Friday, March 7, 2014

Let’s Take a Walk!

Walking, Medical Necessity and Billing
Join us today as we take a few minutes to explore medical necessity issues surrounding patients who can ambulate and how that fact alone may affect billing for an ambulance transport.

Medical Necessity
Any claim for payment billed for ambulance transport must meet a medical necessity definition. The most stringent of those rules are the Medicare and Medicaid rules. However, we often find that there are tie-ins between the Medicare and Medicaid rules to many of the commercial insurance payers who follow some of the same payment rules when defining a patient’s medical necessity.

Always know who you are billing and understand how they define a medically necessary patient.

The Centers for Medicare and Medicaid Services (CMS) National Payment Policy employs this explanation.
“Medicare covers ambulance services only if furnished to a beneficiary whose medical condition at the time of transport is such that transportation by any other means would endanger the patient’s health.”
Using this as a point of reference, let’s look at some possible scenarios for our discussion.

Any one of us who has spent time in the field knows well that there are times when very ill or injured patients present to us as ambulatory.

As one example, we can’t tell you the number of times persons in the throes of a major cardiac event have walked to the ambulance, upon arrival, clutching the chest, complaining of severe chest pain, pale, sweaty.

You know the routine.

So, to represent that any given patient cannot meet medical necessity for ambulance treatment and transport and, by extension, deny reimbursement based on whether the patient can walk or not is not realistic. Note in the excerpt above from the Payment Policy there is no mention of the patient’s ability to ambulate or not ambulate. The focus is on whether or not the patient’s condition is such that transportation by any other means would be contraindicated given the patient’s medical condition at the time of the transport.

Walking patients can fit the definition of being medically necessary, but we caution that providers should clearly document the circumstances of the incident concisely and clearly using clear clinical documentation representing the scenario to support the medical necessity.

We all know that we are often alerted via 9-1-1 to respond to “emergencies” that are anything but emergencies.

When documenting non-emergency or routine transports, repetitive or not-repetitive; here’s where things change drastically.

In our expert opinion, patients who can ambulate and move about typically can be transported by other means safely and do not need an ambulance when the scenario is not life-threatening or is of a routine, pre-scheduled nature.

We find it very rare that a patient who can walk needs an ambulance vehicle to move from one place to another even if the patient has standing medical history issues, when the patient is not suffering a life-threatening emergency.

But when considering non-emergency/routine scenarios for billing, we often are questioned about patients who have obstacles, such as steps or barriers to moving in and out of the origin and/or destination locations (residences, hospitals, etc.) We’ve also fielded questions from persons who call our office to question the medical necessity and reasonableness of ambulance transports based on whether or not there are barriers to transfer of given patients at either the origin or destination spot.

For example, there are times when we’ll be asked if ambulance transport and later payment for that transport, is justified simply because the patient can’t be easily transferred from a wheelchair to an examination table or other device/surface for treatment.

Frankly, Medicare, most State Medicaids and many commercial insurance payers do not feel that they should be responsible to reimburse ambulance providers for claims submitted simply because the means to move the patient from one place to another isn’t readily accessible upon arrival at the destination. Furthermore, those same payers do not feel they should pay for ambulance transportation simply because a patient has stairs leading to and from a residence causing a barrier for movement.

If the patient can be safely transported without endangering the patient’s health while seated in a wheelchair, seated in a private vehicle, taxicab, public transit or any other means and the patient does not require treatment and/or trained monitoring of skilled ambulance personnel then those same insurance payers will ultimately consider the patient to be not medically necessary for ambulance transport and not allow payment for said ambulance transport.

The issue of whether or not there are barriers to moving the patient to and from a location or surface should not come into consideration when considering medical necessity in these cases.

Review Carefully
We strongly suggest that every billing office carefully review each and every PCR, prior to billing, especially when the patient is documented as being ambulatory. The patient’s medical necessity must be established before billing to a payer source. A walking patient will most definitely raise major flags for review of the claim.

Everyday Guidance and Direction
Not sure about medical necessity issues for walking patients? Call Enhanced if your EMS billing program needs the kind of guidance and direction offered by the Enhanced staff.

Contact Chuck Humphrey today to learn how your department can tap into this kind of valuable oversight. You can reach Chuck via e-mail at or by calling toll-free at (800) 369-7544, Extension 108. 
Post a Comment