Friday, September 11, 2015

Documenting Non-Emergency Scenarios Post October 1, 2015

Back Again
We’re back again in the second part of our look at the guidance provided by Novitas Solutions as published in their future Local Coverage Determination (LCD) slated to begin on October 1, 2015.

Documenting Non-Emergency Scenarios Post October 1, 2015
You’ll recall that we focused on emergency documentation in this space, last week. This week we take a look at what the LCD has to say about billing for non-emergency in the post October 1st world.

While Novitas’ LCD does not apply to all of our clients, the Medicare Administrative Contractor is the largest MAC in the United States and we typically find that the other MACs guidance is very similar when it comes down to the basics as they draw from guidance provided by the Center for Medicare and Medicaid Services (CMS) rules.

Non-Emergency Ambulance Services
Novitas’ LCD highlighted two general categories of circumstances that allow coverage for ambulance service in the absence of an emergency condition.

In the first condition they outlined some specific criteria.

At the time…
First, they use bold font to make this statement “…at the time of ground transport.” They highlight here is no lost on us. They elaborate to explain that even though the patient may have a serious illness, injury or surgery at the time or in the past that does not necessarily justify Medicare payment for the ambulance transportation.

The patient must be in such a state that at the time your ambulance transports the patient to the hospital his/her condition is such that the transportation is required at the time and that all other methods of transport have been ruled out because transporting in any other vehicle would endanger the patient’s health.

Thorough assessment for Non-Emergency Runs?
This is a huge point for all non-emergency/routine ambulance claims submitted to Medicare. If the documentation does not describe the patient’s condition is such detail that it easily can be concluded the patient would be at risk if transported any other way, then Medicare does not believe payment should be allowed. The LCD clearly spells this out stating this…
“thus a thorough assessment and documented description of the patient’s current state is essential for coverage. All statements about the patient’s medical condition must be validated in the documentation using contemporaneous objective observations and findings.”
Remember we’re talking about non-emergency transports here. Here in the billing office EMS providers often look cross-eyed at us like we have two heads when we pound home this point. For some reason, there is this perception that assessments and detailed documentation directives only apply to emergency transports. Nothing could be farther from the truth!

To make a case that the patient is in such a condition that only an ambulance can transport him/her to the destination; EMS providers must conduct a thorough assessment of the patient and then document the findings from that assessment in the Patient Care Report (PCR) EACH AND EVERY TIME!

Contemporaneous- a BIG WORD!
Contemporaneous is a big word! Webster defines it is as “existing or occurring in the same period of time.”

So once again, we reiterate that the focus in the guidance provided by this LCD is clear that objective findings and observations that exist in the moment of the transport must be included in the PCR documentation. This requires a written narrative without a doubt and the statements you make in that written narrative must be backed up with clear clinical documentation causing it to be objective as humanly possible.

The second general category outlined by the LCD covers bed-confined or bed-bound patients. By now, the criteria for these patients is clear but let’s go over it one more time.

A patient is bed-confined when he/she meets all of these three criteria…
  • Unable to get up from bed without assistance
  • Unable to ambulate
  • Unable to sit in a chair (including a wheelchair)
EMS providers MUST include statements describing the patient’s bed-bound status outlining the patient’s “…functional physical and/or mental limitations that have rendered him/her bed-bound.”

Final note…
We close out this discussion with a caution. Even if your patient is medically necessary and/or bed-bound but could receive the service at his/her current location then transportation to receive the service elsewhere is not covered. This typically applies to a resident of a Skilled Nursing Facility (SNF), for example.

Just because the SNF doesn’t have a person on location at the time to do whatever needs to be done and the procedure could reasonably be completed at the SNF, does not open the door for ambulance payment.

The Enhanced Ambulance Billing Services blog is brought to you by Enhanced Management Services. Enhanced Management Services is an all-EMS third-party billing contractor serving Fire/EMS clients across the United States. To learn more about the service we provide, visit our website at and click on the “Get Started” button on any landing page.

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