Centers for Medicare & Medicaid Services (CMS) recently issued a Program Memorandum (PM) to clarify issues related to the Medicare Fee Schedule Implementation as well as other issues. Below is a summary of the PM.

 

Ambulance Fee Schedule Appeals

 

Ambulance suppliers may not appeal the Medicare Fee Schedule amounts.

 

Inherent Reasonable (IR) Adjustments

 

Inherent Reasonable (IR) adjustments apply only to the reasonable charge or customary portion of the blended payment for ambulance services, not to the Medicare Ambulance Fee Schedule portion.

 

CMS has not yet issued instructions to the Medicare contractors for applying IR adjustments. Requests made to the contractors will be denied until these instructions are provided.

 

Billing Method Revisions

 

During the transition period, a supplier may not change its billing method. Effective with the full implementation of the fee schedule (2006), all ambulance suppliers will be converted to billing Method 2.

 

PCS Requirements

 

A repetitive patient is defined as medically necessary ambulance transportation that is furnished three or more times during a 10-day period or at least once per week for at least three weeks.

 

Suppliers may use computer-generated PCS forms and computerized physician signatures to meet the PCS requirements.

 

To demonstrate evidence of the attempt to obtain a PCS, a supplier may retain a return receipt of proof of mailing from the US Postal Service or other similar commercial service. Suppliers may also use the US Postal Service Certificate of Mailing, Form 3817 as an acceptable alternative to certified mail.

 

Unsuccessful ALS Intervention

 

An unsuccessful attempt to perform an ALS intervention may qualify the transport for billing at the appropriate ALS level if the intervention would have been reasonable and necessary had it been successful, (e.g., endotracheal intubation was attempted but was not successful)

 

ALS Assessment

 

When a BLS ambulance is dispatched and an ALS assessment is performed, the transport may be billed as ALS only if the transport was an emergency response. The BLS level non-emergency transport is reimbursed at the BLS rate regardless of whether an ALS assessment was performed.

 

Mandated ALS Response

 

Previous instructions stated that in order to bill the temporary HCPCS codes Q3019-Q3020, the supplier should be mandated ALS by the local jurisdiction. CMS further clarified that a contract with a government agency to furnish general ambulance services may also qualify as mandated ALS response if the terms of the contract require an ALS-only response for all requests for service.

 

Intra-facility Transports

 

Intra-facility transportation is defined as a transport within the certified campus of a facility. A certified campus is defined as the physical area immediately adjacent to the providers main building as well as areas within 250 yards of the main building. Intra-facility transportation is not billable to Medicare, as they are not within the scope of the Medicare ambulance benefit.

 

Physician Services Provided During

an Ambulance Transport

 

No separate payment may be made for services provided by a physician during an ambulance transport.

 

Billing/Collection from Beneficiary on

Non-Covered Services

 

When the service is expected to be denied based on reasons in which an ABN would be required, the supplier may only collect the coinsurance and deductible amounts prior to the claim filing. When a transport is expected to be denied based on statutorily exclusions or reasons in which an ABN would not be necessary, a supplier may charge the individual the full fee and collect the fee at the time of its choosing (prior to or after the claim is filed).