Health care compliance today is more difficult than it has ever been before. The easiest way one can understand the intricate regulation is by spending a lot of time with the federal register or the code of the federal regulations. And certainly the Social Security Act which of course is the highest source that one can refer to. The best way to look at ambulance coding, billing, filing claims getting paid or not getting paid is simply to take the stands that well, Medicare doesn’t really cover ambulance services. They need convincing when it comes to payment. It might seem simple in some cases, where you just have a simple run from individual’s home to the hospital five miles down the road. And the patient is admitted to the hospital. But in certain cases, the situation can get really convoluted and complicated. Read this expert ambulance services training article and know more
The new Ambulance Fee Schedule (AFS) is fully in place, at least for the practice purpose as per healthcare training conferences. Although, there is a little piece that needs to be fully put into place and it’s not clear if that’s a part of the ambulance fee schedule or an add-on from Congress. Nonetheless, there's one little piece out there that has to do with setting the payment amount. They're still using a little bit of a blended rate. So, when is ambulance services covered? If you look at the Social Security Act, there are two sections 1861S2 and 1862A1. But this whole coverage issue is involved right at the very top of the hierarchy of guidance. It's in the Social Security Act. And they're very adamant about the fact that for ambulance services to be covered it must not only be medically necessary but you got to be doing it the right way, at the right time, and at the right place.
Why is medical necessity such a big deal? Should we use ABNs? NEMBs? Now, the advanced beneficiary notices or notice of exclusion for Medicare benefit takes quite a while. And ambulance providers whether you're a hospital or independent, whoever you are, you're going to need to use these or at least need to consider using them. And in many cases, ambulance coverage is not covered, and thus, you're supposed to use an NEMB. But if it's not medically necessary, then you would use an ABN. But trying to decide in which situation you can use it can become problematic. For e.g. if you're in a situation where you need to issue something that says, “Hey, Medicare may not pay for this.” And you're not sure whether it's excluded coverage statutorily or whether it's just going to be considered to be not medically necessary, issue an ABN. That generally will keep you safe, even though technically you may have issued an NEMB.
Where to use Diagnosis coding? Now, diagnosis coding is another area of concern. There are places where we should use it and there is a medical conditions list that is driven by diagnosis coding. But typically, ambulance folks are not really updated on diagnosis coding. Now, you could have some third party payers that do require it. And if so, you're going to have to get used to it. Next year we are switching to ICD10 and it’s always better to keep up with the changes.
Is procedure coding required in relation for the Medicare program? Yes! There are some level two HCPC codes that need to be used relatively with ambulance fee schedule. And how are these services reimbursed? The ambulance fee schedule breaks it down into two parts—one part for mileage and another part for the level of service provided, whether it's DLS, ALS, emergency, nonemergency, et cetera. And there is a need to look in the fee schedule. Does the Medicare program have uniform requirements for ambulance billing and claims filing? Yes, for instance you can be an institutional provider, hospital or a SNF and you would fill your claims on the UB04, whereas if you're an independent ambulance provider, you would be filing your claims to the carrier— the geographic carrier which can create problems as to which geographic location you're in. You can file claims to the geographic carrier on the 1500 claim form.
Do other private third-party payers follow the Medicare approach? Recently, in a program from a Blue Cross Blue Shield program, they're paying 170% of whatever the Medicare ambulance fee schedule pays. So, it’s evident that the third party payer is piggybacking on the Medicare program. Will the RACs (Recovery Audit Contractors) look at ambulance services? Yes, they surely will, they might not do it right away because the hospitals are too much of a target. There's a lot of easy money running around the hospitals that they can get at before they tackle ambulance. What happens if the patient dies en route? Now, this is one of many questions. What if they die en route? What if you get them there and they're pronounced dead? What if they die before you get there? You need to be ready to address such scenarios, and there are payment formulas for all of that.
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