CMS Open Door Forum

October 13, 2004

 

Charlotte Yeh, MD (CMS) opened the conference by discussing the Physician Certification Statement (PCS) form as this has been the main topic of concern from past Open Door Forums.  The purpose of PCS form is to provide medical necessity information for non-emergency transports as it relates to coverage under the Medicare ambulance guidelines.  It was agreed that the form is not the perfect tool for obtaining information; nevertheless, it is the requirement that is currently in place.  CMS recommended that the providers work directly with the carriers to handle all issues related to these requirements.

 

Colleen Carpenter, Atlanta Regional Office, CMS, gave an overview of the recent hurricane evacuations in Florida.  CMS allowed coverage for these transports as long as the normal ambulance requirements, such as the origin and destination, nearest appropriate facility, etc.  In addition, CMS allowed providers to file claims on paper as well as to advance payments for those providers in situations where claims could not be filed in a timely manner.

 

Richard Lawlor, MD discussed the issues related to the requirement for an agreement with the Skilled Nursing Facilities (SNF) when the patient is an inpatient in a covered Part A stay.  It is recommended that these agreements should be in the form of a written agreement or contract with the facility to ensure that the proper payment arrangements are made and that both Medicare Part A and Part B are not simultaneously billed for the same transport.  CMS is currently developing sample contracts or agreements that will be posted to their website in the near future.

 

The next topic of discussion was related to Advanced Beneficiary Notices (ABN) for ambulance providers in the following situations;

• Air Ambulance Transports when patient could have been transported safely using ground transport
• Transports when the patient?s level of care is downgraded, ie, ALS vs. BLS
• Transport of a patient when the service could have been provided more economically in the patient?s home or nursing facility

 

Note:  Transportation that is denied by Medicare as not medically necessary, not transported nearest appropriate facility, or as a non-covered transport to such destinations such as physicians offices are not required to have an Advanced Beneficiary Notice (ABN) on file in order to hold the beneficiary liable for payment. 

 

It is not appropriate to provide an ABN to a patient in an emergency situation.

 

 

The forum was opened to questions and answers from the participants:

 

Medicare HMOs are required to follow the same coverage guidelines as traditional Medicare.  They may add coverage policies to the basic Medicare coverage requirements but these policies must, at a minimum, allow the general Medicare policy requirements.

 

The Advanced Beneficiary Notice requirements only apply to non-emergency transports and should not be provided to patients in an emergency situation.  An example was provided of a transport when a beneficiary or family member requested a higher level of care such as ALS level of care when only BLS was warranted.  The patient could be provided an ABN and be held responsible for the amount above and beyond the BLS level of care.

 

CMS recently provided information that they will no longer use restrictive language that obesity in itself is not a disease.  This information does not guarantee coverage based solely on the basis of obesity but each case should be reviewed individually to determine medical necessity.

 

Specialty Care Transport (SCT) has been interpreted by certain carriers that this level of service may only be billed for hospital to hospital transfers.  The Federal Register defined the code as an inter-facility transfer.  CMS stated that their definition of inter-facility would be hospital to hospital transfers.   CMS will follow up with additional clarification of patients being transported from a hospital to skilled nursing facility (SNF) when transporting a ventilator patient.

 

The condition codes are currently being reviewed to ?iron out? the ICD-9 crosswalk before they can be implemented.

 

Provider Enrollment delays sometimes cause financial hardships for ambulance companies.  Regional Offices can help to facilitate advanced payment options or further advancement of the provider enrollment process when these financial hardships occur.

 

Denials frequently occur when the ambulance transport provider bills for a response to DOA calls.  These denials are due to the determination of the date of death preceded the date of service of the ambulance transport.  It was recommended that the provider contact their regional office for assistance with these denials.

 

With the regard to Bariatric Transports, CMS is awaiting specific cost analysis from a large consortium of providers such as the American Ambulance Association (AAA) in order to further develop additional payment recognition for these types of transports.  The AAA responded that they would provide the results of a recent survey related to this issue.

 

The level of care is determined by the level of service that is required by the patient?s medical condition.  If, at the time of dispatch, protocols require an ALS assessment, even if it is later determined that BLS level of care was required, the transport can be billed at the ALS level.  The fact that all transports are responded at the ALS level, does not allow all claims to be filed at the ALS level.