Background Information

The Centers for Medicare and Medicaid Services (CMS), formerly the Health Care Financing Administration, implemented a new payment system for “medically necessary” transports.  This dramatic change is a result of the Balanced Budget Act of 1997, which will involve new HCPCS codes, payment methods, and claim requirements.  No longer will payment be based on reasonable charges or costs, but will be made from a fee schedule that will apply to all ambulance services, hospitals, skilled nursing facilities and home health agencies.  This fee schedule will be implemented over a five-year period (this five-year period ended on 3 January 2006) and will have a significant impact on all providers. The Business Office / Billing Staff at Haynes Ambulance of Alabama, Inc. can provide you with the latest updates and information through in-services and seminars to ensure that your staff remains at the forefront of knowledge with regards to patient benefits for ambulance transport.  They can be reached at (334) 241-5221 if so desired.

Ground Services Are Reimbursable If They Meet One or

More of The Following Medicare Coverage Guidelines

• Services must be medically necessary and reasonable for the condition of the patient;
• The condition of the patient contraindicates transportation by other means (i.e., a private vehicle, taxi, or wheelchair van);
• A diagnosis or a statement of the patient's condition at the time of the transfer must be available in order to determine medical necessity;
• Ambulance personnel must document their observations of the patient's condition at the time of transport;
• Transportation is to a hospital from another hospital when a patient's needs can not be met at the first hospital and the patient is admitted to the second hospital;
• Transportation is to an extended care facility or to the patient's home; and

Six Categories Of Ambulance Services That Are Specific To The Needs Of Your Patient:

• Basic Life Support (BLS)
• Basic Life Support Emergency — provisions of BLS services such as CPR, basic airway management, treatment for shock, control of bleeding, bandaging, splinting, etc. in an emergency situation
• Advanced Life Support (ALS), Level 1 — an assessment by an Advanced Life support provider (such as an EMT-Intermediate or Paramedic) OR the provision of one or more ALS interventions
• Advanced Life Support, Level 1 Emergency — ALS services such as advanced airway management, cardiac monitoring or defibrillation, administration or monitoring of IV therapy, etc. in an emergency situation
• Advanced Life Support, Level 2 — administration of multiple medications OR the provision of at least one of the following ALS procedures:
  • Manual Defibrillation / Cardioversion
  • Endotracheal Intubation
  • Central Venous Line (maintenance)
  • Cardiac Pacing
  • Chest Decompression
  • Intraosseous Line
• Specialty Care Transports — a level of inter-facility service for a critically injured or ill beneficiary provided beyond the standard scope of a Paramedic. This is necessary when a beneficiary's condition requires ongoing care that must be provided by one or more health professionals in an appropriate specialty area such as nursing, respiratory care, or a paramedic with advanced training.

DETERMINING IF YOUR PATIENT MEETS THE

CRITERIA FOR AMBULANCE TRANSPORT

1. Establish Medical Necessity

o    Patient is to be transported in am emergency situation as a result of an accident, injury, or acute illness;

o    Patient needs to be restrained;

o    Patient is unconscious or in shock;

o    Patient requires oxygen or other emergency treatment on the way to the destination;

o    Patient has to remain immobile because of a fracture that has not been set or the possibility of a fracture;

o    Patient sustains an acute stroke or myocardial infarction;

o    Patient is experiencing severe hemorrhaging;

o    Patient has a condition that makes them bed-confined before and after the ambulance trip;

o    Patient condition requires them to be moved ONLY by stretcher (i.e., fetal positioning, severe incapacitation, vegetative state).

2. Is The Patient Bed-Confined?

There is now a national definition of the term "bed-confined". Please note that is not synonymous with "bed rest" or "non-ambulatory". In addition, "bed confined" status is not the only criteria to be used in determining if the patient must be transported by ambulance. It is one factor to be considered when making coverage determinations.

"BED-CONFINED" is defined as:

a.    Unable to get up from bed without assistance

b.    Unable to ambulate

c.    Unable to sit in a chair or wheelchair (unrestrained)

3. Is This An Emergency Transport?

The term "EMERGENCY" relates to "services provided after the sudden onset of a medical condition manifesting itself by acute symptoms of such severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result" in any of the following:

a.    Placing the patient's health in serious jeopardy;

b.    Serious impairment to bodily functions; and/or

c.    Serious dysfunction of any bodily organ or part

4.    Is This A Non-Emergency Transport?

Any ambulance transport that meets the following criteria is considered non-emergent and will require the use of a Physician's Certification Statement (PCS), or more commonly known as a Certificate of Medical Necessity (CMN), at the time of transport:

a)    All SCHEDULED transports (regardless of the origin and destination, including outpatient services or physician services);

b)    Discharges to long term care centers, rehabs, nursing homes, skilled nursing units, or the patient's residence; and

c)    Transports to and from ESRD facilities for maintenance dialysis

PHYSICIAN CERTIFICATION STATEMENTS:

For scheduled and unscheduled non-emergency ambulance transports, Medicare requires ambulance suppliers to obtain a physician's written order certifying the need for an ambulance prior to the transport. This form is commonly known as a PCS or CMN.  These forms can be provided to you at no charge.  Simply contact our office @ (334) 265-1208, and advise us where we should make the delivery.  The form must contain the following information:

• be patient specific;
• contain pertinent medical information in order to determine medical necessity;
• confirm or support the medical information submitted by the transporting EMT / Paramedic, and;
• be signed and dated by authorized personnel such as the Physician, PA, CNS, NP, RN, or Discharge Planner who has knowledge of the patient's condition at the time of transport.

Our team of highly trained Business Office Staff are available (they can be reached at 334-241-5221) for all your questions and needs regarding patient benefits. Through training, we ensure that not only your staff is up-to-date on the latest information, but that your patient will receive the maximum reimbursement benefits due to them.