Clinical Policy: Specialty Care Ground Transport Reference Number: CP.MP.HN223 Effective Date: 07/05 Last Review: 8/2017 Revision Log

Transcription

1 Clinical Policy: Specialty Care Ground Transport Reference Number: CP.MP.HN223 Effective Date: 07/05 Last Review: 8/2017 Revision Log See Important Reminder at the end of this policy for important regulatory and legal information. Description Specialty care transport (SCT) is interfacility transportation of a critically injured or ill patient by a ground mobile intensive care ambulance, which is used only for maintaining specialized or intensive care treatment. It includes provision of medically appropriate supplies and services beyond the scope of the EMT-paramedic. This kind of vehicle becomes necessary when a patient s condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area (e.g., emergency or critical care nursing, respiratory care, cardiovascular care, or an EMT-Paramedic with additional training). Interfacility Transportation Definition: For purposes of SCT payment, an interfacility transportation is one in which the origin and destination are one of the following: a hospital or skilled nursing facility. Policy/Criteria I. It is the policy of Health Net of California that specialty ground transport is medically necessary and appropriate diagnostic and/or interventions must be available for all of the following indications: A. The transport involves a interfacility transfer; and B. The patient's condition is unstable, and there is immediate threat to life or function, for example: 1. Abnormal or deteriorating neurological status; or 2. Life threatening cardiac emergencies; or 3. Cardiorespiratory arrest (suspected or confirmed); or 4. Serious cardiac dysrhythmias non-responsive to conventional therapy; or 5. Hypertensive emergencies, severe hypotension or shock; or 6. Threat to maternal or fetal life; or 7. Airway compromise or severe respiratory distress; or 8. Complex orthopedic injury (eg. life or limb threatening. Replantation team necessary for these type of orthopedic injuries); or 9. Specialized pediatric care for pediatric injury; or 10. Hyperbaric treatment for toxic exposure or an emergent condition; or 11. Burn center care for thermal injures; or 12. Multiple trauma associated with above features, or suspicion of significant injury based on mechanism. C. One or more body systems are abnormal and rapidly deteriorating in association with an acute illness or injury; and Page 1 of 7

2 D. Continuous monitoring, ongoing care and specialized interventions are required to correct and stabilize the patient's condition, for example: 1. Mechanical ventilation, not long term dependent (i.e., artificial airway [endotracheal/nasotracheal tubes, Cricothyroidotomy], chest tubes, capnography); 2. Multiple monitors (i.e., invasive monitors such as pulmonary artery catheters (Swan Ganz), arterial catheters (A-Lines), central venous pressure monitors (CVP), intracranial pressure monitor (ICP needle); 3. Cardiac assist devices (i.e., pacemakers, intra-aortic balloon pumps, ventricular assist devices, heart mate, extra-corporeal support, 12-lead EKG monitoring, interpretation, and intervention); 4. Any other specialized device or procedure unique to the patient's health care needs. E. All specialized equipment and supplies appropriate to the required interventions are available at the time of the transport; and F. Staffing is required that are beyond the general scope and practice of the EMTparamedic. Minimum required staffing includes: 1. One currently certified EMT- Paramedic with the additional training (eg., evidence of successful completion of post paramedic training an appropriate periodic skills verification in management of patients on ventilators, 12 lead EKG and/or other critical care monitoring devices, drug infusion pumps, and cardiac and/or critical care medications, or any other specialized procedures or devices determined at the discretion of the caring physician ) accompanied by at least one of the following: a. Registered Nurse with special knowledge of the patient's care needs; or b. Certified Respiratory Therapist; or c. Licensed Physician or any licensed health care professional designated by the transferring Physician (if delegated to another health care professional, this individual must be competent to manage any current or anticipated complications). G. Patients with any of the following infusions (eg. Intravenous, epidural, intra-osseous, etc.): 1. Vasopressors - Isuprel, Dobutamine, Dopamine, Epinephrine, Norepinephrine, Phenylephrine, etc; 2. Vasoactive compounds - Beta Blockers, Nitroprusside, Nitroglycerine, etc.; 3. Antiarrhythmics - Pronestyl, Amiodarone, Milrinone, etc.; 4. Fibronolytics - tissue plasminogen activator (tpa), Retavase (Reteplase), Heparin, etc.; 5. Tocolytics - Magnesium Sulfate, Ritodrine, etc.; 6. Blood or blood products; 7. Any other parenteral pharmaceutical unique to the patient's special health care needs. Background Specialty care transport (SCT) (A0434)is an interfacility transportation of a critically injured or ill beneficiary by a ground ambulance, including the provision of medically necessary supplies and services, at a level of service beyond the scope of the EMT paramedic. SCT is required when a beneficiary s condition requires ongoing care that must be provided by one or more health Page 2of 7

3 professionals in an appropriate specialty area (e.g., emergency, critical care nursing, emergency medicine, respiratory care, cardiovascular care, or a paramedic with additional training). Specialty Care Transport is considered medically necessary when a beneficiary s condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area. The EMT-Paramedic level of care is set by each state. Medically necessary care that is furnished at a level above the EMT-Paramedic level of care may qualify as SCT. If EMT-Paramedics - without specialty care certification or qualification - are permitted to furnish a given service in a state, then that service does not qualify for SCT. 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 injured patients, to furnish a level of service that otherwise would require a health professional in an appropriate specialty care area (for example, a nurse) to provide. Additional training means the specific additional training that a state requires a paramedic to complete in order to qualify to furnish specialty care to a critically ill or injured patient during an SCT. The specialty units include, but are not limited to, the Emergency Department, Surgical, Medical, Cardiac, Neuro, Neonatal, and Pediatric ICUs, Operating Room, Specialty Labs (Heart Catheterization), and Obstetrical Units. All critical care transport crew should have competence in: Needle Cricothyroidotomy Surgical Cricothyroidotomy Needle Thoracentesis Intraosseous Needle Placement 8.5 Fr. Catheter Introducer Pericardiocentesis Chest Tubes and Collection Systems Emergent Escharotomy Endotracheal Tube Changer Airway Lab/Surgical Rotations All critical care transport crew should have the following skills sets: Monitoring Systems-Invasive lines, IABP, Capnography, Electrical Intervention, Pacing Infusion Pump System Rapid Sequence Intubation Ventilator Set -up and Operation Vehicle Radio Operations/Safety Class Capnography is the indirect monitoring of carbon dioxide (CO2) concentrations in a patient's blood. It provides a rapid and reliable method to detect life-threatening conditions (malposition of tracheal tubes, unsuspected ventilatory failure, circulatory failure and defective breathing Page 3of 7

4 circuits) and to circumvent potentially irreversible patient injury. Capnography and pulse oximetry together could have helped in the prevention of 93% of avoidable anaesthesia mishaps according to the American Society of Anesthesiologists. Coding Implications This clinical policy references Current Procedural Terminology (CPT ). CPT is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2015, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services. CPT Codes N/A HCPCS Codes A0021-A0999 A0425 A0434 A4206-A4223 A4300-A4306 A4450-A608 A4611-A4629 A6000-A6208 A6209-A6215 A6216-A6233 A6234-A6241 A6242-A6248 A6250-A6412 A6413-A6457 A6501-A6550 A7000-A7048 A7501-A7527 B4034-B9999 C1726 C8957 E0424-E0487 E0500 Description Description Ambulance and other transport services and supplies Ground mileage, per statute mile Specialty care transport ((SCT) Injection and infusion supplies Access catheters and drug delivery systems Various medical supplies including tapes and surgical dressings Respiratory supplies and equipment Miscellaneous dressing and wound supplies Foam dressings Gauze dressings Hydrocolloid dressings Hydrogel dressings Other dressings, coverings and wound treatment supplies Bandages Compression garments and stockings Breathing aids Tracheostomy supplies Enteral and parenteral therapy Catheter, balloon dilation Intravenous infusion for therapy/diagnosis; initiation of prolonged infusion (more than 8 hours), requiring use of portable or implantable pump Oxygen delivery systems and related supplies IPPB machine, all types, with built-in nebulization; manual or automatic valves; internal or external power source Page 4of 7

5 ICD-10-CM Diagnosis Codes that Support Coverage Criteria ICD-10-CM Code Description I46.2-I46.9 Cardiac arrest I50.1-I50.9 Heart failure J J Postprocedural respiratory failure J96.00-J96.02 Acute respiratory failure R09.2 Respiratory arrest R58 Hemorrhage, not elsewhere classified S09.90X(A,D,S) Unspecified injury of head, initial encounter T79.4XX (A,D,S) Traumatic shock Reviews, Revisions, and Approvals Date Approval Date Health Net Medical Advisory Council July 2005 Health Net Medical Advisory Council Aug 2007 Health Net Medical Advisory Council Jan 2011 Health Net Medical Advisory Council - Added Revised Medicare Table. No Sept 2011 Revisions Health Net Medical Advisory Council Aug 2012 Health Net Medical Advisory Council Aug 2013 Health Net Medical Advisory Council Aug 2014 Health Net Medical Advisory Council Aug 2015 Health Net Medical Advisory Council Aug 2016 Revised to reflect Medicare guidelines in Medicare Benefit Manual Chapter 10 Ambulance Services. Change to personnel requirements of EMT Paramedic and also changed interhospital to interfacility Aug 2017 References 1. Baird JS, Spiegelman JB, Prianti R, et al. Noninvasive ventilation during pediatric interhospital ground transport. Prehosp Emerg Care Apr-Jun;13(2): Broman L, Frenckner B. Transportation M of Critically Ill Patients on Extracorporeal Membrane Oxygenation. Front Pediatr. 2016; 4: Hall JB, Schmidt GA, Wood LDH. Chapter 7. Transportation of the Critically Ill Patient. Principles of Critical Care. Access Anesthesiology. July Lees M, Elcock M. Safety of interhospital transport of cardiac patients and the need for medical escorts. Emerg Med Australas Feb;20(1): Lim MT, Ratnavel N. A prospective review of adverse events during interhospital transfers of neonates by a dedicated neonatal transfer service. Pediatr Crit Care Med May;9(3): Medicare Benefit Policy Manual. Chapter 10 - Ambulance Services Available at: Guidance/Guidance/Manuals/downloads/bp102c10.pdf Page 5of 7

6 7. Medicare Learning Network. Medicare Ambulance Transports. ICN January Available at: MLN/MLNProducts/Downloads/Medicare-Ambulance-Transports-Booklet-ICN pdf 8. Medicare Administration Portal. WPS. Government Health Administrators. J8 MAC Part B. Specialty Care Transport (SCT) Clarification Questions and Answers. Available at: 9. Qiu J, Wu XL, Xiao ZH, et al. Investigation of the status of interhospital transport of critically ill pediatric patients. World J Pediatr Feb;11(1): Whyte HE, Jefferies AL; Canadian Paediatric Society, Fetus and Newborn Committee. The interfacility transport of critically ill newborns. Paediatr Child Health Jun- Jul;20(5): Wilcox SR, Saia MS, Waden H, et al. Medication Administration in Critical Care Transport of Adult Patients with Hypoxemic Respiratory Failure. Prehosp Disaster Med Jul 16:1-5 Important Reminder This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. Health Plan means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan s affiliates, as applicable. The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures. This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time. Page 6of 7

7 This clinical policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members. This clinical policy is not intended to recommend treatment for members. Members should consult with their treating physician in connection with diagnosis and treatment decisions. Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan. This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members and their representatives agree to be bound by such terms and conditions by providing services to members and/or submitting claims for payment for such services. Note: For Medicaid members, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy. Note: For Medicare members, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs and LCDs should be reviewed prior to applying the criteria set forth in this clinical policy. Refer to the CMS website at for additional information Centene Corporation. All rights reserved. All materials are exclusively owned by Centene Corporation and are protected by United States copyright law and international copyright law. No part of this publication may be reproduced, copied, modified, distributed, displayed, stored in a retrieval system, transmitted in any form or by any means, or otherwise published without the prior written permission of Centene Corporation. You may not alter or remove any trademark, copyright or other notice contained herein. Centene and Centene Corporation are registered trademarks exclusively owned by Centene Corporation. Page 7of 7