Wednesday, April 27, 2016

Claim Outside US - What is the paymnet in Ambulance billing

 Claims Outside of the U.S.

The following policy applies to claims outside of the U.S.:

• Ground transports with pickup and drop off points within Canada or Mexico will be paid at the fee associated with the U.S. ZIP Code that is closest to the POP;

• For water transport from the territorial waters of the U.S., the fee associated with the U.S. port of entry ZIP Code will be paid;

• Ground transports with pickup within Canada or Mexico to the U.S. will be paid at the fee associated with the U.S. ZIP Code at the point of entry; and

• Fees associated with the U.S. border port of entry ZIP Codes will be paid for air transport from areas outside the U.S. to the U.S. for covered claims.

As discussed more fully below, CMS will provide contractors with a file of ZIP Codes that will map to the appropriate geographic location and, where appropriate, with a rural designation identified with the letter “R” or “B.” Urban ZIP Codes are identified with a blank in this position.

Payment for Mileage Charges

Charges for mileage must be based on loaded mileage only, e.g., from the pickup of a patient to his/her arrival at destination. It is presumed that all unloaded mileage costs are taken into account when a supplier establishes his basic charge for ambulance services and his rate for loaded mileage. Suppliers should be notified that separate charges for unloaded mileage will be denied.

Monday, April 25, 2016

Covered POS and Modfier list on Ambulance service

PLACE OF SERVICE (POS) CODES

The POS code must be one of the following:

21 – Inpatient hospital

23 – Emergency room – hospital

26 – Military treatment facility

51 – Inpatient psychiatric facility

55 – Residential substance abuse treatment facility

56 – Psychiatric residential treatment center

61 – Comprehensive inpatient rehabilitation hospital


Please keep the following in mind when submitting claims:

• HCY services are not limited to the above places of service

• POS codes 55, 56, and 61 are not valid for air transport

• POS codes 41 (land) and 42 (air/water) are Medicare codes and not valid MO HealthNet POS codes


VALID AMBULANCE MODIFIERS

EP – HCY services for participants under 21 years of age

GM – Ground transport for multiple participants

HH – Hospital to hospital transfer

HD – Specialized testing and treatment

SC – Medically necessary service or supply

Friday, April 22, 2016

How ZIP code determines the Fee schedule amounts


ZIP Code Determines Fee Schedule Amounts


The POP determines the basis for payment under the FS, and the POP is reported by its 5-digit ZIP Code. Thus, the ZIP Code of the POP determines both the applicable GPCI and whether a rural adjustment applies. If the ambulance transport required a second or subsequent leg, then the ZIP Code of the POP of the second or subsequent leg determines both the applicable GPCI for such leg and whether a rural adjustment applies to such leg. Accordingly, the ZIP Code of the POP must be reported on every claim to determine both the correct GPCI and, if applicable, any rural adjustment. Part B contractors must report the POP ZIP Code, at the line item level, to CWF when they report all other ambulance claim information. CWF must report the POP ZIP Code to the national claims history file, along with the rest of the ambulance claims record.


A. No ZIP Code

In areas without an apparent ZIP Code, it is the provider’s/supplier’s responsibility to confirm that the POP does not have a ZIP Code that has been assigned by the USPS. If the provider/supplier has made a good-faith effort to confirm that no ZIP Code for the POP exists, it may use the ZIP Code nearest to the POP.

Providers and suppliers should document their confirmation with the USPS, or other authoritative source, that the POP does not have an assigned ZIP Code and annotate the claim to indicate that a surrogate ZIP Code has been used (e.g., “Surrogate ZIP Code; POP in No-ZIP”). Providers and suppliers should maintain this documentation and provide it to their contractor upon request.

Contractors must request additional documentation from providers/suppliers when a claim submitted using a surrogate ZIP Code does not contain sufficient information to determine that the ZIP Code does not exist for the POP. They must investigate and report any claims submitted with an inappropriate and/or falsified surrogate ZIP Code.

If the ZIP Code entered on the claim is not in the CMS-supplied ZIP Code File, manually verify the ZIP Code to identify a potential coding error on the claim or a new ZIP Code established by the U.S. Postal Service (USPS). ZIP Code information may be found at the USPS Web site at http://www.usps.com/, or other commercially available sources of ZIP Code information may be consulted.

• If this process validates the ZIP Code, the claim may be processed. All such ZIP Codes are to be considered urban ZIP Codes until CMS determines that the code should be designated as rural, unless the contractor exercises its discretion to designate the ZIP Code as rural. (See Section §20.1.5.B – New ZIP Codes)


• If this process does not validate the ZIP Code, the claim must be rejected as unprocessable using message N53 on the remittance advice in conjunction with reason code 16.


B. New ZIP Codes

New ZIP Codes are considered urban until CMS determines that the ZIP Code is located in a rural area. Thus, until a ZIP Code is added to the Medicare ZIP Code file with a rural designation, it will be considered an urban ZIP Code. However, despite the default designation of new ZIP Codes as urban, contractors have discretion to determine that a new ZIP Code is rural until designated otherwise. If the contractor designates a new ZIP Code as rural, and CMS later changes the designation to urban, then the contractor, as well as any provider or supplier paid for mileage or for air services with a rural adjustment, will be held harmless for this adjustment.

Providers and suppliers should annotate claims using a new ZIP Code with a remark to that effect. Providers and suppliers should maintain documentation of the new ZIP Code and provide it to their contractor upon request.

If the provider or supplier believes that a new ZIP Code that the contractor has designated as urban should be designated as rural (under the standard established by the Medicare FS regulation), it may request an adjustment from the A/MAC or appeal the determination with the B/MAC, as applicable, in accordance with standard procedures.

When processing a claim with a POP ZIP Code that is not on the Medicare ZIP Code file, contractors must search the USPS Web site at http://www.usps.com/, other governmental Web sites, and commercial Web sites, to validate the new ZIP Code. (The Census Bureau Web site located at http://www.census.gov/ contains a list of valid ZIP Codes.) If the ZIP Code cannot be validated using the USPS Web site or other authoritative source such as the Census Bureau Web site, reject the claim as unprocessable.


C. Inaccurate ZIP Codes

If providers and suppliers knowingly and willfully report a surrogate ZIP Code because they do not know the proper ZIP Code, they may be engaging in abusive and/or potentially fraudulent billing. Furthermore, a provider or supplier that specifies a surrogate rural ZIP Code on a claim when not appropriate to do so for the purpose of receiving a higher payment than would have been paid otherwise, may be committing abuse and/or potential fraud.

Wednesday, April 20, 2016

CPT COD A0100 - Non emergency transport - T2001

Non Emergenty Transportation providers

Claims for transportation services provided on or after September 1st, 2010, that meet the definition of non-emergency medical transportation, must be authorized by and submitted to American Medical Response (AMR) for payment. This covers the following service codes; A0100, A0110, A0140, A0170, A0180, A0190, A0200, A0210, S0215, T2003, T2004.


Claims for transportation services that meet the definition of non-emergency medical transportation provided prior to September 1st, 2010, must be submitted to Molina Medicaid Solutions for payment. This covers the following service codes; A0100, A0110, A0140, A0170, A0180, A0190, A0200, A0210, S0215, T2003, T2004 as well as service codes listed in table below.

Service HCPCS Description PA Required Modifier Place of Service

Individual Transportation

Non-emergency transportation, per mile A0080 Aged and Disabled (A&D) or Developmental Disabilities (DD) Waiver non-medical transportation, per mile, as authorized by Regional Medicaid Services. 1 Unit = 1 Mile. Maximum allowable of 1,800 waiver miles per year. Yes No POS 99

Attendant salary T2001 Non-emergency transportation, patient attendant/escort (salary). Spouse or parent of a minor child cannot be paid as attendant. 1 Unit = 15 Minutes. Yes No POS 99


Agency Transportation 

Non-emergency transportation, per mile A0080 Aged and Disabled (A&D) or Developmental Disabilities (DD) Waiver non-medical transportation, per mile, as authorized by Regional Medicaid Services. 1 Unit = 1 Mile. Maximum allowable of 1,800 waiver miles per year. Yes No POS 99


Attendant salary T2001 Non-emergency transportation, patient attendant/escort (salary). Spouse or parent of a minor child cannot be paid as attendants. Yes No POS 99

Commercial Transportation

Non-emergency transportation, per mile A0080 Aged and Disabled (A&D) or Developmental Disabilities (DD) Waiver non-medical transportation, per mile, as authorized by Regional Medicaid Services. 1 Unit = 1 Mile. Maximum allowable of 1,800 waiver miles per year. Yes (First Trip, No modifier) (Subsequent trips, same day, Modifier 76 required) POS 99

 Attendant salary  T2001 Non-emergency transportation, patient attendant/escort (salary). Spouse or parent of a minor child cannot be paid as attendants. Yes No POS 99

Would insurance cover Deceased patient ambulance service

DECEASED PARTICIPANTS

An individual is considered to have expired as of the time the individual is pronounced dead by a person who is legally authorized to make such a pronouncement, usually a physician.

• If the participant was pronounced dead before the ambulance was called, no payment is made by MO HealthNet.

• If the participant was pronounced dead after the ambulance was called but prior to arrival at the scene, payment may only be made for mileage from the base to the point of pickup. Transport from point of pickup to destination is not payable; the base rate is not reimbursable.

• If the participant was pronounced after the ambulance arrived on the scene but prior to transport and life saving measures were performed at the scene, the base rate and mileage from base to point of pickup may be covered. ALS level 1 or 2 must be documented in the participant’s trip documentation (reference section 13.3.D of the MO HealthNet Ambulance provider manual for ALS level 1 and 2 service definitions).

• If the participant was pronounced dead while enroute to or upon arrival at the destination, the base rate and mileage from point of pickup to the destination may be covered. ALS level 1 or 2 must be documented in the participant’s trip documentation.

TRANSPORT FOR SPECIALIZED TESTING

Transporting from one hospital to another hospital and return for specialized testing and/or treatment is covered for ground ambulance. One base charge is payable even though two separate trips or waiting time may be involved. The appropriate place of service when billing for specialized testing and/or treatment is 21 (inpatient hospital) since the hospital is both the point of pickup and final estination after receiving services at the diagnostic or therapeutic site. Mileage may be billed if participant transport from point of pickup to the destination and back is more than five miles. Use procedure code A0428HD to bill for transportation for specialized testing and/or treatment.

Transport from one medical facility to another for specialized testing and/or treatment is non-covered for emergency air ambulance services.

Friday, April 15, 2016

Hospital to Hospital ambulance service CPT codes A0428, A0433 , HH modifier


HOSPITAL TO HOSPITAL TRANSFERS

Ground ambulance transfers of MO HealthNet participants from one hospital to another hospital to receive medically necessary inpatient services not available at the first facility are covered services. Hospital transfers shall be covered when the participant has
been stabilized at the first hospital but needs a higher level of care available only at a second hospital. Examples of medically necessary transfers for services not available at the first facility include, but are not limited to:

• rehabilitation

• burn unit

• ventilator assistance

• other specialized care

The hospital to hospital transfer may not be considered emergent; however, hospital to hospital transfers that meet the transfer criteria listed in section 13.13.O(1) of the MO HealthNet Ambulance provider manual qualify for coverage under the ambulance program.

The documentation in the participant’s record must support the procedure code billed. For accurate reporting purposes, the appropriate base code from the following list should be billed with the “HH” modifier.

• A0428HH – Ambulance service, BLS, non-emergency transport, hospital to hospital transfer

• A0426HH – Ambulance service, ALS 1, non-emergency transport, hospital to hospital transfer

• A0429HH – Ambulance service, BLS, emergency transport, hospital to hospital transfer

• A0427HH – Ambulance service, ALS 1, emergency transport, hospital to hospital transfer

• A0433HH – Ambulance service, ALS 2, emergency transport, hospital to hospital transfer


Transport from a hospital capable of treating the participant because the participant and/or the participant’s family or the participant's physician prefer a specific hospital is not a covered service.

Sunday, April 10, 2016

Would insurance cover if two trips on same DOS

TRANSPORTS TO TWO DIFFERENT HOSPITALS

MO HealthNet covers transportation from the point of pickup to two different hospitals made on the same day by the same ambulance provider when it is medically necessary. This situation can occur when the ambulance transports the participant to the nearest hospital, but before the participant leaves the emergency room it is decided the first hospital is not appropriate and the participant is transported to a second hospital. When it is medically necessary to transport a participant from one hospital to another on the same date of service, providers must bill the base rate procedure code with a quantity of “2”. Mileage and any ancillary charges for both trips are to be combined.



TWO TRIPS ON THE SAME DATE OF SERVICE

Two emergency ambulance trips to a hospital in one day for the same participant may be covered when medically necessary. Proper trip documentation must be maintained in the participant’s record. To bill for two trips on the same day, the same provider must show a quantity of “2” units for the base rate procedure code when appropriate. Mileage and any ancillary charges for both trips are to be combined. If the base rate procedure codes aren't the same for each trip, both trips must be billed on the same claim form as separate line items with the appropriate base rate procedure codes. If two different ambulance services transport the same participant on the same date of service, both providers must maintain proper trip documentation in the participant’s record to substantiate medical necessity.