Wednesday, February 25, 2015

EHR Incentive Program: How to Report Once in 2014 for Medicare Quality Reporting Programs


Providers participating in the 2014 Physician Quality Reporting System (PQRS) program may be eligible to report their quality data one time only to earn credit for multiple Medicare quality reporting programs. Individual eligible professionals and group practices will be able to report once on a single set of clinical quality measures (CQMs) and satisfy some of the various requirements of several of the following programs, depending on eligibility:
•    PQRS
•    Value-Based Payment Modifier (VM)
•    Medicare Electronic Health Record (EHR) Incentive Program
•    Medicare Shared Savings Program Accountable Care Organization (ACO)
•    Pioneer ACO
•    Comprehensive Primary Care Initiative (CPCI)

CMS aligned some of the reporting requirements for these programs starting in 2014 to reduce the burden of data collection. Those eligible professionals who choose to report once will reap several benefits:
•    Earn the 2014 PQRS incentive and avoid the 2016 PQRS payment adjustment.
•    Satisfy the CQM requirements of the Medicare EHR Incentive Program.
•    Satisfy requirements for the 2016 VM, ACO, and/or CPCI, if eligible.
Note: aligned reporting options are only available to eligible professionals beyond their first year of participation in the Medicare EHR Incentive Program.

How to Report Once

Individual eligible professionals and group practices must submit a full year (January 1 through December 31, 2014) of data to receive credit for the various programs. The following resources will help explain how providers can report their quality data one time for 2014 participation in applicable quality programs:
•    Reporting Once Interactive Tool: Provides reporting guidance based on how the eligible professional plans to participate in PQRS in 2014.

•    eHealth University Reporting Once Module: Explains how to report quality measures one time during the 2014 program year and satisfy quality reporting requirements PQRS, the Medicare EHR Incentive Program, the VM, and ACOs.

•    2014 CQM Electronic Reporting Guide: Provides an overview of 2014 CQMs and options for reporting them to CMS.

2014 QRDA III SEVT Testing Available

The Submission Engine Validation Tool (SEVT) for 2014 Quality Reporting Document Architecture (QRDA) III submission is available on the QualityNet Portal. CMS recommends QRDA submitters and certified EHR technology vendors use this tool for 2014 submission testing.

Friday, February 21, 2014

Denied as Admission date , ambulance drop off location required in claims

Admission Date REQUIRED


What this means: For the trading partner, Payer Path, this is a required field for ambulance claims.  This must be added in order for the claims to go through.

Provider action: Add the admission date

Rejection Removal: Rejections will not be removed by Gateway EDI as they are valid.

Re-filing:Once this is corrected, you would want to re-file any claims that rejected for this reason


Ambulance Drop-Off Location is required for Ambulance Claims.


What this means: One of the requirements for ambulance claims is that a drop off city, state and zip code are required

Provider action: Add the drop off location to your claim.

Rejection removal:  Rejections will not be removed by Gateway EDI as they are valid.  

Re-filing: Once this is corrected, you would want to re-file any claims that rejected for this reason.


Ambulance Pick-Up Location is required for Ambulance Claims.

What this means: One of the requirements for ambulance claims is that a pick up city, state and zip code are required

Provider action: Add the pick up location to your claim.

Rejection removal:  Rejections will not be removed by Gateway EDI as they are valid.  

Re-filing: Once this is corrected, you would want to re-file any claims that rejected for this reason.




Tuesday, May 22, 2012

When Tricare cover ambulance services

TRICARE covers ambulance services in the following circumstances:


•     Emergency transport to a hospital

•     Transfer from one hospital to another hospital more capable of providing the required care as ordered by a physician

•     Transfers between a hospital or SNF and another facility for outpatient therapy or diagnostic services ordered by a physician

•     Transfers to and from a SNF when medically indicated

Note: Payment of ambulance transfers to and from a SNF may be included in the SNF prospective payment system (PPS).

Air or boat ambulance is only covered when the pickup point is inaccessible by a land vehicle, or when great distance or other obstacles are involved in transporting the patient to the nearest hospital with appropriate facilities, and the patient’s medical condition warrants speedy admission or is such
that transfer by other means is contraindicated. TRICARE does not cover ambulance services for these conditions:

•     Non-emergency ambulance services used instead of a taxi service or other normal transportation means when the patient’s condition would permit
use of regular transportation (Ambulance transportation is covered under the TRICARE Extended Care Health Option [ECHO] benefit when the beneficiary is being transported to and from institutions or facilities when the
beneficiary is receiving institutional care.)

•     Transport or tra nsfer of a patient primarily for the purpose of having the patient closer to home, family, friends, or a physician

•     Any type of medicabs or ambicabs that function as public passenger services transporting patients to and from medical appointments

Saturday, January 28, 2012

Ambulance billing - Denied and Non Covered Service

Denied Services
Program payment will not be made when other transportation could be utilized without endangering the patient’s health, whether such means of transportation is actually available.
A claim may be denied on the grounds that the use of an ambulance service was unreasonable in the treatment of the illness or injury involved.
Non-Covered Services
Medicare does not cover the following services:
 Transportation in Ambi-buses, ambulettes (Mobility Assistance Vehicle (MAV)), Medi-cabs, vans, privately owned vehicles, taxicabs or wheelchair vans.
 Parking fees.
  Tolls for bridges, tunnels and highways.

What are the documents required when you submit the claims to Medicare

Documentation Requirements for Ambulance Billing
The trip record documentation of each patient encounter should include the following:
 Complete and legible information.
 Reason for the transport.
 A concise explanation of symptoms reported by the patient and/or other observers and details of the patient’s physical assessments that explain why the patient requires ambulance transportation and cannot be safely transported by an alternate mode.
 Relevant history (when available).
  Observations and findings (patient’s condition at the time of transfer).
  A description of the patient’s physical condition in sufficient detail to demonstrate that the patient’s condition or functional status at the time of transport meets Medicare limitation of coverage for ambulance services.
 A detailed description of existing safety issues.
  A detailed description of special precautions taken (if any) and explanation of the need for such precautions.
 Assessment and clinical evaluations that should include:
oVital signs.
o Neurological assessment.
o Cardiac information.
                 Documentation of procedures and supplies provided such as:
O IV therapy.
o Respiratory therapy.
o Intubation.
o Cardiopulmonary Resuscitation (CPR).
o Oxygen administered.
o Drug therapy.
o Restraints. 
 A description of specific monitoring and treatments ordered and performed/ administered; that a treatment (such as oxygen) and/or monitoring (such as cardiac rhythm monitoring) was performed absent sufficient description of the patient’s condition (to demonstrate that the treatment and/or monitoring was medically necessary) is inadequate on its own merit to justify payment for the ambulance service. 
 The patient’s progress, responses to treatment and changes as treatment is given (e.g., monitoring of vital signs after medication has been given).

· Point of pickup (identify place and complete address). 
 Number of loaded miles/cost per mile/mileage charge. For services rendered with dates of service on or after January 1, 2011, miles must be reported as fractional units. For instructions on fractional units refer to “Mileage” under the “Services and Procedure Codes” section in this manual. 
 Minimal or base charge and charge for special items or services with an explanation/itemization of the special items or services. 
 For hospital-to-hospital transports, the trip record must clearly indicate the precise treatment or procedure (or medical specialist) that is available only at the receiving hospital. Non-specific or vague statements such as “needs cardiac care” or “needs higher level of care” are insufficient. 
 Any additional available documentation that supports medical necessity of ambulance transport (e.g., emergency room report, Skilled Nursing Facility (SNF) record, End-Stage Renal Disease (ESRD) facility record, hospital record). 
 A separate run sheet for each transport (e.g., two run sheets for round trips).
 Date and legible identity of the observer. Note: Refer to Signature Guidelines for Medical Review Purposes in this section.

Note: The HCPCS codes and ICD-9-CM codes reported on the health insurance claim must be supported by the documentation on the run sheet

Sunday, January 22, 2012

Signature Guidelines for Medical Review Purposes in Ambulance billing

Medicare requires that services provided/ordered be authenticated by the author. The method used must be a handwritten or electronic signature. Stamped signatures are not acceptable. These guidelines impact the ambulance trip/run sheets and the Physician Certification Statements (PCSs). 
Run sheets must have legible signatures, including credentials, from the provider(s) who renders the services documented. 
The signature of the medical professional completing the PCS must also be legible (or accompanied by a typed or printed name) and include credentials. Furthermore, signatures on the PCS must be dated at the time they are completed. 
Signature Authentication Process 
If the signature is found to be illegible or missing from the medical documentation, a signature log or attestation statement to determine the identity of the author may be requested by the reviewer before the claim is processed.

Signature Log

A signature log includes the typed or printed name and usual signature of the author associated with initials or an illegible signature. The signature log may be submitted when records are requested. The signature log may be included on the actual page where the initials or illegible signatures are used or it may be a separate document. 

Attestation Statement
An attestation statement is required when a signature is missing from the documentation; it must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary and date of service. An attestation is specific to the service documented.
Providers should not add late signatures to the medical record, but make use of the signature authentication process. When medical records are requested, you may notice changes within the request letter. To meet the requirements for signatures, additional documentation (attestation statement or signature log) may need to be submitted with your medical records.

Tuesday, January 10, 2012

Beneficiary Signature Requirements for ambulance billing

Medicare requires the signature of the beneficiary or that of his representative for both the purpose of accepting assignment and submitting a claim to Medicare. If the beneficiary is unable to sign because of a mental or physical condition, the following individuals may sign the claim form on behalf of the beneficiary: 

 The beneficiary’s legal guardian.
 A relative or other person who receives Social Security or other governmental benefits on behalf of the beneficiary.
 A relative or other person who arranges for the beneficiary’s treatment or exercises other responsibility for his affairs.
 A representative of an agency or institution that did not furnish the services for which payment is claimed, but furnished other care, services or assistance to the beneficiary. 
· A representative of the provider or of the non-participating hospital claiming payment for services it has furnished if the provider or non-participating hospital is unable to have the claim signed in accordance with 42 CFR 424.36(b) (1–4). 
 A representative of the ambulance provider or supplier who is present during an emergency and/or non-emergency transport, provided that the ambulance provider or supplier maintains certain documentation in its records for at least four years from the date of service.

A provider/supplier (or his employee) cannot request payment for services furnished except under circumstances fully documented to show that the beneficiary is unable to sign and that there is no other person who could sign. 
Medicare does not require that the signature to authorize claim submission be obtained at the time of transport for the purpose of accepting assignment of Medicare payment for ambulance benefits. When a provider/supplier is unable to obtain the signature of the beneficiary or that of his representative at the time of transport, the provider/supplier may obtain this signature any time prior to submitting the claim to Medicare for payment. 
If the beneficiary/representative refuses to authorize the submission of a claim, including a refusal to furnish an authorizing signature, the ambulance provider/supplier may not bill Medicare but may bill the beneficiary (or his estate) for the full charge of the ambulance items and services furnished. If, after seeing this bill, the beneficiary/ representative decides to have Medicare pay for these items and services, a beneficiary/representative signature is required and the ambulance provider/supplier must afford the beneficiary/representative this option within the claims filing period.