Saturday, October 16, 2010

Billing CPT A0434 - Specialty care transport

I have received a denial for my submission of specialty care transport HCPCS code A0434. What could be wrong?

Answer:

Did you submit a payable trip? CMS rules specify that 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.

Did you submit a modifier combination that is not payable, such as HR (hospital to residence)? If the answer is yes, this is not an interfacility trip; therefore, you may file an appeal with a corrected HCPCS code.



HCPCS A0434 – Specialty Care Transport

Specialty Care Transport (SCT) – SCT is hospital-to-hospital 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.

Effective for Dates of Service 1-1-07 and after the definition of Specialty care transport (SCT) has been changed to read “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.” For purposes of SCT payment, CMS considers a “facility” to include only a SNF or a hospital that participates in the Medicare program, or a hospital-based facility that meets CMS’ requirements for provider-based status. Medicare hospitals include, but are not limited to, rehabilitation hospitals, cancer hospitals, children’s hospitals, psychiatric hospitals, critical access hospitals (CAHs), inpatient acute-care hospitals, and sole community hospitals (SCHs).

The EMT-Paramedic level of care is set by each State. 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.

GROUND GUIDELINES Base Rate

A0225, A0426, A0427, A0428, A0429, A0433, A0434

• All of our base rate reimbursement allowances include supplies, disposables and non-disposables.

• If you bill supplies separately they will be combined into the base. The procedure code for the supplies will be cancelled and will not appear on your RA.


Emergency Medical Condition

An Emergency Medical Condition is defined as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:

* Placing the health of the individual (or, with respect to pregnant women, the health of the woman or her unborn child) in serious jeopardy,

* Serious impairment to bodily functions, or

* Serious dysfunction of any bodily organ or part.

Emergency Patient An individual whose physical or mental condition is such that it meets the definition of "emergency medical condition."

Emergency Response A response that, at the time the ambulance provider is called, is provided after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity such that in the absence of immediate medical attention could reasonably be expected to result in placing the beneficiary's health in serious jeopardy, in impairment to bodily functions, or in serious dysfunction to any bodily organ or part.

Emergency Transport

An emergency, pre-hospital service in which no physician has yet seen the patient, e.g., a transport from the scene of an accident to an emergency department.




Medically Necessary Transport

An ambulance transport which is required because no other effective and less costly mode of transportation can be used due to the patient's medical condition. The transport is required to transfer the patient to or from a medically necessary service
not available at the primary location.


Transfer A non-emergency transport in which the patient is moved from one facility to another for care that is not available at the originating facility.


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