Saturday, June 25, 2016

DOS and POint of Pickup, Provider in Ambulance billing ? Definition


Definitions


Most of the definitions previously found in this chapter can now be found in IOM Pub. 100-02, Medicare Benefit Policy Manual, chapter 10 - Ambulance Services. Other definitions pertaining to payment and claims processing follow.


A/B MAC (A)

Definition: For the purposes of this chapter only, the term refers to those contractors that process claims for institutionally-based ambulance providers billed on the ASC X12 837 institutional claim transaction or Form CMS-1450.


A/B MAC (B)

Definition: For the purposes of this chapter only, the term refers to those contractors that process claims for ambulance suppliers billed on the ASC X12 837professional claim transaction or a CMS-1500 form.


Date of Service

Definition: The date of service (DOS) of an ambulance service is the date that the loaded ambulance vehicle departs the point of pickup. In the case of a ground transport, if the beneficiary is pronounced dead after the vehicle is dispatched but before the (now deceased) beneficiary is loaded into the vehicle, the DOS is the date of the vehicle’s dispatch. In the case of an air transport, if the beneficiary is pronounced dead after the aircraft takes off to pick up the beneficiary, the DOS is the date of the vehicle’s takeoff.

Point of Pickup (POP)

Definition: Point of pickup is the location of the beneficiary at the time he or she is placed on board the ambulance.

Application: The ZIP Code of the POP must be reported on each claim for ambulance services so that the correct Geographic Adjustment Factor (GAF) and Rural Adjustment Factor (RAF) may be applied, as appropriate.

Provider
Definition: For the purposes of this chapter only, the term “provider” is used to reference a hospital-based ambulance provider which is owned and/or operated by a hospital, critical access hospital, skilled nursing facility, comprehensive outpatient rehabilitation facility, home health agency, hospice program, or, for purposes of section 1814(g) and section 1835(e), a fund.

Supplier

Definition: For the purposes of this chapter, the term supplier is defined as any ambulance service that is not institutionally based. A supplier can be an independently owned and operated ambulance service company, a volunteer fire and/or ambulance company, a local government run firehouse based ambulance, etc., that provides Part B Medicare covered ambulance services and is enrolled as an independent ambulance supplier.

Wednesday, June 22, 2016

How to report total charges on UB 04 WITH example


H. Total Charges Reporting

For line items reflecting HCPCS codes A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434;

Providers are required to report in Total Charges the actual charge for the ambulance service including all supplies used for the ambulance trip but excluding the charge for mileage. For line items reflecting HCPCS code A0380, A0390, A0435, or A0436, report the actual charge for mileage.

NOTE: There are instances where the provider does not incur any cost for mileage, e.g., if the beneficiary is pronounced dead after the ambulance is called but before the ambulance arrives at the scene. In these situations, providers report the base rate ambulance trip and mileage as separate revenue code lines. Providers report the base rate ambulance trip in accordance with current billing requirements. For purposes of reporting mileage, they must report the appropriate HCPCS code, modifiers, and units as a separate line item. For the related charges, providers report $1.00 in FL48 for non- covered charges. A/B MACs (A) should assign remittance adjustment Group Code OA to the $1.00 non- covered mileage line, which in turn informs the beneficiaries and providers that they each have no liability.

Prior to submitting the claim to CWF, the A/B MAC (A) will remove the entire revenue code line containing the mileage amount reported in Non-covered Charges to avoid non-acceptance of the claim.

NOTE: Information regarding the claim form locator that corresponds to the Charges fields is found in Pub. 100-04, Medicare Claims Processing Manual, Chapter 25 – Completing and Processing the Form CMS-1450 Data Set.


EXAMPLES: The following provides examples of how bills for Part B ambulance services should be completed based on the reporting requirements above. These examples reflect ambulance services furnished directly by providers. Ambulance services provided under arrangement between the provider and an ambulance company are reported in the same manner except providers report a QM modifier instead of a QN modifier.

EXAMPLE 1: Claim containing only one ambulance trip:

For the hard copy CMS-1450 Form, providers report as follows:

Revenue Code    HCPCS/ Modifiers    Date of Service         Units        Total Charges  

  0540       A0428RHQN       082701      1 (trip)      100.00
   
  0540         A0380RHQN          082701            4 (mileage)           8.00


EXAMPLE 2: Claim containing multiple ambulance trips:

For the hard copy Form CMS-1450, providers report as follows:

0540            A0429        RH         QN        082801         1 (trip)           100.00

0540          A0380        RH         QN         082801     2 (mileage)        4.00

0540           A0330      RH         QN        082901         1 (trip)           400.00

0540            A0390         RH       QN        082901        3 (mileage)           6.00


EXAMPLE 3: Claim containing more than one ambulance trip provided on the same day:

For the hard copy CMS-1450, providers report as follows:


0540      A0429      RH     QN          090201       1 (trip)        100.00

0540        A0380        RH     QN        090201         2 (mileage)        4.00

0540        A0429     HR       QN          090201         1 (trip)          100.00

0540      A0380     HR        QN      090201        2 (mileage)          4.00

Monday, June 20, 2016

Does Amublance billing covered under part A ?

Summary of the Benefit


Ambulance services are covered under Medicare Part B. However, a Part B payment for an ambulance service furnished to a Medicare beneficiary is available only if the following, fundamental conditions are met:

• Actual transportation of the beneficiary occurs.

• The beneficiary is transported to an appropriate destination.

• The transportation by ambulance must be medically necessary, i.e., the beneficiary’s medical condition is such that other forms of transportation are medically contraindicated.

• The ambulance provider/supplier meets all applicable vehicle, staffing, billing, and reporting requirements.

• The transportation is not part of a Part A service.


Other requirements specified in this chapter or in the above-cited CMS Manuals may also apply to the provider/supplier or to a particular transport or billing.


 Payment Rules


Medicare covered ambulance services are paid based on the Medicare ambulance fee schedule.

The following subsections describe how contractors calculate the payment amount. Section 20.1 and its subsections describe how the payment amount is calculated for the fee schedule. The other subsections in §20 provide information on certain components of the payment amount (e.g., mileage) or specialized payment amounts (e.g., air ambulance).

Wednesday, June 15, 2016

Billing/Coding/Physician Documentation Information in ambulance billing


This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page. Applicable codes: A0021, A0080, A0090, A0100, A0110, A0120, A0130, A0140, A0160, A0170, A0180, A0190, A0200, A0210, A0225, A0380, A0382, A0384, A0390, A0392, A0394, A0396, A0398, A0420, A0422, A0424, A0425, A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, A0434, A0435, A0436, A0888, A0998, A0999, S0207, S0208, S0209, S0215, S9960, S9961 All ambulance transport codes and mileage codes must be reported with both the corresponding origin and destination modifiers. BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.


Policy Guidelines

Ambulance and medical transport services are regulated by local, state and federal laws. The ambulance and medical transport services should be operated according to all applicable laws and must have all the appropriate, valid licenses and permits.

Reusable devices are considered an integral part of the general ambulance and medical transport services and are not eligible for coverage as separate services. Unusual ambulance and medical transport services, such as advanced life support charges, and those situa-tions involving air or sea transport should be reviewed by individual consideration.

Sunday, June 12, 2016

DOS and unit reporting on CMS 1450 - cpt code A0030, A0040, A0322 AND A0427

F. Line-Item Dates of Service Reporting

Providers are required to report line-item dates of service per revenue code line. This means that they must report two separate revenue code lines for every ambulance trip provided during the billing period along with the date of each trip. This includes situations in which more than one ambulance service is provided to the same beneficiary on the same day. Line-item dates of service are reported in the Service Date field.

NOTE: Information regarding the claim form locator that corresponds to the Service Date is found in Pub. 100-04, Medicare Claims Processing Manual, Chapter 25 – Completing and Processing the Form CMS-1450 Data set.


G. Service Units Reporting

For line items reflecting HCPCS code A0030, A0040, A0050, A0320, A0322, A0324, A0326, A0328, or A0330 (services before January 1, 2001) or code A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434 (services on and after January 1, 2001), providers are required to report in Service Units each ambulance trip provided during the billing period. Therefore, the service units for each occurrence of these HCPCS codes are always equal to one. In addition, for line items reflecting HCPCS code A0380 or A0390, the number of loaded miles must be reported. (See examples below.)

Therefore, the service units for each occurrence of these HCPCS codes are always equal to one. In addition, for line items reflecting HCPCS code A0380, A0390, A0435, or A0436, the number of loaded miles must be reported.

Friday, June 10, 2016

What situation ambulance service would be covered and not covered

When Ambulance and Medical Transport Services are covered

1. Ground emergency ambulance service for the transport of a patient is considered medically necessary when all the following criteria are met:

a. The ambulance must be equipped with appropriate emergency and medical supplies and equipment;

b. The patient’s condition must be such that any other form of transportation would be medically contraindicated;

c. The patient must be transported to the nearest hospital with the appropriate facilities for the treatment of the patient’s illness or injury.

2. Non-emergency medical transport services for the transport of a hospital inpatient to another facility for specialized services are considered eligible for coverage when all of the following criteria are met:

a. The patient is a registered inpatient in an acute care hospital;

b. The specialized services are not available in the hospital in which the patient is registered Ambulance and Medical Transport Services  and those specialized services are considered reasonable, medically necessary, and covered under the members benefit plan;

c. The provider of the specialized services is the nearest one with the required capabilities.


3. Air or Sea Ambulance services may be medically necessary in exceptional circumstances. All of the criteria pertaining to ground transportation must be met, as well as one of the following additional conditions:

a. The patient’s medical condition must require immediate and rapid ambulance transport to the nearest appropriate medical facility that could not have been provided by land ambulance;

b. The point of pick-up is inaccessible by land vehicle;

c. Great distances, limited time frames, or other obstacles are involved in getting the patient to the nearest hospital with appropriate facilities for treatment;

d. The patient’s condition is such that the time needed to transport a patient by land to the nearest appropriate medical facility poses a threat to the patient’s health.


4. Ambulance or medical transport services are considered eligible for coverage if the patient is legally pronounced dead after the ambulance was called, but before pickup, or enroute to the hospital.


5. Transportation from a hospital, skilled nursing facility or rehabilitation facility to a patient’s residence when the patient’s condition requires skilled monitoring during transport with the services of an EMT attendant or other licensed healthcare practitioner.


When Ambulance and Medical Transport Services are not covered

1. When the medical guidelines shown above are not met:

2. If the patient is legally pronounced dead before the ambulance is called, the services are not considered medically necessary.

3. Transportation provided primarily for the convenience of the patient, patient’s family or physician is not covered.

4. Transportation for the purpose of receiving a service considered NOT medically necessary is also considered NOT medically necessary, even if the destination is an appropriate facility.

Tuesday, June 7, 2016

Revenue Code/HCPCS Code Reporting - cpt code A0380,A0390, A0435


Providers must report revenue code 054X and, for services provided before January 1, 2001, one of the following CMS HCPCS codes for each ambulance trip provided during the billing period:

A0030 (discontinued 12/31/2000); A0040 (discontinued 12/31/2000);

A0050 (discontinued 12/31/2000); A0320 (discontinued 12/31/2000); A0322 (discontinued 12/31/2000); A0324 (discontinued 12/31/2000); A0326 (discontinued 12/31/2000); A0328, (discontinued 12/31/2000); or A0330 (discontinued 12/31/2000).


In addition, providers report one of A0380 or A0390 for mileage HCPCS codes. No other HCPCS codes are acceptable for reporting ambulance services and mileage. Providers report one of the following revenue codes:

0540;

0542;


0543;

0545;



0546; or

0548.


Do not report revenue codes 0541, 0544, or 0547.

For claims with dates of service on or after January 1, 2001, providers must report revenue code 540 and one of the following HCPCS codes for each ambulance trip provided during the billing period:

A0426; A0427;

A0428; A0429; A0430; A0431; A0432; A0433; or

A0434.

Providers using an ALS vehicle to furnish a BLS level of service report HCPCS code, A0426 (ALS1) or A0427 (ALS1 emergency), and are paid accordingly. In addition, all providers report one of the following mileage HCPCS codes: A0380; A0390; A0435; or A0436.

Since billing requirements do not allow for more than one HCPCS code to be reported for per revenue code line, providers must report revenue code 0540 (ambulance) on two separate and consecutive lines to accommodate both the Part B ambulance service and the mileage HCPCS codes for each ambulance trip provided during the billing period. Each loaded (e.g., a patient is onboard) 1-way ambulance trip must be reported with a unique pair of revenue code lines on the claim. Unloaded trips and mileage are NOT reported.

However, in the case where the beneficiary was pronounced dead after the ambulance is called but before the ambulance arrives at the scene: Payment may be made for a BLS service if a ground vehicle is dispatched or at the fixed wing or rotary wing base rate, as applicable, if an air ambulance is dispatched. Neither mileage nor a rural adjustment would be paid. The blended rate amount will otherwise apply. Providers report the A0428 (BLS) HCPCS code. Providers report modifier QL (Patient pronounced dead after ambulance called) in Form Locator (FL) 44 “HCPCS/Rates” instead of the origin and destination modifier. In addition to the QL modifier, providers report modifier QM or QN.