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1. EMS Billing and Coding Key Issues Hosted by: Presented by:

2. Disclaimer • The information contained in this presentation is not intended and should not be construed as legal advice or direction. • The consultant plans to share knowledge and practical experience with the attendees. • The consultant does not provide legal advice and strongly advises attendees to seek professional legal advice from an attorney before implementing any material change in their operational polices, procedures or any other matter which is governed by law or regulation © Copyright 2011 - J.R. Henry Consulting Inc.

3. Welcome and Introductions E.M.S. Issues and Trends Reimbursement Issues Compliance Issues Questions and Answers Agenda and Topics © Copyright 2011 - J.R. Henry Consulting Inc.

4. Winds of Change… coming soon to a neighborhood near you! • Declining payments per trip: • Medicare Fee Schedule Below our average costs! No longer covers the “Cost of Readiness” • Health Care Reform • Rising Deductibles • New Co-payment Requirements • Medicaid Rates still well below our costs! © Copyright 2011 - J.R. Henry Consulting Inc.

5. Winds of Change… coming soon to a neighborhood near you! • Ever-increasing Labor and System Costs • Expensive New Technologies and Meds • Limited Subsidy: Have we have spoiled our local communities??? Who pays for the “Cost of Readiness” © Copyright 2011 - J.R. Henry Consulting Inc.

6. HEALTH CARE REIMBURSEMENT Most EMS services only collect ~40% - 50% of their billed charges! © Copyright 2011 - J.R. Henry Consulting Inc.

7. E.M.S. Subsidy • Municipal subsidy levels vary widely from community to community • None • Partial • Indirect expenses such as volunteer workers compensation premiums, fuel expenses, building / utility costs • Direct - Annual donation or subsidy • Dedicated % of Real Estate Tax • Annual amount based upon budget request © Copyright 2011 - J.R. Henry Consulting Inc.

8. Ambulance Industry Being Targeted for Fraud & Abuse © Copyright 2011 - J.R. Henry Consulting Inc.

9. © Copyright 2011 - J.R. Henry Consulting Inc.

10. FEDERAL INITIATIVES • CMS is mandating renewed Carrier emphasis on compliance in these core areas: • Signature Authorizations • Physician Certifications • Repetitive Transports • Medical Necessity • Up coding of Claims • Office of Inspector General (OIG) Compliance Guidelines for Ambulance and Billing Companies © Copyright 2011 - J.R. Henry Consulting Inc.

11. © Copyright 2011 - J.R. Henry Consulting Inc.

12. Medicare Reimbursement Update • New Anti-Fraud Regulations © Copyright 2011 - J.R. Henry Consulting Inc.

13. PPACA INITIATIVES • Effective March 25, 2011 • CMS new authority to investigate suspected fraud • New rules now give CMS the ability to suspend Medicare payments based upon “creditable” allegation of fraud • 18 month cap on suspensions • Except when “good cause: exists © Copyright 2011 - J.R. Henry Consulting Inc.

14. PPACA INITIATIVES • Revalidation is now required for all providers and suppliers at least every 5 years – with a fee!!! • Screening Measures vary on type of health care organization • Limited, Moderate and High • Database checks, credentialing, license verifications, etc. • CMS can show up “unannounced” to inspect • States can implement higher standards for Medicaid and CHIP providers © Copyright 2011 - J.R. Henry Consulting Inc.

15. Corporate Compliance Programs • Why Have One? • Promotes prevention, detection and resolution of problems • Self-Disclosure can usually keep the issues at the carrier level • Careful monitoring can identify under / over payments • Increased organizational efficiency • Reduced likelihood of negative audit outcome • Mitigating factor in criminal sentencing per DOJ sentencing guidelines © Copyright 2011 - J.R. Henry Consulting Inc.

16. Corporate Compliance Programs • Components • Audit/Assessment • Written Plan • Training • Monitoring • Updating • Self-Disclosure • Hotline / Reporting Mechanism © Copyright 2011 - J.R. Henry Consulting Inc.

17. Corporate Compliance Programs Contact Page, Wolfberg and Wirth LLC at www.pwwemslaw.com for low cost sample compliance plans and policies © Copyright 2011 - J.R. Henry Consulting Inc.

18. Billing and Coding Issues © Copyright 2011 - J.R. Henry Consulting Inc.

19. Fee Schedule Fundamentals Medicare HCPCS Codes • A0428 BLS • A0429 BLS - E • A0426 ALS 1 - NE • A0427 ALS 1 - E • A0433 ALS 2 • A0434 SCT • A0432 Paramedic Intercept • Only applicable in certain parts of New York © Copyright 2011 - J.R. Henry Consulting Inc.

20. Fee Schedule Fundamentals Payment for Base Rate and loaded mileage ONLY! Urban vs. Rural Base Rates Rural Mileage Bonus of 25% for first 17 loaded miles © Copyright 2011 - J.R. Henry Consulting Inc.

21. Medicaid – SC Dept. of Public Assistance SC has a fixed payment system $ 117 – $136 BLS - $ 140 – $170 ALS $ 2.60 per mile Commercial Insurance Payers HMO’s , PPO’s and Indemnity Companies Medicare fee schedule definitions and rates often used as the basis of payments OTHER PAYER INFORMATION © Copyright 2011 - J.R. Henry Consulting Inc.

22. Alternative Medical Transportation (WCV) and pre-hospital prevention programs are typically not included in commercial Insurance coverage's OTHER PAYERS © Copyright 2011 - J.R. Henry Consulting Inc.

23. Medical Necessity • Emergencies • Non-Emergency Transports • Physician’s Certification Statement (PCS) Required • Medical Necessity • Patient could have been safely transported by other means • Non-covered destinations © Copyright 2011 - J.R. Henry Consulting Inc.

24. Fee Schedule Fundamentals Who can sign the PCS? • Attending Physician • MD required for repetitive patients • Physician’s Assistant • Nurse Practitioner • Clinical Nurse Specialist • Registered Nurse • Discharge Planner Effective on 1/31/00 *Employed by the hospital, facility or attending physician where the beneficiary is being treated, with knowledge of the beneficiary’s condition at the time the transport was ordered or service was furnished. © Copyright 2011 - J.R. Henry Consulting Inc.

25. Two Essential Questions for Billing Purposes “What was the nature of the call at the time of dispatch?” “Why did the patient need to be transported by ambulance at this particular time?” © Copyright 2011 - J.R. Henry Consulting Inc.

26. Non-Emergency Transports • Describe the patient's condition at the time of transport – not just the past medical history! • Did we transport to the nearest appropriate facility? • What is the reason for transfer to other facility? • What tests or other treatments were or will be performed? © Copyright 2011 - J.R. Henry Consulting Inc.

27. Hospital-to-Hospital Transfers • Transported To / For? • Transport to the nearest facility for care of symptoms, complaints or both. • Transports for the care of a specialist or for availability of specialized equipment • Patient transferred to rehabilitation facility • Non-covered services typically include: • Transports for the benefit of a preferred physician or nearness of family members © Copyright 2011 - J.R. Henry Consulting Inc.

28. Other Issues • Multiple Arrivals • Paramedic Level First Responders • Could encourage more ALS first responders • Two-Tiered ALS Systems • Only transporting unit may bill Medicare! • Can BLS bill without a contract with ALS? • Yes, BLS only! • ALS /BLS payment “split” or flat rate amount should be established between the providers • Since ALS vs. BLS payment differential is shrinking, many are considered flat fee rather than percentage-based or “split” contracts © Copyright 2011 - J.R. Henry Consulting Inc.

29. Other Issues • Multiple Patients • If two patients are transported simultaneously, for each Medicare beneficiary, will allow 75 percent of the payment allowance for the base rate • If three or more patients are transported simultaneously, then the payment allowance for the Medicare beneficiary (or each of them) is equal to 60 percent of the base rate • However, a single payment allowance for mileage would continue to be prorated by the number of patients onboard. © Copyright 2011 - J.R. Henry Consulting Inc.

30. Medicare Fee Schedule Issues • Paramedic Assessment • Emergency Vs. Non-Emergency • Mileage Rounding Rules (next whole mile) • Rural Mileage Adjustment of 1-17 • New regulations will require tenths of miles – no rounding until miles >100 © Copyright 2011 - J.R. Henry Consulting Inc.

31. Definitions Emergency Response - Emergency response is a BLS or ALS1 level of service that has been provided in immediate response to a 911 call or the equivalent. An immediate response is one in which the ambulance provider/supplier begins as quickly as possible to take the steps necessary to respond to the call. © Copyright 2011 - J.R. Henry Consulting Inc.

32. Definitions Advanced life support, level 1 (ALS1) means transportation by ground ambulance vehicle, medically necessary supplies and services and either an ALS assessment by ALS personnel or the provision of at least one ALS intervention. © Copyright 2011 - J.R. Henry Consulting Inc.

33. Definitions • Advanced life support (ALS) Intervention “a procedure that is, in accordance with State and local laws, beyond the scope of practice of an emergency medical technician-basic (EMT-Basic).” © Copyright 2011 - J.R. Henry Consulting Inc.

34. Emergency Dispatched Calls • Documentation of Dispatch Information • Response Priority • Patient's reported condition at “time of dispatch” • Documentation if a Paramedic Assessment was performed by an ALS crew, if applicable © Copyright 2011 - J.R. Henry Consulting Inc.

35. Paramedic Assessment Coding • Dispatch Information is critical • National accepted EMD protocols or locally developed (Medical Director) • Emergency calls which are dispatched ALS (without ALS on scene intervention and BLS transport) can be billed as ALS 1-E transports! © Copyright 2011 - J.R. Henry Consulting Inc.

36. Paramedic Assessment Coding Advanced Life Support Assessment: • 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. © Copyright 2011 - J.R. Henry Consulting Inc.

37. Paramedic Assessment Coding “ The determination to respond emergently with an ALS ambulance must be in accordance with the local 911 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 911 or equivalent service. © Copyright 2011 - J.R. Henry Consulting Inc.

38. “ In areas that do not have a local 911 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.” © Copyright 2011 - J.R. Henry Consulting Inc.

39. Paramedic Assessment Coding • If call comes in directly to you, then your dispatch protocol must meet, at a minimum, the standards of the dispatch protocol “of the local 911 or equivalent service” • If no local 911 or equivalent service, then protocol must meet, at a minimum, the standards of a dispatch protocol in another similar jurisdiction within the state, or if no similar jurisdiction, then the standards of any dispatch protocol in the state © Copyright 2011 - J.R. Henry Consulting Inc.

40. Paramedic Assessment Coding • If dispatch was inconsistent with the standard of protocol including where no dispatch protocol was used, then condition at the scenedetermines the level of payment • Medicare Claims Processing Manual, 100-4, Chapter 15, Sec. 10.3 © Copyright 2011 - J.R. Henry Consulting Inc.

41. Paramedic Assessment Coding • CMS understands that dispatch protocols may vary widely! • Are your billers familiar with and understand the dispatch protocols? • Have your dispatch protocols reviewed and approved by your Medical Director? • Key area for future reviews by CMS / Carriers !!!! © Copyright 2011 - J.R. Henry Consulting Inc.

42. Paramedic Assessment Coding • Don’t be afraid to bill all aspects - If the definitions are met! • Problem with this level of service being “counterintuitive” to how we did it before! • Monitor carefully: quality assurance, audits, etc. • Understand and have input into the dispatch protocol at the county level! © Copyright 2011 - J.R. Henry Consulting Inc.

43. ALS 2 Coding Advanced life support, level 2 (ALS2) means either transportation by ground ambulance vehicle, medically necessary supplies and services, and the administration of at least three medications by intravenous push/bolus or by continuous infusion excluding crystalloid, hypotonic, isotonic, and hypertonic solutions (Dextrose, Normal Saline, Ringer's Lactate);or transportation, medically necessary supplies and services, and the provision of at least one of the following ALS procedures: © Copyright 2011 - J.R. Henry Consulting Inc.

44. ALS 2 Coding ALS 2 ADVANCED SKILLS (Con’t) • Manual defibrillation/cardioversion • Endotracheal intubation • Central venous line • Cardiac pacing • Chest decompression • Surgical airway • Intraosseous line © Copyright 2011 - J.R. Henry Consulting Inc.

45. ALS 2 Coding ALS 2: Non-Qualifying Medications / Solutions • Aspirin (ASA) • Oxygen • Crystalloids, Hypotonic, Isotonic, hypertonic solutions (e.g: Dextrose, Saline, Ringers Lactate) © Copyright 2011 - J.R. Henry Consulting Inc.

46. SCT Coding Specialty Care Transport (SCT): “hospital-to-hospital transportation of a critically injured or ill beneficiary by a ground ambulance vehicle, including the provision of medically necessary supplies and services, at a level of service beyond the scope of the EMT-Paramedic. SCT is necessary when a beneficiary’s condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area, for example, emergency or critical care nursing, emergency medicine, respiratory care, cardiovascular care, or a paramedic with additional training. © Copyright 2011 - J.R. Henry Consulting Inc.

47. SCT Coding Note: “Additional training” means the specific additional training that a State requires a paramedic to complete in order to qualify to furnish specialty care to a critically ill or Injured patient during an SCT. © Copyright 2011 - J.R. Henry Consulting Inc.

48. Medicare Reimbursement Update • Mileage and Signature Authorization Requirements © Copyright 2011 - J.R. Henry Consulting Inc.

49. Fractional Mileage Issues • Medicare implemented a new policy on 1/1/2011 • Affects Medicare HMO beneficiaries also • Record odometer readings in tenths of miles • Use actual odometer or trip odometer for loaded miles • Can use Mapquest and other software products • Maintain thorough documentation with each claim © Copyright 2011 - J.R. Henry Consulting Inc.

50. Fractional Mileage Issues • What about Non-Medicare Payors? • What are the Medicaid mileage policies in your state??? • Commercial insurance companies??? • Do they permit fractional mileage? • Can they process you claim with fractional mileage • Use conventional rounding, when necessary! © Copyright 2011 - J.R. Henry Consulting Inc.