Thursday, July 23, 2015

would insurance pay if Transport of Persons Other Than the Beneficiary in ambulance?

Transport of Persons Other Than the Beneficiary

No payment may be made for the transport of ambulance staff or other personnel when the beneficiary is not onboard the ambulance (e.g., an ambulance transport to pick up a specialty care unit from one hospital to provide services to a beneficiary at another hospital). This policy applies to both ground and air ambulance transports.

Effect of Beneficiary Death on Medicare Payment for Ground
Ambulance Transports
Because the Medicare ambulance benefit is a transport benefit, if no transport of a Medicare beneficiary occurs, then there is no Medicare-covered service. In general, if the beneficiary dies before being transported, then no Medicare payment may be made.

Thus, in a situation where the beneficiary dies, whether any payment under the Medicare ambulance benefit may be made depends on the time at which the beneficiary is pronounced dead by an individual authorized by the State to make such pronouncements.

The chart below shows the Medicare payment determination for various ground ambulance scenarios in which the beneficiary dies. In each case, the assumption is that the ambulance transport would have otherwise been medically necessary.

Ground Ambulance Scenarios: Beneficiary Death
Time of Death Pronouncement Medicare Payment Determination
Before dispatch. None.
After dispatch, before beneficiary is
loaded onboard ambulance (before
or after arrival at the point-ofpickup).
The provider’s/supplier’s BLS base rate, no
mileage or rural adjustment; use the QL
modifier when submitting the claim.
After pickup, prior to or upon arrival
at the receiving facility.
Medically necessary level of service furnished.

The Destination
An ambulance transport is covered to the nearest appropriate facility to obtain necessary diagnostic and/or therapeutic services (such as a CT scan or cobalt therapy) as well as the return transport. In addition to all other coverage requirements, this transport situation is covered only to the extent of the payment that would be made for bringing the service to the patient.

Medicare covers ambulance transports (that meet all other program requirements for
coverage) only to the following destinations:
• Hospital;
• Critical Access Hospital (CAH);
• Skilled Nursing Facility (SNF);
• Beneficiary’s home;
• Dialysis facility for ESRD patient who requires dialysis; or
• A physician’s office is not a covered destination. However, under special
circumstances an ambulance transport may temporarily stop at a physician’s
office without affecting the coverage status of the transport.

As a general rule, only local transportation by ambulance is covered, and therefore, only mileage to the nearest appropriate facility equipped to treat the patient is covered. However, if two or more facilities that meet the destination requirements can treat the patient appropriately and the locality of each facility encompasses the place where the ambulance transportation of the patient began, then the full mileage to any one of the facilities to which the beneficiary is taken is covered. Because all duly licensed hospitals and SNFs are presumed to be appropriate sources of health care, only in exceptional situations where the ambulance transportation originates beyond the locality of the institution to which the beneficiary was transported, may full payment for mileage be considered. And then, only if the evidence clearly establishes that the destination institution was the nearest one with appropriate facilities under the particular circumstances. The institution to which a patient is transported need not be a participating institution but must meet at least the requirements of the Social Security Act (the Act.).

Institution to Beneficiary’s Home
Ambulance service from an institution to the beneficiary’s home is covered when the home is within the locality of such institution or where the beneficiary’s home is outside of the locality of such institution but the institution, in relation to the home, is the nearest one with appropriate facilities.

Institution to Institution

Occasionally, the institution to which the patient is initially taken is found to have inadequate or unavailable facilities to provide the required care, and the patient is then transported to a second institution having appropriate facilities. In such cases, transportation by ambulance to both institutions would be covered to the extent of the mileage to be the nearest institution with appropriate facilities. Responsibility for payment would follow the rules in § 10.3.3. In these cases, transportation from such second institution to the patient's home could be covered if the home is within the locality served by that institution, or the locality served by the first institution to which the patient was taken.

Wednesday, July 8, 2015

Ambulance Services Furnished by Providers of Services

The Part A intermediary is responsible for the processing of claims for ambulance service furnished under arrangements by participating hospitals, skilled nursing facilities, and home health agencies. Since provider ambulance services furnished “under arrangements” with suppliers can be covered only if the supplier meets the above requirements, the Part A intermediary may ask the carrier to identify those suppliers who meet the requirements. Where the "under arrangement" supplier also supplies ambulance services directly to Medicare beneficiaries, i.e., services that are not pursuant to an arrangement with a provider, the intermediary contacts the Part B carrier to ascertain whether it has already determined whether the crew and ambulance requirements are met.

In such a situation, the intermediary should accept the carrier’s determination without
pursuing its own investigation.

Equipment and Supplies

As mentioned above, the ambulance must have customary patient care equipment and
first aid supplies, including reusable devices and equipment such as backboards,
neck boards, and inflatable leg and arm splints. These are all considered part of the
general ambulance service and payment for them is included in the payment rate for the

Necessity and Reasonableness

To be covered, ambulance services must be medically necessary and reasonable.

Necessity for the Service

Medical necessity is established when the patient's condition is such that use of any other method of transportation is contraindicated. In any case in which some means of transportation other than an ambulance could be used without endangering the individual's health, whether or not such other transportation is actually available, no payment may be made for ambulance services. In all cases, the appropriate documentation must be kept on file and, upon request, presented to the carrier/intermediary. It is important to note that the presence (or absence) of a physician’s order for a transport by ambulance does not necessarily prove (or disprove) whether the transport was medically necessary. The ambulance service must meet all program coverage criteria in order for payment to be made.
In addition, the reason for the ambulance transport must be medically necessary. That is, the transport must be to obtain a Medicare covered service, or to return from such a service.

Reasonableness of the Ambulance Trip
Under the FS payment is made according to the level of medically necessary services actually furnished. That is, payment is based on the level of service furnished (provided they were medically necessary), not simply on the vehicle used. Even if a local government requires an ALS response for all calls, payment under the FS is made only for the level of service furnished, and then only when the service is medically necessary.

Medicare Policy Concerning Bed-Confinement
As stated above, medical necessity is established when the patient’s condition is such that the use of any other method of transportation is contraindicated. Contractors may presume this requirement is met under certain circumstances, including when the beneficiary was bed-confined before and after the ambulance trip.

A beneficiary is bed-confined if he/she is:
• Unable to get up from bed without assistance;
• Unable to ambulate; and
• Unable to sit in a chair or wheelchair.
The term "bed confined" is not synonymous with "bed rest" or "nonambulatory". Bedconfinement, by itself, is neither sufficient nor is it necessary to determine the coverage for Medicare ambulance benefits. It is simply one element of the beneficiary's condition that may be taken into account in the intermediary's/carrier's determination of whether means of transport other than an ambulance were contraindicated.

Documentation Requirements
In all cases, the appropriate documentation must be kept on file and, upon request, presented to the carrier. It is important to note that neither the presence nor absence of a signed physician’s order for an ambulance transport necessarily proves (or disproves) whether the transport was medically necessary. The ambulance service must meet all program coverage criteria in order for payment to be made.

Thursday, June 25, 2015

Ambulance Service - Part B - Medicare basic guidelines

Ambulance Service - Part B

Ambulance services are separately payable only under Part B. There are certain
circumstances in which the service is covered and payable as a beneficiary transportation service under Part A; however in this case the service cannot be classified and paid for as an ambulance service under Part B. Payment may be made for expenses incurred for ambulance service provided the conditions specified in the following subsections are met.

The Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service. When multiple ground and/or air ambulance providers/suppliers respond, payment may be made only to the ambulance provider/supplier that actually furnishes the transport.

Vehicle and Crew Requirement
Any vehicle used as an ambulance must be designed and equipped to respond to medical emergencies and, in nonemergency situations, be capable of transporting beneficiaries with acute medical conditions. The vehicle must comply with State or local laws governing the licensing and certification of an emergency medical transportation vehicle. At a minimum, the ambulance must contain a stretcher, linens, emergency medical supplies, oxygen equipment, and other lifesaving emergency medical equipment and be equipped with emergency warning lights, sirens, and telecommunications equipment as required by State or local law. This should include, at a minimum, one 2-way voice radio or wireless telephone.

Vehicle Requirements for Basic Life Support and Advanced
Life Support
Basic Life Support ambulances must be staffed by at least two people, at least one of
whom must be certified as an emergency medical technician (EMT) by the State or local
authority where the services are being furnished and be legally authorized to operate all
lifesaving and life-sustaining equipment on board the vehicle. Advanced Life Support
(ALS) vehicles must be staffed by at least two people, at least one of whom must be
certified by the State or local authority as an EMT-Intermediate or an EMT-Paramedic.

Verification of Compliance

In determining whether the vehicles and personnel of each supplier meet all of the above requirements, carriers may accept the supplier’s statement (absent information to the contrary) that its vehicles and personnel meet all of the requirements if:
1. The statement describes the first aid, safety, and other patient care items with
which the vehicles are equipped;
2. The statement shows the extent of first aid training acquired by the personnel
assigned to those vehicles;
3. The statement contains the supplier’s agreement to notify the carrier of any
change in operation which could affect the coverage of ambulance services; and
4. The information provided indicates that the requirements are met.

The statement must be accompanied by documentary evidence that the ambulance has the equipment required by State and local authorities. Documentary evidence could include a letter from such authorities, a copy of a license, permit, certificate, etc., issued by the authorities. The carrier will keep the statement and supporting documentation on file.

When a supplier does not submit such a statement or whenever there is a question about a supplier’s compliance with any of the above requirements for vehicle and crew (including suppliers who have completed the statement), carriers will take appropriate action including, where necessary, on-site inspection of the vehicles and verification of the qualifications of personnel to determine whether the ambulance service qualifies for reimbursement under Medicare. Since the requirements described above for coverage of ambulance services are applicable to the overall operation of the ambulance supplier’s service, information regarding personnel and vehicles need not be obtained on an individual trip basis.

Friday, June 19, 2015

New HCPCS Codes Subject to CLIA Edits for 2015

HCPCSCode Descriptor
G0464Colorectal cancer screening; stool-based dna and fecal occult hemoglobin (e.g., kras, ndrg4 and bmp3)
G6036Assay of imipramine
G6040Alcohol (ethanol) any specimen except breath
G6041Alkaloids, urine, quantitative
G6042Amphetamine or methamphetamine
G6043Barbiturates, not elsewhere specified
G6044Cocaine or metabolite
G6056Opiate(s), drug and metabolites, each procedure
G6058Drug confirmation, each procedure
80163Digoxin level
80165Valproic acid level
80300-80304Drug screen
80320-80377Alcohols levels
81246Test for detecting genes associated with blood cancer
81288Test for detecting genes associated with colon cancer
81313Test for detecting genes associated with prostate cancer
81410Test for detecting genes associated with heart disease
81411Test for detecting genes associated with heart disease
81415Test for detecting genes associated with diseases
81416Test for detecting genes associated with disease
81417Reevaluation test for detecting genes associated with disease
81420Test for detecting genes associated with fetal disease
81425Test for detecting genes associated with disease
81426Test for detecting genes associated with disease
81427Reevaluation test for detecting genes associated with disease
81430Test for detecting genes causing hearing loss
81431Test for detecting genes causing hearing loss
81435Test for detecting genes associated with colon cancer
81436Test for detecting genes associated with colon cancer
81440Test for detecting genes associated with cancer of body organ
81445Test for detecting genes associated with cancer of body organ
81450Test for detecting genes associated with blood related cancer
81455Test for detecting genes associated with cancer
81460Test for detecting genes associated with disease
81465Test for detecting genes associated with disease
81470-81471Test for detecting genes associated with intellectual   disability
81519Test for detecting genes associated with breast cancer
87505-87507Detection test for digestive tract pathogen;
83006Test for detecting genes associated with growth stimulation
87623-87625Detection test for human papillomavirus (hpv)
87806Detection test for HIV1
88341Special stained specimen slides to examine tissue
88344Special stained specimen slides to examine tissue
88364Cell examination
88366Cell examination
88369Microscopic genetic examination manual
88373Microscopic genetic examination using computerassisted technology
88374Microscopic genetic examination using computerassisted technology
88377Microscopic genetic examination manual.

Monday, June 15, 2015

Advance Beneficiary Notice of Nonc overage: When Should You Sign an ABN?

Medicare has broad coverage, but there are some services that are not covered because they are considered reasonable, medically necessary, and appropriate. The purpose of the ABN is to give you the necessary information to make informed decisions about whether or not to get the services your provider is suggesting.

The following are some examples of when an ABN can be used for non-covered services:
•    Services where there is no legal obligation to pay (e.g., for the purchase of some vaccines). In those cases, your doctor can charge Medicare for administering the vaccine, but they cannot charge Medicare for the vaccine.
•    Services paid for by a government entity other than Medicare
•    Personal comfort items
•    Routine eye care
•    Dental care
•    Routine foot care

ABNs cannot be issued for services that the provider knows is medically necessary and is covered by Medicare. In addition, an ABN cannot be issued for emergency ambulance transportation because the patient is presumed to be under ‘great duress’. An ABN cannot be issued to a patient if they are under great duress.

An ABN must be given to you (or your representative) prior to receiving the item or service in question. The Centers for Medicare & Medicaid (CMS) mandates your provider give you the ABN far enough in advance for you to have time to consider your options and make an informed choice.
CMS has created a standardized ABN form to use; however, it does allow your health care provider to use their own form, as long as it contains the same information.

If your provider asks you to sign an ABN, the document must:
•    Give the name or description of the service they are providing
•    Provide a statement that explains why they believe the services may not be covered by Railroad Medicare. Some common statements are: 'Medicare does not pay for this test for your condition,' 'Medicare does not pay for this test as often as this (denied as too frequent)', or 'Medicare does not pay for experimental or research tests.'
•    Give you the estimated cost of the service or procedure
•    Provide you with three options, worded in the following ways:
o    Option 1. 'I want the (service or procedure) listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.'
o    Option 2. 'I want the (service or procedure) listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.'
o    Option 3. 'I don’t want the (service or procedure) listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.'
The ABN will also have a place for additional information, such as a dated witness signature.
There must be a place on the ABN for you to sign and date, which indicates you have reviewed the document and understand the information in it. You cannot sign the ABN in advance of the rest of the notice.

Some points to remember:
•    Just because you sign an ABN does not mean Railroad Medicare will not pay for the service. Federal law still requires the claim be submitted for proper review.
•    Even if you sign the ABN and Railroad Medicare denies payment, you are still entitled to appeal the decision. You can pay the provider and later have your money returned to you from the provider if your appeal is successful.
•    If you have a secondary insurance, have the provider submit the claim to Railroad Medicare for denial. Some secondary insurances may cover services that Railroad Medicare does not.

Wednesday, May 13, 2015

Prior Authorization Process for Repetitive Scheduled Non-Emergent Ambulance Transport

Fact sheets: Prior Authorization Process for Repetitive Scheduled Non-Emergent Ambulance Transport


The Centers for Medicare & Medicaid Services (CMS) will begin implementing a prior authorization demonstration program for repetitive scheduled non-emergent ambulance transport in New Jersey, Pennsylvania, and South Carolina. CMS will test whether prior authorization helps reduce expenditures, while maintaining or improving quality of care. CMS believes using a prior authorization process will help ensure services are provided in compliance with applicable Medicare coverage, coding, and payment rules before services are rendered and claims are paid. 

In 2012, CMS launched a prior authorization process for certain power mobility devices in seven demonstration states (California, Florida, Illinois, Michigan, New York, North Carolina, and Texas).  Since implementing the demonstration, CMS has observed a decrease in expenditures for power mobility devices.  CMS will leverage this success by creating a prior authorization process for certain non-emergent services under Medicare. CMS seeks to use this process to address growing concerns about beneficiaries receiving non-medically necessary repetitive scheduled non-emergent ambulance transport services. New Jersey, Pennsylvania, and South Carolina were selected for initial implementation of this process because of their high utilization and improper payment rates for these services.

Under Section 1115A of the Social Security Act, the Secretary has authority to test innovative payment and service delivery models to reduce program expenditures, while preserving or enhancing the quality of care furnished to individuals under such titles.

Prior authorization will not create new clinical documentation requirements. Instead, it will require the same information necessary to support Medicare payment, just earlier in the process.  Prior authorization allows providers and suppliers to address issues with claims prior to rending services and to avoid an appeal process. This will help ensure that all relevant coverage, coding, and clinical documentation requirements are met before the service is rendered to the beneficiary and before the claim is submitted for payment. 

The model will establish a prior authorization process for repetitive scheduled non-emergent ambulance transport services. This process will allow all relevant documentation to be submitted for review prior to rendering services.  CMS or its contractors will review the request and provide an affirmative or non-affirmative decision. A claim submitted with an affirmative prior authorization will be paid so long as all other requirements are met. A claim submitted with a non-affirmative decision will be denied.  Unlimited resubmissions are allowed. If a provider or supplier chooses to forego prior authorization and submits a claim without prior authorization decision, that claim shall undergo pre-payment review.

CMS Medicare Review Contractors will review prior authorization requests to ensure requests are consistent with all existing applicable regulations, National Coverage Determination and Local Coverage Determination requirements, and other CMS policies. Decisions on initial requests will be postmarked within 10 business days and subsequent requests will be processed within 20 business days.  A provisional affirmative prior authorization decision will affirm a specified number of trips within a specific amount of time. The prior authorization decision, justified by the beneficiary’s condition, may affirm up to 40 round trips (which equates to 80 trips) per prior authorization request in a 60-day period. 

To address circumstances where applying the standard timeframe for making a prior authorization decision could seriously jeopardize the life or health of the beneficiary, CMS will include an expedited review process.  The request for an expedited review must provide rationale supporting the expedited review request.  Such a request must include documentation that shows that applying the standard timeframe for making a decision could seriously jeopardize the life or health of the beneficiary.  In these situations, the review entity will make reasonable efforts to communicate the decision within 2 business days of receipt of all applicable Medicare required documentation. 

Under this model, if a prior authorization has not been requested before the fourth round trip in a 30-day period, claims will be subject to pre-payment medical review. CMS believes that the repetitive scheduled non-emergent ambulance transport trips for a beneficiary will generally be scheduled through one provider or supplier at the beginning of the authorization period. CMS will allow one ambulance provider or supplier to request prior authorization per beneficiary per time period. Any provider or supplier submitting claims for which no prior authorization request is recorded will be subject to 100 percent medical review.

Tuesday, April 14, 2015

Physician Signature Requirements for Diagnostic Testing

Medicare has identified a recent increase in the number of CERT errors attributed to the lack of physician orders for diagnostic tests. A diagnostic test includes all diagnostic x-ray tests, all diagnostic laboratory tests, and other diagnostic tests furnished to a beneficiary.

An 'order' is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physician/practitioner (e.g., if test X is negative, then perform test Y). An order may be delivered via the following forms of communication:

A written document signed by the treating physician/practitioner, which is hand-delivered, mailed, or faxed to the testing facility;

A telephone call by the treating physician/practitioner or his/her office to the testing facility; and
An electronic mail by the treating physician/practitioner or his/her office to the testing facility.
If the order is communicated via telephone, both the treating physician/practitioner or his/her office, and the testing facility must document the telephone call in their respective copies of the beneficiary's medical records.

NOTE: While a physician order is not required to be signed on orders for clinical diagnostic tests paid on the basis of the clinical laboratory fee schedule, the physician fee schedule, or for physician pathology services; the physician must clearly document, in the medical record, his or her intent that the test be performed.    Failure to do so may result in denial of the service which may subsequently lead to the patient being responsible for payment.   Furthermore, the absence of a signature on an order may lead to a medical record audit of the ordering physician to verify that the physician's intent is indeed documented as directed in the regulation.   Therefore, Novitas recommends that physicians provide their signature on all orders for diagnostic and laboratory services.

Make sure that your office, billing, and/or laboratory staffs are aware of this updated guidance regarding the signature requirement for diagnostic tests and are complying with this regulation.   Also, note that in keeping with standard auditing principles, items such as signatures, attestations, and other addendums which are added to the medical record after the date of the Additional Documentation Request (ADR) letter will generally not be considered as acceptable documentation.   Furthermore, providers who exhibit a pattern of adding documentation after ADR requests could be subject to corrective action.

If you receive a request for medical records from the CERT contractor or Novitas Solutions, it is critical that the signed physician order for all diagnostic tests be included.   Without the order, the services could be determined to be medically unnecessary and the claim will be denied.