Medical Review of Ambulance Emergency Transports

Railroad Medicare's Medical Review (MR) unit is conducting pre-payment and post-payment  service-specific reviews as well as Targeted Provider Education (TPE)  reviews for emergency ambulance ground transports. 

Our MR unit selected this code family based on internal and external data analysis. The codes under review are in the table below:

Ambulance Emergency Land Codes Under Review

Coverage
Medicare covers ambulance transportation when the patient’s medical condition is such that transportation by other means would endanger the beneficiary’s health. Coverage is dependent on the condition of the patient at the actual time of transport regardless of the patient’s diagnosis. Payment under the Ambulance Fee Schedule is made only for the level of service furnished, and then only when the service is medically necessary.

Basic Life Support (BLS) includes provision of medically necessary supplies and services including BLS ambulance services as defined by the state. The ambulance must be staffed by personnel trained at the emergency medical technician-basic (EMT-Basic) level in accordance with state and local laws. EMT-Basic techniques and skills included in EMT-Basic training must be utilized during transport.

Advanced Life Support: Includes provision of assessment by ALS personnel or the provision of one or more ALS interventions. ALS personnel should be trained at or above the EMT-Intermediate level. 

An ALS assessment is an assessment performed by an ALS crew as part of a 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 service. An ALS assessment does not necessarily result in a determination that the patient requires an ALS level of service.

An ALS intervention is a procedure that is in accordance with state and local laws. An ALS intervention must be medically necessary to qualify as an intervention for payment for an ALS level of service. If the crew is ALS certified but the patient requires only BLS interventions, the transport is usually considered a BLS transport.

Emergency Transportation
The phrase '911 Call or Equivalent' is intended to establish the standard of the nature of the call at the time of dispatch as the determining factor. These are classified as emergency based on requiring ‘immediate response.”

• However the call is made (e.g., a radio call could be appropriate), it is considered to be of an emergent nature when, based on the information available to the dispatcher at the time of the call, it is reasonable for the dispatcher to issue an emergency dispatch in light of accepted, standard dispatch protocol
• An emergency call need not come through 911, even in areas where a 911 call system exists
• The determination to respond must be in accord with the local 911 or equivalent service dispatch protocol
• There are instances in which the dispatch does not match the level of service required. In these cases, an ALS dispatch occurs, but the beneficiary only requires a BLS intervention. Medicare will only pay for the level of service you provide.
• An emergency medical condition is one manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in any of the following:
  • Placing the beneficiary's health in serious jeopardy
  • Serious impairment to bodily functions
  • Serious dysfunction of any bodily organ or part

Preparing for the Review
As a reminder to providers, regardless of the type of claims selected for review, coverage guidelines require that documentation contain the following:

• The place of service 
• The medical necessity and appropriateness of the services being provided
• That services furnished have been accurately reported
• The medical record should be complete and legible and include:
  • Beneficiary name
  • Date of service
  • Valid signatures

Records Under Review Must Contain:
The provider of services who transports the beneficiary should maintain all documentation to support the rendering of the service and medical necessity of the treatment and transport.

Keep these records available upon request:

• A run sheet documenting 
  • Type of dispatch
  • Reason for the transport
  • Relevant history
  • Assessment and clinical evaluations (A description of the patient’s condition and functional status at time of transfer)
  • Monitoring and procedures performed
  • Beneficiary’s response to treatment
  • Point of pick up (place and address) and accepting facility
  • Mileage associated with transport
  • Any documentation supporting medical necessity

When the transport is a hospital to hospital transport, records should indicate the precise reason why the required services were not available at the first hospital (i.e. services not available at the first hospital, no beds available, etc.) Hospital records such as emergency room records may be supportive of the medical necessity of transport to another facility. MR also has a Checklist available to assist with elements to submit.
 

Signature Requirements

Valid Signatures 

• A valid signature of the author of the medical record, i.e. run sheet
• Identification including names and credentials of crew ( at least one licensed for ALS for ALS transports)
• A signature from the beneficiary or that of his/her representative (for the purpose of accepting assignment and submitting a claim to Medicare (see IOM 100-02, Chapter 10, § 20.1.2 (PDF) or Code of Federal Regulations - 42 CFR § 410.40 - Coverage of Ambulance Services (PDF) for details and a list of acceptable representatives)

Conducting the Review
Our MR department will review claims and additional documentation to determine if the services billed were reasonable, necessary and correctly coded based on Medicare’s coverage and coding guidelines. Remittance advice (RAs) will contain claim determination details. If claims are denied or paid at a lower level of service, notification will be displayed on the RA.  

TPE reviews are provider-based reviews that have more education built into the program.  During a round of TPE a provider’s point-of-contact may receive a call to request additional information or clarification to assist with the review. After each claim review is completed, the provider will receive a RA with a claim decision. At the conclusion of each round, MR will mail a letter with the comprehensive review results. The letter will include the number of claims reviewed, the number of claims allowed in full, and the number of claims denied in full or in part.

Appeals Rights
If you disagree with a  prepayment claim denial or level of payment, you can request a first level appeal. Information on this is available on the Appeals page. This prepayment appeal type applies to TPE denials as well as service-specific review denials.

Appeals for denials on claims that were previously paid generally result in an overpayment. Once a provider has notice of an overpayment, a provider may submit an Overpayment appeal. This postpayment appeal type applies to TPE denials as well as service-specific review denials.

For further assistance, please contact our Provider Contact Center at 888-355-9165. Representatives are available from 8:30 a.m. to 4:30 p.m. in all time zones with the exception of PT, which receives service from 8 a.m. to 4 p.m. PT.

Additional Resources: CMS

• CMS guidance for ambulance suppliers regarding Advance Beneficiary Notice (PDF)
• CMS Ambulance Services Center 
• Medicare Benefit Policy Manual, Chapter 10, Ambulance (PDF)
• Medicare Claims Processing Manual, Chapter 15, Ambulance (PDF)
• Code of Federal Regulations 
  • §410.40 Coverage of Ambulance Services
  • §410.41 Requirements for Ambulance Suppliers
• Ambulance Fee Schedule - Medical Conditions List - ICD-9-CM (PDF) 

Palmetto GBA – RRB SMAC

• Ambulance Page
• FAQs - Ambulance
• Ambulance Services Checklist (PDF)