Wednesday, January 20, 2016

Guidance on Hospital Inpatient Admission Decisions

It is important that any staff involved with the clinical decision to admit the patient stay abreast of all CMS national inpatient hospital policy and National and Local Coverage Determinations. Additionally, make sure medical documentation submitted demonstrates evidence of the clinical need for the patient to be admitted to the inpatient facility and fully and accurately identifies any subsequent care that was provided during the inpatient stay.


Background

Some hospitals have recently expressed concern about how the Centers for Medicare & Medicaid Services (CMS) Recovery Audit Contractors (RACs), MACs, FIs, and the Comprehensive Error Rate Testing Contractor (CERT) are utilizing screening criteria to analyze medical documentation and make a medical necessity determination on inpatient hospital claims.

There are several commercially available screening tools that Medicare contractors in specific jurisdictions may use to assist in the review of medical documentation to determine if a hospital admission is medically necessary. These include Interqual, Milliman, and other proprietary systems.


CMS Policy Guidance

To assist hospitals regarding inpatient admission decisions, CMS would refer hospitals to the following:

Program Integrity Manual Guidance Chapter 6, Section 6.5.1, of the Medicare Program Integrity Manual requires that contractor review staff use a screening tool as part of their medical review process for inpatient hospital claims. CMS does not require that the contractor use specific criteria nor endorse any particular brand of screening guidelines. CMS contractors are not required to pay a claim even if screening criteria indicate inpatient admission is appropriate Conversely, CMS contractors are not required to automatically deny a claim that does not meet the admission guidelines of a screening tool. In all cases, in addition to screening instruments, the reviewer shall apply his/her own clinical judgment to make a medical review determination based on the documentation in the medical record.


For each case, the review staff will utilize the following when making a medical necessity determination

• Admission criteria;
• Invasive procedure criteria;
• CMS coverage guidelines;
• Published CMS criteria; and
• Other screens, criteria, and guidelines (e.g., practice guidelines that are well accepted by the medical community).

NOTE: CMS considers the use of screening criteria as only one tool that should be utilized by contractors to assist them in making an inpatient hospital claim determination.

Chapter 6, Section 6.5.2, of the Medicare Program Integrity Manual states that the review of the medical record must indicate that inpatient hospital care was medically necessary, reasonable, and appropriate for the diagnosis and condition of the beneficiary at any time during the stay. The beneficiary must demonstrate signs and/or symptoms severe enough to warrant the need for medical care and must receive services of such intensity that they can be furnished safely and
effectively only on an inpatient basis.

The reviewer will consider, in his/her review of the medical record, any pre-existing medical problems or extenuating circumstances that make admission of the beneficiary medically necessary. Factors that may result in an inconvenience to a beneficiary or family do not, by themselves, justify inpatient admission.

Inpatient care, rather than outpatient care, is required only if the beneficiary's medical condition, safety, or health would be significantly and directly threatened if care was provided in a less intensive setting. Without accompanying medical conditions, factors that would only cause the beneficiary inconvenience in terms of time and money needed to care for the beneficiary at home or for travel to a physician's office, or that may cause the beneficiary to worry, do not justify a continued hospital stay.

Chapter 6 of the Medicare Program Integrity Manual, Section 6.5 is available at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/pim83c06.pdf
on the CMS website.

Medicare Benefit Policy Manual Guidance

The Medicare Benefit Policy Manual, Chapter 1, Section 10 also contains relevant information regarding what constitutes an appropriate inpatient admission. According to that manual section, an inpatient is a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services. Generally, a patient is considered an inpatient if formally admitted as an inpatient with the expectation that he or she will remain at least overnight and occupy a bed even though it later develops that the patient can be discharged or transferred to another hospital and not actually use a hospital bed overnight.

The physician or other practitioner responsible for a patient's care at the hospital is also responsible for deciding whether the patient should be admitted as an
inpatient. Physicians should use a 24-hour period as a benchmark (i.e., they should order admission for patients who are expected to need hospital care for 24
hours or more, and treat other patients on an outpatient basis). However, the decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors, including the patient's medical history and current medical needs, the types of facilities available to inpatients and to outpatients, the hospital's by-laws and admissions policies, and the relative appropriateness of treatment in each setting. Factors to be considered
when making the decision to admit include such things as:

• The severity of the signs and symptoms exhibited by the patient;
• The medical predictability of something adverse happening to the patient;
• The need for diagnostic studies that appropriately are outpatient services (i.e., their performance does not ordinarily require the patient to remain at the
hospital for 24 hours or more) to assist in assessing whether the patient should be admitted; and
• The availability of diagnostic procedures at the time when and at the location where the patient presents.

Admissions of particular patients are not covered or non-covered solely on the basis of the length of time the patient actually spends in the hospital.

Thursday, January 7, 2016

What document provider to prepare when admit patient if Medicare ask for audit?

What factors should the physician take into consideration when making the admission decision and document in the medical record?

A4.2: For purposes of meeting the 2-midnight benchmark, in deciding whether an inpatient admission is warranted, the physician must assess whether the beneficiary requires hospital services and whether it is expected that such services will be required for 2 or more midnights. The decision to admit the beneficiary as an inpatient is a complex medical decision made by the physician in consideration of various factors, including the beneficiary’s age, disease processes, comorbidities, and the potential impact of sending the beneficiary home. It is up to the physician to make the complex medical determination of whether the beneficiary’s risk of morbidity or mortality dictates the need to remain at the hospital because the risk of an adverse event would otherwise be unacceptable under reasonable standards of care, or whether the beneficiary may be discharged. If, based on the physician's evaluation of complex medical factors and applicable risk, the beneficiary may be safely and appropriately discharged, then the beneficiary should be discharged, and hospital payment is not appropriate on either an inpatient or outpatient basis. If the beneficiary is expected to require medically necessary hospital services for 2 or more midnights, then the physician should order inpatient admission and Part A payment is generally appropriate per the 2-midnight benchmark. Except in cases involving services identified by CMS as inpatient-only, if the beneficiary is expected to require medically necessary hospital services for less than 2 midnights, then the beneficiary generally should remain an outpatient and Part A payment is generally inappropriate.

We note that in the FY 2014 IPPS final rule we stated the 2-midnight benchmark provides that hospital stays expected to last less than 2 midnights are generally inappropriate for hospital admission and Medicare Part A payment absent rare and unusual circumstances. In that rule, we stated that we would provide additional subregulatory guidance on those circumstances. We believe that we have already identified many of these rare and unusual exceptions in our Inpatient Only List. In that list, we identify those services that we have said are rarely provided to outpatients and which typically require, for reasons of quality and safety, a significantly protracted stay at the hospital. We believe that it would be rare and unusual for a stay of 0 or 1 midnights, for patients with known diagnoses entering a hospital for a specific minor surgical procedure or other treatment that is expected to keep them in the hospital for less than 2 midnights, to be appropriately classified as inpatient and paid under Medicare Part A. This is consistent with our historical guidance in which we defined certain minor therapeutic and diagnostic services as appropriately furnished outpatient on the basis of an expected short length of stay. We also do not believe that the use of telemetry, by itself, constitutes a rare and unusual circumstance that would justify an inpatient admission in the absence of a 2 midnight expectation. We note that telemetry is neither rare nor unusual, and that it is commonly used by hospitals on outpatients (ER and observation patients) and on patients fitting the historical definition of outpatient observation (that is, patients for whom a brief period of assessment or treatment may allow the patient to avoid an inpatient hospital stay). We also specified in the final rule that we do not believe that the use of an ICU, by itself, would be a rare and unusual circumstance that would justify an inpatient admission in the absence of a 2 midnight expectation. In some hospitals, placement in an ICU is neither rare nor unusual, because an ICU label is applied to a wide variety of facilities providing a wide variety of services. Due to the wide variety of services that can be provided in different areas of a hospital, we do not believe that a patient assignment to a specific hospital location, such as a certain unit or location, would justify an inpatient admission in the absence of a 2 midnight expectation.


CMS identified newly initiated mechanical ventilation (excluding anticipated intubations related to minor surgical procedures or other treatment) as its first rare and unusual exception to the 2 midnight rule (see Question 4.3). We recognize that there could be rare and unusual circumstances that we have not identified that justify inpatient admission absent an expectation of care spanning at least 2 midnights. As we continue to work with facilities and physicians to identify such other situations, we reiterate that we expect these situations to be rare and unusual exceptions to the general rule. If any such additional situations are identified, we will include them in subregulatory instruction, and we will expect that in these situations the physician at the time of admission must explicitly document the reason why the specific case requires inpatient care, as opposed to hospital services in an outpatient status. We do not believe that these rare and unusual circumstances can be imputed from the medical record.

Monday, December 28, 2015

Ambulance Service (Ground Ambulance) Coverage Guidance



Coverage Indications, Limitations, and/or Medical Necessity

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Compliance with the provisions in this policy may be monitored and addressed through prepayment and/or post payment data analysis and subsequent medical review audits.

The Medicare payment benefit for ambulance services is very restricted. Ambulance suppliers must understand the benefit and refrain from seeking Medicare payment for services that do not conform to the limited benefit requirements as stated in regulation. Physicians and others who order and certify medical necessity of ambulance services must also understand and abide by the limitations of Medicare coverage of ambulance services. This LCD includes, for reference only, portions of CMS national payment policy as found in relevant Internet-Only Manual (IOM) sections and regulations. This LCD further provides “limited coverage” diagnosis to procedure edit requirements for ambulance suppliers who choose to submit ICD-9-CM codes on their claims. The LCD also contains utilization guidelines for the purpose of automated ambulance claim denial by the contractor in its jurisdictions.

CMS National Payment Policy 

Medicare covers ambulance services only if furnished to a beneficiary whose medical condition at the time of transport is such that transportation by other means would endanger the patient’s health. A patient whose condition permits transport in any type of vehicle other than an ambulance does not qualify for Medicare payment. Medicare payment for ambulance transportation depends on the patient’s condition at the actual time of the transport regardless of the patient’s diagnosis. To be deemed medically necessary for payment, the patient must require both the transportation and the level of service provided.

Medicare covers both emergency ambulance transportation and non-emergency ambulance transportation as follows:

Medical Necessity

Ambulance transportation is covered when the patient’s condition requires the vehicle itself and/or the specialized services of the trained ambulance personnel. A requirement of coverage is that the needed services of the ambulance personnel were provided and clear clinical documentation validates their medical need and their provision in the record of the service (usually the run sheet).

Emergency Ambulance Services

Medicare will cover emergency ambulance services when the services are medically necessary, meet the destination limits of closest appropriate facilities and are provided by an ambulance service that is licensed by the state. Emergency response means responding immediately at the Basic Life Support (BLS) or Advanced Life Support 1 (ALS1) level of service to a 911 call or the equivalent. An immediate response is one in which the ambulance supplier begins as quickly as possible to take the steps necessary to respond to the call.

Application: The determination to respond emergently with a BLS or ALS1 ambulance must be in accord with the local 911 or equivalent service dispatch protocol (ALS2 has additional requirements). If the call came in directly to the ambulance provider/supplier, then the provider's/supplier's dispatch protocol must meet, at a minimum, the standards of the dispatch protocol of the local 911 or equivalent service. In areas that do not have a local 911 or equivalent service, then the protocol must meet, at a minimum, the standards of a dispatch protocol in another similar jurisdiction within the State or, if there is no similar jurisdiction within the State, then the standards of any other dispatch protocol within the State. Where the dispatch was inconsistent with this standard of protocol, including where no protocol was used, the beneficiary's condition (for example, symptoms) at the scene determines the appropriate level of payment.

The patient’s condition is an emergency that renders the patient unable to be safely transported to the hospital in a moving vehicle (other than an ambulance) for the amount of time required to complete the transport. Emergency ambulance services are services provided after the sudden onset of a medical condition. For the purposes of this LCD, acute signs and/or symptoms of sufficient severity must manifest the emergency medical condition such that the absence of immediate medical attention could reasonably be expected to result in one or more of the following:

Place the patient’s health in serious jeopardy.
Cause serious impairment to bodily functions.
Cause serious dysfunction of any body organ or part.

Wednesday, December 23, 2015

Specialty Care Transport (SCT) and Paramedic Intercept (PI)

Specialty Care Transport (SCT)

Definition: Specialty care transport (SCT) is the interfacility transportation of a critically injured or ill beneficiary by a ground ambulance vehicle, including the provision of medically necessary supplies and services, at a level of service beyond the scope of the EMT-Paramedic. SCT is necessary when a beneficiary’s condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area, for example, emergency or critical care nursing, emergency medicine, respiratory care, cardiovascular care, or a paramedic with additional training.

Application: The EMT-Paramedic level of care is set by each State. SCT is necessary when a beneficiary’s condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area. Care above that level that is medically necessary and that is furnished at a level of service above the EMT-Paramedic level of care is considered SCT. That is to say, if EMT-Paramedics - without specialty care certification or qualification - are permitted to furnish a given service in a State, then that service does not qualify for SCT. The phrase “EMT-Paramedic with additional training” recognizes that a State may permit a person who is not only certified as an EMT-Paramedic, but who also has successfully completed additional education as determined by the State in furnishing higher level medical services required by critically ill or critically injured patients, to furnish a level of service that otherwise would require a health professional in an appropriate specialty care area (for example, a nurse) to provide.
“Additional training” means the specific additional training that a State requires a paramedic to complete in order to qualify to furnish specialty care to a critically ill or injured patient during an SCT.

Paramedic Intercept (PI)
Definition: Paramedic Intercept services are ALS services provided by an entity that does not provide the ambulance transport. This type of service is most often provided for an emergency ambulance transport in which a local volunteer ambulance that can provide only basic life support (BLS) level of service is dispatched to transport a patient. If the patient needs ALS services such as EKG monitoring, chest decompression, or I.V. therapy, another entity dispatches a paramedic to meet the BLS ambulance at the scene or once the ambulance is on the way to the hospital. The ALS paramedics then provide services to the patient.

This tiered approach to life saving is cost effective in many areas because most volunteer ambulances do not charge for their services and one paramedic service can cover many communities. Prior to March 1, 1999, Medicare payment could be made for these services, but only when the claim was submitted by the entity that actually furnished the ambulance transport. Payment could not be made directly to the intercept service provider. In those areas where State laws prohibit volunteer ambulances from billing Medicare and other health insurance, the intercept service could not receive payment for treating a Medicare beneficiary and was forced to bill the beneficiary for the entire service.

Paramedic intercept services furnished on or after March 1, 1999, may be payable separate from the ambulance transport, subject to the requirements specified below.

The intercept service(s) is:
• Furnished in a rural area;
• Furnished under a contract with one or more volunteer ambulance services; and,
• Medically necessary based on the condition of the beneficiary receiving the ambulance service.

In addition, the volunteer ambulance service involved must:
• Meet the program’s certification requirements for furnishing ambulance services;
• Furnish services only at the BLS level at the time of the intercept; and,
• Be prohibited by State law from billing anyone for any service.
Finally, the entity furnishing the ALS paramedic intercept service must:
• Meet the program’s certification requirements for furnishing ALS services, and,
• Bill all recipients who receive ALS paramedic intercept services from the entity,
regardless of whether or not those recipients are Medicare beneficiaries.
For purposes of the paramedic intercept benefit, a rural area is an area that is designated as rural by a State law or regulation or any area outside of a Metropolitan Statistical Area or in New England, outside a New England County Metropolitan Area as defined by the Office of Management and Budget. The current list of these areas is periodically published in the Federal Register.

Friday, December 18, 2015

What is 2-midnight rule and how to calculate it?

Q2.1: Can CMS clarify when the 2 midnight benchmark begins for a claim selected for medical review, and how it incorporates outpatient time prior to admission in determining the general appropriateness of the inpatient admission?

A2.1: For purposes of determining whether the 2‑midnight benchmark was met and, therefore, whether inpatient admission was generally appropriate, the Medicare review contractor will consider time the beneficiary spent receiving outpatient services within the hospital. This will include services such as observation services, treatments in the emergency department, and procedures provided in the operating room or other treatment area. From the medical review perspective, while the time the beneficiary spent as a hospital outpatient before the beneficiary was formally admitted as an inpatient pursuant to the physician order will not be considered inpatient time, it will be considered during the medical review process for purposes of determining whether the 2-midnight benchmark was met and, therefore, whether payment for the admission is generally appropriate under Medicare Part A.

Whether the beneficiary receives services in the emergency department (ED) as an outpatient prior to inpatient admission (for example, receives observation services in the emergency room) or is formally admitted as an inpatient upon arrival at the hospital (for example, inpatient admission order written prior to an elective inpatient procedure or a beneficiary who was an inpatient at another hospital and is transferred), the starting point for the 2 midnight timeframe for medical review purposes will be when the beneficiary starts receiving services following arrival at the hospital. CMS notes that this instruction excludes wait times prior to the initiation of care, and therefore triaging activities (such as vital signs before the initiation of medically necessary services responsive to the beneficiary's clinical presentation) must be excluded. A beneficiary sitting in the ED waiting room at midnight while awaiting the start of treatment would not be considered to have passed the first midnight, but a beneficiary receiving services in the ED at midnight would meet the first midnight of the benchmark. The Medicare review contractor will count only medically necessary services responsive to the beneficiary's clinical presentation as performed by medical personnel.


Q2.2: How should providers calculate the 2-midnight benchmark when the beneficiary has been transferred from another hospital?

A2.2: The receiving hospital is allowed to take into account the pre-transfer time and care provided to the beneficiary at the initial hospital. That is, the start clock for transfers begins when the care begins in the initial hospital. Any excessive wait times or time spent in the hospital for non-medically necessary services shall be excluded from the physician’s admission decision. (Note: for the purposes of this question, hospital is defined as acute care hospital, long-term care hospital (LTCH), critical access hospital (CAH), and inpatient psychiatric facility.) Medicare review contractors may request records from the transferring hospital to support the medical necessity of the services provided and to verify when the beneficiary began receiving care to ensure compliance and deter gaming or abuse. Claim submissions for transfer cases will be monitored and any billing aberrancy identified by CMS or the Medicare review contractors may be subject to targeted review. The initial hospital should continue to apply the 2-midnight benchmark based on the expected length of stay of the beneficiary for hospital care within their
facility


Q2.3: How should providers calculate the 2-midnight benchmark when the beneficiary has received care in an Off-Campus ED?

A2.3: If the ED is established as a provider-based/practice location of the hospital, CMS does not separately pay to move the patient from an off-campus location of the Medicare hospital to the campus of the same Medicare hospital. Moving the beneficiary within the hospital that participates in Medicare under a single CMS Certification Number (CCN) from a provider-based off-campus ED to a separate on-campus unit, or moving the bene from an on-campus ED to a specified floor on the same campus would be considered the same from a Medicare perspective.

The provider-based or practice location (off-campus) ED is subject to all of the hospital Conditions of Participation (COPs) and is considered an integral part of the Medicare participating hospital.

Therefore, if a hospital ED is either an on-campus ED or an off-campus provider-based ED/practice location of a Medicare-certified hospital, the ED is considered part of that hospital for purposes of the 2-midnight rule, and therefore the total time in the hospital should be counted for purposes of the 2 midnight benchmark. On the other hand, if the ED is not established as an off-campus provider/practice location (unrelated to that hospital’s CCN), then the beneficiary movement would be considered a transfer and the rules outlined in question 2.2 are applicable.

Thursday, December 10, 2015

what is Advanced Life Support, Level 1 (ALS1)



Definition: Advanced life support, level 1 (ALS1) is the transportation by ground ambulance vehicle and the provision of medically necessary supplies and services including the provision of an ALS assessment or at least one ALS intervention.

Advanced Life Support Assessment
Definition: An advanced life support (ALS) assessment is an assessment performed by an ALS crew as part of an emergency response that was necessary because the patient's reported condition at the time of dispatch was such that only an ALS crew was qualified to perform the assessment. An ALS assessment does not necessarily result in a determination that the patient requires an ALS level of service.

Application: The determination to respond emergently with an ALS ambulance must be in accord with the local 911 or equivalent service dispatch protocol. If the call came in directly to the ambulance provider/supplier, then the provider’s/supplier’s dispatch protocol must meet, at a minimum, the standards of the dispatch protocol of the local 911 or equivalent service. In areas that do not have a local 911 or equivalent service, then the protocol must meet, at a minimum, the standards of a dispatch protocol in another similar jurisdiction within the State or, if there is no similar jurisdiction within the State, then the standards of any other dispatch protocol within the State. Where the dispatch was inconsistent with this standard of protocol, including where no protocol was used, the beneficiary’s condition (for example, symptoms) at the scene determines the appropriate level of payment.

Advanced Life Support Intervention
Definition: An advanced life support (ALS) intervention is a procedure that is in accordance with State and local laws, required to be done by an emergency medical technician-intermediate (EMT-Intermediate) or EMT-Paramedic.

Application: An ALS intervention must be medically necessary to qualify as an intervention for payment for an ALS level of service. An ALS intervention applies only to ground transports.

Advanced Life Support, Level 1 (ALS1) - Emergency
Definition: When medically necessary, the provision of ALS1 services, as specified above, in the context of an emergency response. An emergency response is one that, at the time the ambulance provider or supplier is called, it responds immediately. An immediate response is one in which the ambulance provider/supplier begins as quickly as possible to take the steps necessary to respond to the call.

Application: The determination to respond emergently with an ALS ambulance must be in accord with the local 911 or equivalent service dispatch protocol. If the call came in directly to the ambulance  provider/supplier, then the provider’s/supplier’s dispatch protocol must meet, at a minimum, the standards of the dispatch protocol of the local 911 or equivalent service. In areas that do not have a local 911 or equivalent service, then the protocol must meet, at a minimum, the standards of a dispatch protocol in another similar jurisdiction within the State or, if there is no similar jurisdiction within the State, then the standards of any other dispatch protocol within the State. Where the dispatch was inconsistent with this standard of protocol, including where no protocol was used, the beneficiary’s condition (for example, symptoms) at the scene determines the appropriate level of payment.

Advanced Life Support, Level 2 (ALS2)
Definition: Advanced life support, level 2 (ALS2) is the transportation by ground ambulance vehicle and the provision of medically necessary supplies and services including (1) at least three separate administrations of one or more medications by intravenous push/bolus or by continuous infusion (excluding crystalloid fluids) or (2) ground ambulance transport, medically necessary supplies and services, and the provision of at least one of the ALS2 procedures listed below:

a. Manual defibrillation/cardioversion;
b. Endotracheal intubation;
c. Central venous line;
d. Cardiac pacing;
e. Chest decompression;
f. Surgical airway; or
g. Intraosseous line.

Application: Crystalloid fluids include fluids such as 5 percent Dextrose in water, Saline and Lactated Ringer’s. Medications that are administered by other means, for example: intramuscular/subcutaneous injection, oral, sublingually or nebulized, do not qualify to determine whether the ALS2 level rate is payable. However, this is not an all-inclusive list. Likewise, a single dose of medication administered fractionally (i.e., one-third of a single dose quantity) on three separate occasions does not qualify for the ALS2 payment rate. The criterion of multiple administrations of the same drug requires a suitable quantity and amount of time between administrations that is in accordance with standard medical practice guidelines. The fractional administration of a single dose (for this purpose meaning a standard or protocol dose) on three separate occasions does not qualify for ALS2 payment.

In other words, the administration of 1/3 of a qualifying dose 3 times does not equate to three qualifying doses for purposes of indicating ALS2 care. One-third of X given 3 times might = X (where X is a standard/protocol drug amount), but the same sequence does not equal 3 times X. Thus, if 3 administrations of the same drug are required to show that ALS2 care was given, each of those administrations must be in accord with local protocols. The run will not qualify on the basis of drug administration if that administration was not according to protocol.

An example of a single dose of medication administered fractionally on three separate occasions that would not qualify for the ALS2 payment rate would be the use of Intravenous (IV) Epinephrine in the treatment of pulseless Ventricular Tachycardia/Ventricular Fibrillation (VF/VT) in the adult patient. Administering this
medication in increments of 0.25 mg, 0.25 mg, and 0.50 mg would not qualify for the ALS2 level of payment. This medication, according to the American Heart Association (AHA), Advanced Cardiac Life Support (ACLS) protocol, calls for Epinephrine to be administered in 1 mg increments every 3 to 5 minutes. Therefore, in order to receive payment for an ALS2 level of service, based in part on the administration of Epinephrine, three separate administrations of Epinephrine in 1 mg increments must be administered for the treatment of pulseless VF/VT.

A second example that would not qualify for the ALS2 payment level is the use of Adenosine in increments of 2 mg, 2 mg, and 2 mg for a total of 6 mg in the treatment of an adult patient with Paroxysmal Supraventricular Tachycardia (PSVT). According to ACLS guidelines, 6 mg of Adenosine should be given by rapid intravenous push (IVP) over 1 to 2 seconds. If the first dose does not result in the elimination of the supraventricular tachycardia within 1 to 2 minutes, 12 mg of Adenosine should be administered IVP. If the supraventricular tachycardia persists, a second 12 mg dose of Adenosine can be administered for a total of 30 mg of Adenosine. Three separate administrations of the drug Adenosine in the dosage amounts outlined in the later case would qualify for ALS2 payment.

Endotracheal intubation is one of the services that qualifies for the ALS2 level of payment; therefore, it is not necessary to consider medications administered by endotracheal intubation for the purpose of determining whether the ALS2 rate is payable.

The monitoring and maintenance of an endotracheal tube that was previously inserted prior to transport also qualifies as an ALS2 procedure.

Advanced Life Support (ALS) Personnel
Definition: ALS personnel are individuals trained to the level of the emergency medical technician-intermediate (EMT-Intermediate) or paramedic.

Monday, November 30, 2015

Lab Code For Drug Testing and Incorporation of Revalidation Policies



Lab codes for drug testing Issue

The 2015 Current Procedural Terminology (CPT®) codes 80100-80102 have been discontinued and replaced with CPT® 80300-80304 (presumptive drug class screening) and 80320-80377 (definitive drug testing). CPT® codes 80300-80377 have incorrectly been tagged with a procedure code status "X” (statutory exclusion), signifying that payment is not made based on the Medicare physician fee schedule database (i.e. not a physician service).

Resolution
First Coast notified the Centers for Medicare & Medicaid Services (CMS) that CPT® codes 80300-80377 have incorrectly been tagged with a procedure code status "X" (statutory exclusion). Until the status/payment indicator has been corrected, CMS has provided approval for First Coast to return claims for services billed with CPT® codes 80300-80377 to the provider.

Status/date resolved Closed/January 7, 2015

Provider action

According to the clinical laboratory fee schedule (CLFS) final determinations listed on the CMS website, providers are to use procedure codes G6030-G6058 to report these services. These procedure codes will be allowed and paid based on the CLFS. Until the status/payment indicator has been corrected, First Coast will return claims for services billed with CPT® codes 80300-80377 to the provider.

Incorporation of Revalidation Policies into Pub. 100-08, “Program Integrity Manual (PIM),” Chapter 15

This MLN Matters® Article is intended for providers and suppliers submitting claims to Medicare Administrative Contractors(MACs), including Home Health & Hospice(HH&H) MACs,for services
provided to Medicare beneficiaries.

The Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 9011 to incorporate various existing Medicare enrollment revalidation policies into Chapter 15 of the
"Program Integrity Manual" (PIM).

CR 9011 incorporates various existing revalidation policies into the PIM. As these policies were previously established via business requirements, those business requirements are not being repeated in this article. The new polices announced in CR9011 are as follows:

•When processing a voluntary termination of a reassignment, the MAC will contact the group to confirm that the group member's Provider Transaction Access Number(PTAN) is being terminated from all locations and, if multiple group member PTANs exist for multiple group locations, each PTAN is terminated.

•Many enrolled providers may actually be subparts of other enrolled providers, and some of those subparts entered their “doing business as name” as their LBN when applying for their NPIs. Once a contractor determines for certain that this situation exists, the contractor shall ask the provider to correct its NPPES information. The provider can (1) change its LBN in NPPES to read in accordance with the IRS CP-575, and (2) report its “doing business as” name in NPPES as an “Other Name”


and indicate the type of other name as a “doing business as” name.