Often misunderstood
EMS billing is a science all of its own.
One of the often misunderstood topics is when and how to
properly bill for an ALS Assessment.
Today’s blog serves to educate our clients and friends who
read this space regarding when and how to bill for an ALS Assessment.
The Product of
Trusted Individuals
Because this subject of ALS Assessment has so many facets
and has been kicked around so much by those of us who dissect all matters EMS
on a regular basis; it doesn’t surprise us when we read communication that is
published by other authors that sometimes serves only to create more confusion
on the subject.
With so many different interpretations floating around, it
is important that we take the time to clarify for the readers of this space,
our friends and clients, the correct application of the rules when billing
Medicare.
Please know, that this blog is the product of many different
persons that combine to provide our readers with the most up-to-date educational
information about ambulance billing that we can provide. Each blog we release
is as accurate as possible using the best collection of knowledge and
interpretation that we can put together prior to our posting to this space.
Not only do we rely on sources from within our own company,
but we regularly network, communicate and solicit input from other nationally
known and trusted ambulance industry experts.
Today’s Focus
Today, we will focus on the ALS Assessment definition as
outlined in the Code of Federal Regulations (42 CFR §414.605.)
Advanced Life Support
Assessment Definition
An advanced life
support (ALS) assessment is an assessment performed by an ALS crew as part of
an emergency 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 assessment. An ALS assessment does not necessarily result in a
determination that the patient requires an ALS level of service.
Application: The
determination to respond emergently with an ALS ambulance must be in accord
with the local 9-1-1 or equivalent service dispatch protocol. If the call came
in directly to the ambulance provider supplier, then the provider’s /supplier’s
dispatch protocol must meet, at a minimum, the standards of the dispatch
protocol of the local 9-1-1 or equivalent service. In areas that do not have a
local 9-1-1 or equivalent service, then the protocol must meet, at a minimum,
the standards of a dispatch protocol in another similar jurisdiction within the
State or, if there is no similar jurisdiction within the State, then the
standards of any other dispatch protocol within the State. Where the dispatch
was inconsistent with this standard of protocol, including where no protocol
was used, the beneficiary’s condition (for example, symptoms at the scene
determines the appropriate level of payment.)
Different Payers,
Different Rules
First and foremost allow us to remind you that different
payers have issued different rules regarding billing for ALS assessment. Some
payers will not pay for ALS assessment while others have not addressed the
subject at all!
Before we go any further we suggest that you determine what
each insurance payer allows or disallows when it comes to billing for scenarios
where the ALS provider arrives on the scene and provides an assessment but no
ALS interventions (e.g.: IV, monitor, medication, etc.)
For our purposes today, we’ll primarily focus on what the
Centers for Medicare and Medicaid Services (CMS) says and how those rules apply to
the Medicare beneficiaries. This is important as Medicare and Medicare HMO’s
typically account for a large percentage of an ambulance service’s payer mix.
Just because Medicare pays for a properly documented and
coded ALS assessment does not mean that a State’s Medicaid program will pay
using the same parameters. In addition, just because Medicare may pay for an
ALS Assessment, that does not mean that a commercial insurer will allow payment
based on the same criteria.
Know who you’re billing and bill accordingly!
There are several key areas which need to be thoroughly
understood in order to properly bill for an “ALS Assessment.”
First Things-First!
One of the best techniques to properly determine which
transports qualify for “ALS Assessment” coding is to first determine which
transports already qualify for ALS level of reimbursement because an ALS
intervention was performed.
We Suggest initial processing of a billable transport PCR by
searching for any and all ALS interventions. Once an ALS intervention has been
identified in the PCR, the transport should be properly classified as emergency
or non-emergency and the proper ALS level HCPCS code can be assigned.
In the event that there are no ALS interventions documented,
review the PCR and/or dispatch records to determine if ALL of the
following criteria have been met”
- The initial dispatch required an emergency response; and
- The dispatch center who handled the call stipulated that the patient’s reported condition at the time of dispatch required an “ALS level” response- based upon approved dispatch protocols; and
- An ALS Provider arrived on scene and conducted an “ALS Assessment; and
- The patient was transported to an approved destination such as a hospital; and
- The transport meets Medicare’s reasonableness and medical necessity standards
Transports which meet all of the above
criteria may be appropriately billed to Medicare as an ALS1-Emergency even
though no ALS interventions were provided.
However, as outlined in the regulations, if
the transport is dispatched as a non-emergency and/or the dispatch center does
not have approved protocols in place which, at a minimum, designate which calls
require ALS vs. BLS, then the on-scene condition of the patient and treatment
provided are the only determinants which can be used to assign the level of
service provided.
Dispatch Sets the
Tone for an ALS Assessment
The Centers for Medicare and Medicaid Services (CMS) has
made it quite clear that dispatch protocols are one of the key requirements
necessary in order to properly bill for an ALS Assessment.
First, ALS Assessment billing can only be considered for
emergency responses.
Furthermore, the EMS service must take the steps necessary
to respond immediately to that dispatch request.
Next, the 9-1-1 or other Dispatch Center, which receives the
call for medical assistance, must utilize a recognized dispatch protocol in
order to consider billing for an ALS assessment.
The dispatch protocol, at a minimum, must have parameters
which allow the call taker to obtain information based on the patient’s
reported condition and determine if an ALS response is required. All of this
must occur at the time of dispatch!
If the patient’s reported condition, at the time of
dispatch, does not require an ALS level response, in accordance with the
dispatch protocol, then an ALS assessment cannot be used as the ONLY basis for
billing ALS 1-Emergency to a Medicare payer.
Arrival on Scene and
Assessment
Let’s assume that a call was dispatched by the 9-1-1 Center
and requires an ALS response, in accordance with its dispatch protocols, and an
ALS provider arrives at the scene and performs an assessment of the patient.
Let’s also assume that after the assessment, the ALS provider
(with or without a consult with medical command) determines that no ALS
interventions are required. The patient is eventually packaged and transported
with BLS care to a local hospital for further evaluation and treatment.
A well-documented PCR should then be drafted by the crew
which specifies, at a minimum, the name of the dispatch center, the response
priority, code or protocol which designated the call as ALS and all other
required and appropriate information about the specific details related to the
response, assessment, treatment, transport and transfer of the patient.
Assuming that this
transport meets Medicare’s reasonableness and medical necessity standards, it
can be appropriately billed to Medicare as an ALS1-E, even though no ALS
interventions were provided.
Another version of the above scenario occurs in certain
types of two-tiered EMS systems. Let’s assume that an ALS provider responds in
a separate unit, arrives on the scene and performs a patient assessment. After
determining that no ALS intervention is warranted, the ALS provider returns
into service and does not accompany the transporting unit to the hospital.
The ALS provider and the BLS transporting crew should both
draft well-documented PCR’s. The PCR’s, at a minimum, the name of the dispatch
center, the response priority, code or protocol which designated the call as
ALS and all other required and appropriate information about the specific
details related to the response, assessment, treatment, transport and transfer
of the patient.
Assuming that the transport meets Medicare’s reasonableness
and medical necessity standards, the transport can be appropriately billed to
Medicare as an ALS1-E, even though no ALS interventions were provided and the
ALS provider did not accompany the transporting unit.
Obviously, if no ALS responder arrives at the scene (or en
route) to perform an ALS assessment and/or an ALS intervention, then ALS
Assessment cannot be used as the basis for billing the transport as an ALS1-E.
BOTTOM LINE
No Dispatch Protocol,
No ALS Assessment Billing
We know of EMS systems where there are no dispatch protocols
separating ALS from BLS level responses. In these areas, the EMS system is
alerted by a common request for ambulance response and it’s quite possible that
a fully-staffed ALS ambulance may respond to every call for help.
But remember, CMS long ago, has made it clear that they
will no longer pay all billed claims at an ALS level in areas which has “ALS
Mandates” In that era, all emergency transports claims were automatically
accepted and paid by Medicare at the ALS level regardless of the patient’s
condition or level of treatment provided.
Those days are long
gone.
So let’s make this clear…
Where no dispatch protocol is in place, ALS assessment
cannot be used to bill Medicare when the assessment is the only reason to
upgrade a call to an ALS1-E. Period!
Keep in mind that if any of the following issues or
statements are true, then “ALS assessment” CANNOT BE USED as the only means to
justify ALS1-E level billing
- The initial dispatch did NOT require an emergency response; or
- The dispatch center does not utilize any type of dispatch protocols; or
- The dispatch center uses a protocol which is not in compliance with the definition outlined in the above cited CMS regulations; or
- The dispatch center does not designate which calls require an ALS level response based upon protocols and the patient’s reported condition at the time of dispatch
Document Clearly
Anyone who reads this space on a regular basis knows that we
constantly are reminding providers to document their runs clearly and concisely
using an appropriate amount of detail in the written narrative.
ALS assessment-only scenarios should contain all the detail
possible to explain, not just for billing reasons, why the ALS provider found
it possible for him/her to release care to a lesser-trained care provider.
ALWAYS document the nature of dispatch in your written
narrative.
“Station 40 dispatched via Anywhere County 9-1-1 for an ALS Emergency, male patient experiencing chest pains with a past history of MI. Medic 45 responded at time noted on this report.”
Please notice, in the example above, our documentation
includes the agency dispatched, captures that a 9-1-1 center alerted for the
emergency and defined the initial report of the patient’s condition as provided
by the 9-1-1 center. Our sample documentation also includes written
verification that the responding agencies were notified that the 9-1-1 center
followed protocol in alerting specifically for an ALS level response.
Naturally, this documentation would tie together with
written 9-1-1 protocol on file at the PSAP and hopefully with copies of said
dispatch protocol maintained at the local ambulance station for verification in
the event of an audit or post-payment review.
Proper Education,
Communication and Preparation
It’s important that your billing office educate all
providers regarding these important parts of the process.
Accurate communication is the key to an effective ambulance
billing program. Patient care providers at all levels along with ambulance
company administrators, supervisory staff and most importantly the billing
office itself must be prepared and well-versed in sorting out these sometimes
confusing scenarios.
For these reasons, every Enhanced Management Services staff
member is a Certified Ambulance Coder using the National Academy of Ambulance
Coding curriculum. Our staff is well-trained and includes veterans of the
ambulance billing industry who combine for decades of experience.
Our clients can rest easily that they are protected by
Enhanced’s informed knowledge at all levels.
If that’s not the case in your world, then maybe it’s time
to give Enhanced a call.
Business Development Manager, Chuck Humphrey will be happy
to speak with you about how you can tap into Enhanced’s ambulance billing
knowledge and expertise. Contact him today at chumphrey@enhancedms.com or by
calling toll-free 1-800-369-7544, Extension 108.
