A “google” search of news in the EMS industry will quickly find articles of ambulance services being assessed fines and penalties for billing transports that are not considered medically necessary.  In the past, these stories typically read of non-emergency transports of patients that could walk or ride in a wheelchair to/from dialysis services and a physician’s office.  Lately, these stories also include prominent city and county EMS agencies that provide only emergency 911 services.  It is important to take note of these articles, as they provide insight into the changing landscape of coding requirements for emergency ambulance services.

It is important to understand the complexities of ambulance coding as it applies to the Centers of Medicare and Medicaid Services (CMS) guidelines.  These guidelines can be broken down into three independent coding areas for decision:

Emergency or Non-Emergency

CMS defines an emergency response as:

An ambulance supplier responding immediately at the BLS or ALS1 level of service to a 911 call or the equivalent in areas without a 911 call system.  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.

Further, CMS stated:

The purpose of the higher payment is to recognize the additional cost required in order to be prepared to respond immediately to a 911 call when it is received without regard to the condition of the beneficiary.

Therefore, this allows the ambulance supplier to bill at the emergency level when the ambulance is dispatched as an emergency response due to an accident, illness, or injury that prompted the 911 response.

It is important to note that the beneficiary’s condition is used to determine whether the ambulance was medically necessary. Therefore, not all emergency dispatched services are considered medically necessary (see below).

Non-emergency transports are considered when the ambulance supplier is providing transportation service due to the patient’s condition requiring stretcher transport. Examples include: discharge from hospital, transportation to/from dialysis treatment, physician’s offices and some inter-facility hospital transfers in which the patient was stabilized prior to transport.

Level of Service

CMS considers the level of service based on the care that was provided to the patient and only if the care provided is reasonable and necessary. The level of care is determined based on the state and local regulations that govern the EMS Agency and their staff.

Basic Life Support (BLS) is defined as a ground transport in which the patient’s condition required the need for BLS treatment and interventions, in accordance with State and Local laws. An Advanced Level Service (ALS) is defined as a ground transport in which the patient’s condition required an ALS Assessment or ALS Intervention, in accordance with State and Local laws.

An ALS Assessment is defined as one that is performed by an ALS crew as part of an emergency response because the patient’s reported condition at the time of dispatch was such that only an ALS provider was qualified to perform the assessment. An ALS assessment does not necessarily result in a determination that the patient requires an ALS intervention.

In order to apply the ALS Assessment Policy to your organization, the EMS agency must utilize a standard dispatch protocol, such as Emergency Medical Dispatch (EMD). In the absence of a standard dispatch protocol, (ex. all calls are dispatched as “hot”), the level of service provided to the patient must be used.

In recent articles, Medicare has cited fraudulent billing practices when an agency chooses to bill all calls at an ALS level due to the fact that all ambulances are staffed as ALS. In addition, it is inappropriate to establish protocols for patient care based solely on the fact that the billing rate is higher. For example, establishing an IV on all patients in order to bill at the ALS level.

Medical Necessity

An overarching theme in the CMS regulations states:

Medical necessity is established when the patient’s condition was such that any other means of transportation was contraindicated and that other means of transportation could endanger the patient’s condition.

This definition can be vague and subject to interpretation by the Medicare Contractors, Auditors, and EMS Agencies. To assist with this very generic definition, CMS published the Ambulance Medical Condition List in 2006. While this list is said to be not all-inclusive, not mandatory, and does not guarantee medical necessity, it can assist EMS providers in establishing benchmarks for medical necessity. More importantly, this Conditions List can be used in the case of an audit to determine if the documentation met the intention of Condition Code as published by CMS.

As stated above, it is imperative that EMS review the patient’s condition to determine whether the patient’s condition required ambulance transportation. Most Medicare and Medicaid Contractors do not review documentation for ambulance services prior to processing the claim, nor do they have edits in place to deny certain ICD-10 codes on the initial claim submission. These contractors place the responsibility of establishing medical necessity on the ambulance supplier to bill only those services that meet the requirements for coverage. These contractors will conduct audits on a post-payment basis to determine when the services should not have been covered.

Everyone speaks of the proverbial “stubbed toe” example of a reason in which the patient did not need to be transported by ambulance. Although I have never officially seen the “stubbed toe” PCR, this would represent a transport in which the ambulance provider should submit the claim as a non-covered service using the GY modifier.

Documentation

It is equally important the EMS staff document a narrative field that provides a detailed account of the patient’s condition and the care provided in order to make the necessary decisions for coding. Below are three examples of narrative fields to illustrate the need for documentation:

Insufficient Narrative

Chief Complaint of Abdominal Pain. Transported to ABC Hospital without incident.

Sufficient Narrative of Medically Necessary Ambulance Transport

Chief Complaint of Abdominal Pain x 6 hours with worsening of symptoms x 1 hour. Patient appears to be in obvious distress with sharp stabbing pain to lower left quadrant of abdomen. Patient has associated nausea and vomiting. Patient rates pain as 8/10 on Pain Scale.

Sufficient Narrative on Not Medically Necessary Ambulance Transport

Chief Complaint of Abdominal Pain x 6 hours. Patient does not appear to be in any distress. Patient is ambulatory to the ambulance with his bag in hand and puts on his coat without grimacing. Patient rates pain as 8/10 on Pain Scale and wishes to be transported to Emergency Department for refill on pain medications.

Questions

If you have questions related to your specific demographics or accurate coding for EMS transports, feel free to contact [email protected]. Clients may call your Strategic Account Manager at EMS|MC.