UNDERSTANDING MEDICARE LEVELS OF SERVICE Brian S. Werfel, Esq. Werfel & Werfel, PLLC
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MEDICARE AMBULANCE LEVELS OF SERVICE Ground Ambulance BLS emergency (HCPCS Code A0429) BLS non-emergency (A0428) ALS emergency (A0427) ALS non-emergency (A0426) ALS-2 (A0433) Specialty Care Transport (A0434) Paramedic Intercept (A0432) Air Ambulance Fixed Wing (A0430) Rotary Wing (A0431)
THE MEDICARE AMBULANCE BENEFIT Section 1861(s)(7) of Social Security Act Medicare will cover: ambulance service where the use of other methods of transportation is contraindicated by the individual's condition, but only to the extent provided in regulations
BASIC LIFE SUPPORT (BLS) Ground Transport At least one individual qualified as EMT-Basic in accordance with State & Local Laws BLS Non-Emergency (A0428) BLS Emergency (A0429)
EMERGENCY RESPONSE Immediate Response BLS or ALS-1 Level 911 Call or Equivalent Can be on Private Line LIGHTS/SIRENS IS NOT THE TEST!
ADVANCE LIFE SUPPORT (ALS) Ground Transport At least one individual qualified as paramedic or EMT-I in accordance with State & Local Laws ALS Non-Emergency (A0426) ALS Emergency (A0427)
ALS-1 NON-EMERGENCY (A0426) Medical necessary ambulance transport, and At least one ALS Intervention
ALS INTERVENTION Procedure beyond the scope of EMT- Basic or as defined by State & Local Laws e.g., EKG, IV, etc.
ALS-1 EMERGENCY (A0427) Emergency Response and EITHER: ALS Intervention, or ALS Assessment
ALS 2 (A0433) The provision of one or more designated ALS-2 procedures or the administration of 3 or more qualifying medications by IV push/bolus or continuous infusion
ALS 2 PROCEDURES Manual Defibrillation Cardioversion Endotracheal Intubation Central Venous Line Cardiac Pacing Chest Decompression Surgical Airway Intraosseous Line
ALS 2 MEDICATIONS Qualifying Epinephrine Atropine Sodium Bicarbonate Narcan Non-Qualifying Aspirin Oxygen Crystalloid, hypotonic, isotonic or hypertonic solutions (e.g., Dextrose, Saline, Ringer s Lactate) IM, Nebulizers, Sprays, Tablets Morphine Fentanyl
SPECIALTY CARE TRANSPORT (A0434) Interfacility e.g., Hospital to Hospital e.g., SNF to Hospital Critically Injured or Ill Patient Beyond the Scope of Standard Paramedic i.e., RN, RT OR Paramedic with Additional Training
SPECIALTY CARE TRANSPORT (A0434) Typical SCT Procedures/Medications Ventilators Balloon Pumps Heparin Drips Nitro Drips Propofol Drips Cardizem Antibiotic Drips Blood Transfusions
The ALS Assessment A Simple Concept Made Difficult
ALS ASSESSMENT
ALS ASSESSMENT An ALS assessment does not necessarily result in a determination that the patient required an ALS level of service. This statement is a constant source of confusion among Medicare contractors Their Interpretation: An ALS assessment does not necessarily result in you being able to submit the claim as an ALS emergency
MEDICARE CONTRACTORS WOULD BE CORRECT IF They mean the patient s condition on scene must also establish that all other modes of transport are contraindicated (i.e., the transport was medically necessary)
MEDICARE CONTRACTORS ARE INCORRECT IF They mean that you would not be able to bill a medically necessary transport for the ALS emergency base rate based on a valid ALS assessment
FEBRUARY 27, 2002 FINAL RULE
CMS ONLINE MANUAL PRE-2015
CMS ONLINE MANUAL SEPTEMBER 2015 REVISIONS
DISPATCH PROTOCOLS Established dispatch protocols drive the determination as to whether a paramedic was warranted to assess the patient!! All-ALS Services Your protocols must distinguish between: 1. Situations where an ALS vehicle is sent based on the expected needs of the patient 2. Situations where an ALS vehicle is sent solely because of the mandate i.e., if you were a 2-tiered system, would you still be sending an ALS vehicle?
MEDICAL PRIORITY DISPATCH
MAJOR URBAN COUNTY
ALS ASSESSMENT PROPOSED BILLING WORKFLOW Step 1: Review paperwork to determine if patient s ON-SCENE condition justifies medical necessity for the ambulance. Yes Step 2: Did reported condition of patient at time of dispatch require an assessment by a paramedic? Yes Step 3: Did paramedic document that he/she assessed the patient? No No No Yes Bill Medicare for a denial using GY modifier Bill Medicare for a BLS-E Base Rate (A0429) Bill A0429) Bill Medicare for a, ALS-E Base Rate (A0429)
Why this Matters?
HEADLINES City of Dallas to pay $2.47 million to resolve allegations of improper Medicare and Medicaid billing -- June 2011 DoJ Press Release Government recovers more than $1.6 million from 11 cities to resolve allegations of improper Medicare and Medicaid billing -- August 2011 DoJ Press Release
Brian Werfel, Esq. A.A.A. Medicare Consultant 631-265-5650 bwerfel@aol.com