Ambulance
Specialty Care Transports (SCT)
Question: If a supplier provides an inter-facility
SCT transport utilizing the RN or SCT level personnel employed by
the originating or receiving facility, may the supplier still submit
the claim at an SCT level of service - even if it does not have
an agreement to reimburse the facility for the use of its personnel?
Answer: There must be an agreement in place between
the ambulance supplier that furnishes the transport and the facility
that furnishes the SCT level personnel. However, the compensation
between the BLS entity and SCT personnel’s facility is not
a matter for the Medicare program to regulate.
Emergency Response
Question: If an ambulance drives up to an accident
or injured party or is requested to respond by a bystander, without
being dispatched, would this qualify as an emergency (such as a
car accident or man-down?)
Answer: No. This scenario represents an exception
to the general rule that emergency transports should be paid at
the emergency payment rate. As established during the negotiated
rulemaking, the emergency payment rate is intended to cover the
cost of readiness to respond immediately to a “911”
type call. The emergency payment is not designed to accommodate,
nor was it established based on, serendipitous or chance events.
Joint BLS/ALS Response
Question: A BLS Volunteer company and ALS provider
respond jointly to a call. The ALS provider assists (assessment
and/or intervention) and the BLS volunteer company transports. The
fee schedule stipulates that the BLS Volunteer can bill at the ALS
level if they are certified at the BLS level. Is the carrier going
to pay them an ALS rate without an ALS certification?
Answer: Yes. If the local Medicare carrier requires
a certification, then the BLS supplier can submit a copy of the
agreement it has with the ALS entity and explain that the ALS personnel
furnishing the ALS service was not an employee of the BLS supplier.
Any problems can be resolved by referring them to the Medicare Regional
Office.
Beneficiary Dies Before Transport
Question: The rule currently states that responses
where patients are pronounced dead before transport may be billed
and paid at the BLS Emergency Rate. In the event an ALS unit arrives
on the scene before death is pronounced, loads the individual in
the ambulance and provides ALS-level care on patients (such as cardiac
arrest patients) before transport begins, should these responses
be paid at the ALS-1 Emergency or ALS- 2 level instead depending
upon the care rendered?
Answer: This depends upon the time at which the
beneficiary is officially pronounced dead. If the official pronouncement
of death occurs after the ambulance has left for the scene but prior
to the ambulance transport, then only the BLS level -- not the BLS
emergency level -- of payment may be made. The BLS emergency rate
is not appropriate because no Medicare covered transport occurred.
If a Medicare covered transport occurs, then the level of payment
may be made appropriate to the level of services provided.
Temporary (Q) Codes
Question: The ALS Assessment payment discussion
in the final rule does not limit the ability to use codes Q3019/Q3020
to bill for BLS emergencies with ALS personnel/units to those who
are currently mandated to bill that way throughout the transition
period. We believe CMS should make clear that only those providers
who currently bill under an ALS mandate situation should be using
the Q-codes during the phase-in of the fee schedule as a part of
the all-ALS phase-out.
Answer: While it would generally be true that use
of an ALS vehicle to furnish only BLS level services would most
often occur in local jurisdictions that mandate all ambulances to
be ALS, this is not always true. There is a longstanding program
instruction (section 5116.1 of the Medicare Carriers Manual) that
permits payment at the ALS rate unless a supplier establishes a
pattern of uneconomical care such as repeated use of ALS ambulances
in situations in which it should have been known that a less expensive
basic ambulance was available and that its use would have been medically
appropriate. An
example of appropriate use of Q3019/Q3020 would be when no BLS ambulance
was available at the time of the call. Ambulance suppliers and Medicare
carriers should continue to follow the established practice for
administering this policy.
Repetitive Services
Question: What is the definition of a repetitive
patient as discussed in the PCS requirement? We have previously
advised our members that repetitive transports are those where transportation
is required three or more times during a ten day period for treatment
of the same condition. This would include dialysis and respiratory
therapy treatment, which are clearly repetitive, but would exclude
routine or unexpected followup visits relating to a single and non-continuing
incident.
Answer: We generally agree. That is, we consider
“repetitive ambulance services” to be medically necessary
ambulance transportation that is furnished either three or more
times during a ten-day period or at least once per week for at least
three weeks. Dialysis and respiratory therapy are types of treatments
for which repetitive ambulance services are often necessary. However,
it is the quantitative standard of 3-in-10 or 1-times-3 that determines
whether the physician certification statement requirement for repetitive,
scheduled, non-emergency ambulance services applies. Similarly,
regularly scheduled ambulance services for follow-up visits, whether
routine or unexpected, are not “repetitive” for purposes
of this requirement unless one of the quantitative standards is
met.
Zip Codes
Question: In order to properly bill their transports,
ambulance suppliers need access to the same zip code files provided
to the carriers and intermediaries. Can you tell us how to obtain
access to these files or arrange for their public access through
the CMS Web site?
Answer: A zip code file is available now at www.gamedicare.com/provider/ambzip.htm.
CMS will soon post a zip code public use file on CMS’ Medlearn
Web site. Carriers and
Intermediaries will also be making the zip code files available
on their Web sites.
Question: Who do I contact with questions about
using the zip code on the claim and about rural designation of certain
zip codes?
Answer: For questions about the use of the zip
code in claims for ambulance services, contact Bart Kershbaum at
mkershbaum@cms.hhs.gov. For questions about the appropriateness
of the rural designation, or lack thereof, of a particular zip code,
including the implementation of the “Goldsmith modification,”
contact Glenn McGuirk at gmcquirk@cms.hhs.gov.
ALS-2 Drugs.
Question: The rule establishes a number of qualifications
for medications to be counted as one of the three medications the
administration of which would qualify a trip as ALS- 2. Excluded
from the three qualifying medications are "crystalloid, hypotonic,
isotonic and hypertonic solutions (for example, Dextrose, Normal
Saline, Ringer's Lactate). In order to make this limitation clear
to ambulance billers, would it be correct to state that the ALS-2
qualifying medications do not include the solutions listed in "J"
codes J7030- J7130?
Answer: Yes. It is correct that the drugs represented
by the HCPCS in the range J7030 through J7130 do not qualify as
ALS2 drugs.
Paramedic Intercept
Question: The response in the preamble to the rule
to a comment about payment for paramedic intercept services (in
areas other than those that qualify for ALS intercept services under
section 4531(c) of the Balanced Budget Act of 1997), states "If
the paramedic intercept supplier wants to receive payment, it would
have to make an agreement with the volunteer supplier regarding
payment." We would like your confirmation that this means—
a) For Medicare Part B to pay ALS, the paramedic intercept supplier
must have an agreement with the BLS volunteer supplier. The volunteer
supplier would bill Part B for ALS and then pay the Paramedic intercept
supplier in accordance with the agreement.
Answer: There must be an agreement in place between
the BLS supplier that furnishes the transport and the ALS entity
that furnishes the ALS paramedic service. However, the compensation
between the BLS entity and ALS entity is not a matter for the Medicare
program to regulate.
b) If the paramedic intercept supplier and a BLS volunteer supplier
cannot reach an agreement, the volunteer supplier may not bill for
ALS and the paramedic intercept supplier must look to the patient
for payment.
Answer: Yes. If there is no agreement between the
BLS ambulance supplier and the ALS entity furnishing the paramedic,
then only BLS level may be paid and the paramedic’s services
are not covered. Therefore, the beneficiary would be liable for
the expense of the paramedic’s ALS services; that is, to the
extent that the paramedic’s services were beyond the scope
of the BLS level payment.
Ancillary Services
Question: The chart on 67 Fed. Reg. p. 9120 does
not include "J" codes, A0394 or local codes. Also, reference
is made to only Method 3 and Method 4 suppliers being allowed to
bill for EKG, Drugs, Waiting Time and Extra Attendant. However,
in a few states, some of these are allowed for all billers. We would
like your confirmation that:
a) Drugs (usually using "J" codes), IV supplies and local
codes may still be billed during the phase-in period in states where
these are allowed before the fee schedule goes into effect.
Answer: Yes, that is correct. Drugs and supplies
may still be billed separately during the transition period in those
jurisdictions where this was the practice prior to implementation
of the fee schedule. Local codes may be used until the end of the
transition period or until eliminated by the implementation of the
HIPAA standards for electronic submission of claims, whichever is
sooner. These separately billed items would contribute to the calculation
of the “old” (that is, the reasonable charge/cost) portion
of the blended rate.
b) Where local codes need to be eliminated, carriers will bundle
the amounts allowed for those items into the base rate, using a
weighted average. EKG, Drugs, Waiting Time and Extra Attendant may
be billed by suppliers using any Method (Method 1 through 4) but
only if they are currently allowed.
Answer: Yes, that is correct.
New Suppliers
A question concerning new suppliers was posted to the Web site and
subsequently withdrawn. The answer will be further developed.
Rural Mileage
Question: If a rural suppliers' actual charge for
mileage is less than the amount allowed under the fee schedule (.
e.g., $3.00), we understand the rule to be that the supplier would
still be entitled to be paid the additional rural allowance for
miles 1 though 50 (in this case $4.50 for miles 1-17 and $3.75 for
miles 18 – 50). We believe this is the consequence of the
language in the regulation that provides for the rural mileage rate
(fee schedule amount or actual charge, if lower) to be increased
50 percent for miles 1 – 17 and 25 percent for miles 18 –
50.
Answer: No, this is not correct. The rural bonus
is not applied to the billed charge. It is applied only to calculate
the FS rural mileage payment rate from the FS urban mileage payment
rate. The program’s payment is based on the lesser of the
billed charge or the applicable fee schedule amount.
Question: How is a rural supplier is expected to
bill for mileage? Is the rural supplier required on its claim to
do the calculation of the rural adjustment in relation to the number
of miles billed, or will the carrier calculate the rural adjustment
based on reported mileage? Rural suppliers need to know whether
to claim the adjusted amount as their actual charge.
Answer: Ambulance suppliers must calculate the
rural adjustment in relation to the number of rural miles billed,
if they wish to obtain the additional fee schedule payment amount
available for rural mileage. Carriers will not perform this calculation.
The supplier’s charge as reported on the line item for mileage
on the ambulance claim will be taken as the supplier’s complete
and entire charge for all miles reported on the claim.
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