related to ground ambulance transport services paid by Medicare Part B to identify vulnerabilities, inefficiencies, and fraud trends and offer recommendations to improve detected vulnerabilities and minimize inappropriate payments for ambulance services
7/19/2015
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OIG Review of Ambulance
Services (Cont.)
• Prior OIG work identified fraud schemes and trends indicating overuse and medically unnecessary payments
• The planned portfolio will offer recommendations to address the vulnerabilities that we have identified and improve efficiency
• Medicare does not pay for items or services that are not “reasonable and necessary. Specifically, ambulance services are covered “where the use of other methods of transportation is contraindicated by the individual’s condition
• The Medicare Benefit Policy Manual, § 10.2.1, more specifically states that Medicare covers ambulance transports when a beneficiary’s medical condition at the time of the transport is such that using other means of transportation would endanger the beneficiary’s health. Coverage requirements and requirements for ambulance suppliers are in 42 CFR §§ 410.40 and 41
Ambulance Documentation
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Medical Necessity
Documentation Requirements
• The supplier must have documentary evidence to support the claim for Medicare services o Documentation should “paint a picture” of the patient’s condition
• Without the documentation to support medical necessity, the claim may be non-covered by Medicare o Medical record documentation is required to record pertinent facts,
findings and observations
o Run sheet assists the physician in evaluating the patient’s condition prior to transport in certain situation
o Run sheet assists the physician in communication and continuity of care
o Comprehensive Error Rate Testing (CERT) contractor may request documentation for its auditing process
o Contractors may request documentation during an appeal or audit process
Trip Documentation
Requirements
• Trip Documentation
o Complete and legible information
o Indication of emergency or non-emergency situation. This information should come from the reported condition of
the patient at the time of dispatch
o Reason for the transport (why the patient could only travel by ambulance) A concise explanation of symptoms reported by the patient
and/or other observers and details of the patient’s physical assessments that explain why the patient requires ambulance transportation and cannot be safely transported by an alternative mode
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Patient’s Condition
Requirements
• Trip Documentation o An objective description of the patient’s physical
condition in sufficient detail to demonstrate that the patient’s condition or functional status at the time of transport meets Medicare limitation of coverage for ambulance services
o Relevant history (when available)
o Observation and findings (patient’s condition at the time of transport) A detailed description of the patient’s physical condition in
sufficient detail to demonstrate that the patient’s condition or functional status at the time of transport meets Medicare’s limitation of coverage for an ambulance transport
Assessment
Documentation
• Trip Documentation o Assessment and clinical evaluations, which should include
Vital signs
Neurological assessment
Cardiac information
o Procedures and supplies provided, such as IV therapy
Respiratory therapy
Intubation
Cardiopulmonary Resuscitation (CPR)
Oxygen administered
Drug therapy
Restraints
o The treatment should be medically necessary based on the patient’s condition
o Documentation should reflect the medical necessity
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Additional Documentation
Requirements
• Trip Documentation o Patient’s progress (responses to treatment and
changes as treatment is given)
o Point of pickup Complete name and address of origin and destination
o Hospital-to-hospital transports The trip record must clearly indicate the precise treatment or
procedure that is available only at the receiving hospital
o Number of loaded miles
o Date and legible identity of the observer
o Any additional available documentation that supports medical necessity
Physician Certification Statement
(PCS) Requirements
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Physician Certification
Statement (PCS)
• Are required for scheduled and non-scheduled non-emergency transports for patients who are under the direct care of a physician
• A PCS is not required for emergency transports or for non-scheduled non-emergency transports of patients residing at home or in facilities where they are not under the direct care of a physician
• Suppliers/providers are required to obtain written orders from the patient’s attending physician certifying that the medical necessity requirements are met
Physician Certification
Statement (PCS) Form
• Physician Certification Statement (PCS) Form o The signed PCS does not, by itself, demonstrate that the
transport was medically necessary and does not absolve the ambulance provider from meeting all other coverage and documentation criteria Be patient-specific
Contain pertinent medical information
Confirm or support information on run sheet
For repetitive services, the PCS may include the expected length of time ambulance transport would be required but may not exceed 60 days
The signature of the medical professional completing the PCS must be legible (or accompanied by a typed or printed name) and include credentials
Signatures on the PCS must be dated at the time they are completed
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Requirements for
Non-Emergency Scheduled
• Requirements for Non-Emergency Scheduled, Repetitive Transports o The Physician Certification Statement (PCS) must be
signed and dated by the attending physician prior to the transport Signature of the medical professional completing the PCS
must also be legible (or accompanied by a typed or printed name) and include credentials
o The PCS must be dated no earlier than 60 days in advance of the transport for those patients who require repetitive transports
o For repetitive services, the PCS may include the expected length of time ambulance transport would be required but may not exceed 60 days
Definition of Repetitive
Services
• Repetitive Services o Non-emergency ambulance services may be
those that are scheduled in advance (scheduled services being either repetitive or non-repeating)
o A repetitive ambulance service is defined as medically necessary ambulance transportation that is furnished three or more times during a 10-day period or at least once per week for at least three weeks
• Transportation to hemodialysis is a common example of repetitive ambulance services
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Requirements for
Non-Emergency Non-Scheduled
• Requirements for Non-Emergency Non-Scheduled or Scheduled on a Non-Repetitive Basis Transport o Before submitting the claim, a certification must
be signed by the attending physician within 48 hours after the transport
o If unable to get the attending physician to sign within 48 hours, either a Physician Assistant (PA), Nurse Practitioner (NP), Clinical Nurse Specialist (CNS), Registered Nurse (RN) or discharge planner employed by the facility with knowledge of the patient’s condition can sign the form
Requirements If Unable
To Obtain Certification
• Requirements for Non-Emergency
Non-Scheduled or Scheduled on a
Non-Repetitive Basis Transport o If unable to obtain a signed Physician Certification
Statement (PCS) by the attending physician within 21 days, the ambulance supplier must document efforts to obtain certification
o Letter via United States Postal Service certified mail with return receipt and proof of mailing or other similar service demonstrating delivery of the letter as evidence of attempt to obtain the PCS
o United States Postal Service Certificate of Mailing, Form 3817, is acceptable alternative to certified mail
7/19/2015
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2017 Prior Authorization Process
HCPCS Codes
• The following codes are subject to prior
authorization
o A0426 – Ambulance service, advanced life
support (ALS), non-emergency transport,
Level 1
o A0428 – Ambulance service, basic life support
(BLS), non-emergency transport
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Prior Authorization Cover
Sheet
• Requests need to identify o The beneficiary’s first and last name
o Health Claim Number (HICN)
o Gender
o Date of Birth
o Rendering Providers NPIs:
o Rendering Provider’s Name and Address
o Contact Name
o Contact Phone Number
o Contact Fax Number
o Procedure Code(s)
o Number of Trips (not to exceed 80 in 60 days)
o Start Date of Authorization
o State Where Ambulances are Garaged (NJ, PA)
o Request Completed by
o Date (of signature)
• http://www.novitas-solutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00083988
Additional Required
Documentation
• Completed and current Physician Certification Statement (PCS)
• Medical records to support the medical necessity of repetitive scheduled non-emergent ambulance transport
• Exact street address of the origin and destination of the transports (including ZIP Codes)
• Any other relevant medical record as deemed necessary by Novitas (the contractor) to process the prior authorization
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PCS Specifications
• The PCS should contain information on
the beneficiary's condition, to include
diagnoses and a description of the
beneficiary's condition(s) that necessitate
the type and level of transports requested
PCS Signature and Date
• The PCS must
o Be signed and dated by the patient’s
attending physician
The signature and date must be readable
– Credentials next to the signature will facilitate the prior
authorization process
– The prefix “Dr.” is a title and not a credential
Stamped signatures or file signatures are not
acceptable
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PCS Specifications:
Timeframe and Limit
• Timeframes and limitations
o The PCS cannot be dated more than 60 days
in advance of the requested start date, nor
can it be dated after the requested start date
A PCS signed 11/01/14 would not be valid for a
request with a start date of 02/20/15
A PCS signed 01/28/15 is not valid for a 12/15/14
start date
o The PCS should be valid for the duration of
the requested timeframe
PCS and Medical Records
• PCS information must be verifiable
o Medical records must be attached that
support the PCS and that describe the
beneficiary’s condition(s) that necessitate(s)
the type and level of ambulance transport
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Medical Records
• A signed and dated PCS or supplementary form
does not, by itself, demonstrate that the
repetitive scheduled transports are medically
necessary
• A signed and dated attestation letter alone does
not qualify as a medical record
• Medical records should provide sufficient
information to support the cover sheet data and
the Physician Certification Statement (PCS)
Medical Record
Specifications
• The record should
o Reveal the exact origin address and
destination address
o Specify the beneficiary, provider and date of
service
o Be dated prior to, but no more than 60 days
prior to, the requested start date
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Medical Record Contents
• Medical records should
o Capture the beneficiary’s condition(s) that
necessitate(s) the transports
Reveal the medical necessity of the type and level
of transport services
Paint a picture of the patient’s mobility and
functional status
o Support the PCS with clinical assessment
data and objective findings
Sources of Medical
Records
• The medical records submitted can
include, but are not limited to
o Doctor's progress notes
o Nursing notes
o History and Physical
Physical or occupational therapy notes
Admission and discharge summaries
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Supporting the PCS
• For a condition itemized on the PCS, the
medical records must contain statements
that capture the “what” and the “why”
o The “what” is a statement of the mobility
status issue and/or condition
“Patient is bedbound”
o The “why” is clinical assessment data on the
conditions that make up the mobility status
issue
Documentation is
Insufficient…
• The top reasons the medical record proves to be insufficient are
o The records have data that contradicts the PCS
o The records have data that contradicts other data therein
o The records lack clinical assessment data that comprehensively captures the mobility status/condition
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Insufficient Data
• Statements such as the following, absent
supporting clinical assessment data with
objective findings, are insufficient to justify
Medicare payment for ambulance services
o “Contractures", "Amputations", "Paralysis",
"Generalized weakness", "Ulcers", "Is bed-
confined (or bedbound)"
Sufficient Data
• Clinical assessment data includes
objective findings on each condition,
including but not limited to
o Measurements
o Degrees of magnitude or scale
o Exact body location of condition
o The origin or history of the condition, with
timeframes and dates of/for treatment
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Ambulance References
• Ambulance Services (Ground Services) o JH - L32606
http://www.novitas-solutions.com/webcenter/spaces/MedicalPolicy_JH
• Ambulance Prior Authorization Documentation Checklist for Medical Professionals o http://www.novitas-
solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00088255
• Ambulance Service Center o http://www.cms.gov/Center/Provider-Type/Ambulances-Services-
Center.html
• Ambulance Services o IOM 100-2; Chapter 10
http://www.cms.gov/manuals/Downloads/bp102c10.pdf
o IOM 100-4; Chapter 15 http://www.cms.gov/manuals/downloads/clm104c15.pdf
Enrollment and Revalidating
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Enrolling as a New Medicare
Supplier or Revalidating
• There are two ways for suppliers to enroll
and revalidate in the Medicare program
o Internet-based Provider Enrollment Chain and
Ownership System (PECOS) web
https://pecos.cms.hhs.gov
o Paper application
http://www.novitas-
solutions.com/webcenter/spaces/Enrollment_JH
Internet-based Provider Enrollment
Chain and Ownership System
(PECOS)
• PECOS is an electronic Medicare enrollment system through which providers and suppliers can o Submit an initial Medicare enrollment application
o Complete the revalidation process
o View your enrollment information
o Track the status of your enrollment application through the web submission process
o Add or change a reassignment of benefits
o Submit changes to existing Medicare enrollment information
o Reactivate an existing enrollment record
o Withdraw from the Medicare Program
o Submit a Change of Ownership (CHOW) of the Medicare-enrolled provider
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Provider Enrollment Chain and
Ownership System (PECOS)
Conditions
• Providers must have a web user account (user ID/password) established in the National Plan and Provider Enumeration System (NPPES)
• Access the Internet –based PECOS with the same user ID and Password that is utilized for NPPES
• Providers and suppliers may electronically sign or mail the hardcopy certification statement when utilizing Internet-based PECOS
• CMS has updated PECOS to allow the ability to submit electronic copies of supporting documentation to a Digital Document Repository (DDR)
o http://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/SE1230.pdf
o https://pecos.cms.hhs.gov
Paper Applications
• To enroll in Medicare via paper you must download the appropriate, current CMS-855B Medicare Enrollment application
• It is recommended applications be completed in blue ink
• Mail all hardcopy applications along with any supporting documentation
• Signatures must be original when mailing in paper applications
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Electronic Funds Transfer (EFT)
Authorization Agreement (CMS-588)
• The Centers for Medicare & Medicaid Services (CMS) requires all providers/suppliers enrolling in Medicare or making changes to their enrollment file complete the Electronic Funds Transfer (EFT) Authorization Agreement o This will eliminate paperwork and save time by
reducing routine banking
o http://www.cms.hhs.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS588.pdf
• Jurisdiction H (JH)
o Arkansas, Colorado, Louisiana, Mississippi, New
Mexico, Oklahoma, and Texas Providers
Novitas Solutions Inc.
Provider Enrollment Services
P.O. Box 3095
Mechanicsburg, PA 17055-1813
Mailing Address for
Hardcopy Applications
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Enrollment
Application Fees
• Hospitals, ambulance, Ambulatory Surgical Center (ASCs) and Durable Medical Equipment (DME) suppliers initially enrolling in Medicare, adding a practice location or revalidating their enrollment information must submit with their application
o Proof of payment of the application fee in an amount prescribed by CMS
And/or
o A request for a hardship exception to the application fee.
• This requirement applies to applications that Medicare contractors receive on or after March 25, 2011
• The application fee for 2015 is $553
• Payment of the application fee can be made through o Intra-Government Payment and Collection System (IPAC)
o PECOS on-line application fee payment system
Enrollment Processing
Timeframes
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Processing Timeframes-
Paper Applications
• Initial Enrollments, Revalidations, and Reactivations o 60-210 calendar days from receipt
o 80% of applications will be processed within 60 – 80 calendar days
• Reassignments/Change Requests o 60-120 calendar days from receipt
o 80% of applications will be processed within 60 calendar days
• Processing times will vary contingent upon the number of development requests o To avoid delays ensure all sections of the enrollment
applications are completed and any supporting documentation is provided
Processing Timelines- Internet-
based PECOS Applications
• Initial Enrollments, Revalidation, and Reactivations o 45-120 calendar days from receipt
o 80% of applications will be processed within 45 – 80 calendar days
• Reassignments and Change Requests o 45-90 calendar days from receipt
o 90% of applications will be processed within 45 calendar days
• Processing times will vary contingent upon the number of development requests o To avoid delays ensure all sections of the enrollment
applications are completed and any supporting documentation is provided
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Site Visits Required
• Site visits are conducted by MSM Security, LLC who also sub-contracts with Computer Evidence Specialists, LLC and Health Integrity, LLC
• Site visits are required for o Moderate level of categorical screening
Ambulance Service providers
Community mental health centers
Comprehensive outpatient rehabilitation facilities
Hospice organizations
Independent clinical laboratories
Independent diagnostic testing facilities
Physical therapists enrolling as individuals or as group practices
Portable x-ray suppliers
Revalidating home health agencies
Revalidating DMEPOS suppliers
o High level of categorical screening Newly enrolling DMEPOS suppliers
Newly enrolling Home Health Agencies (HHA)s
Revalidation Process
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Revalidation
• Existing providers/suppliers must revalidate every five (5) years o Provider/suppliers will be sent a revalidation letter
o Need to submit a complete CMS-855 application Please wait for the revalidation letter before completing and
submitting application
o Revalidation application is required to be received within 60 days of the letter Failure to submit the enrollment forms as requested may result
in deactivation of your Medicare privileges
o Send in all required documentation The most recent CMS-855 application
Electronic Funds Transfer Authorization Agreement (EFT), if needed
All supporting documentation
Steps to Revalidation
• When providers and suppliers receive notification to revalidate they must o Utilize PECOS web or complete the appropriate
paper application
o Send in all supporting documentation
o Ensure all documents are completed by the assigned timeframe
o If you are receiving paper checks you will be required to convert to EFT during the process Fill out the CMS-588 EFT Authorization Agreement
– http://www.cms.hhs.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS588.pdf
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Mailing Address For
Revalidation
• Mailing Address
o Novitas Provider Enrollment
P.O. Box 44155
Jacksonville, FL 32231
Provider Enrollment
• Provider Enrollment Status Inquiry Tool
o http://www.novitas-solutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00004864
• Upcoming Revalidation Mailings
o http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Revalidations.html
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Provider Enrollment
Status Tool Enhancements
• Enhancements included
o The incorporation of "Help" text into the interface The "Help" text related to the various search criteria was removed from
the landing page and now appears in the box associated with the specific search criterion when selected from the dropdown menu.
This feature helps define the criterion when selected and cleans-up the landing page of excess verbiage which eliminates the scrolling previously required to view the status of an application
o National Provider Identifier (NPI) field error check The Tool now validates the NPI keyed to execute a search is exactly 10-
digits in length
o "Search with " dropdown menu selections A revision was made to change "Tracking Number" to "PECOS
Tracking Number" to better define this selection
o Narrative verbiage. Changes were made to some of the status narratives to help eliminate
customer confusion
Self-Service Options
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Jurisdiction H Customer
Contact Information
• Provider o 1-855-252-8782
o Hours of Operation, Central Time (CT)/Mountain Time (MT) Monday - Friday: 8:00 am – 4:00 pm CT/MT
• Interactive Voice Response (IVR) o Hours of Operation
Eligibility and General Information – 24 Hours a day 7 Days a week
Full IVR Options – Mondays: 5:00 am – 7:00 pm CT
– Tuesday – Friday: 3:00 am – 7:00 pm CT
– Saturdays: 5:00 am – 3:00 pm CT
o Step-by-Step Guide JH Part A
– http://www.novitas-solutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00004409
JH Part B – http://www.novitas-solutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00004421
Beneficiary Contact
Information
• Patient / Medicare Beneficiary
o 1-800-MEDICARE (1-800-633-4227)
http://www.medicare.gov/index.html
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Stay Up-to-Date
• Electronic Mailing List o Daily E-mail of the latest Medicare Updates
o Newly designed and streamlined newsletter format
o Subscribe JH http://www.novitas-
solutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00007968
• Podcast o Podcast of the latest Medicare Updates and other informative topics
http://www.novitas-solutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00025071
• Educational Videos and Tutorials o http://www.novitas-
solutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00082787
Novitas Medicare
Learning Center
• Features o Create an individualized education account
o Register for webinars, teleconferences, and workshops
o Download your Continuing Education Unit (CEU) Certificates
o Be placed on a waitlist if the educational event you register for is closed
• Benefits o Centralized location for all educational materials
o Track all of the educational events you’ve attended
o Access Medicare education 24 hours a day, 7 days a week with web-based training modules
• JH o http://www.novitas-
solutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00081812
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Calendar of Events
• Our Education and Training Center offers a wide variety of education
• Join us for Workshops, Teleconferences, and Webinars
• The most current calendar of events o JH Part B
http://www.novitas-solutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00084382
Thank you for attending!
