July 21, 2016
The recent scams have hit the Ambulance service sector hard in the US. This has set the red beacon going and has led to changes in the way the CMS now views Ambulance billing. The vigilance and tightening of billing services has impacted the reimbursements of the Ambulance services, now wary of the focus on how their services are being billed.
However, if one follows all procedures and guidelines laid down by the Medicare center, and follows the norms of the medical coding and billing methods with a fair knowledge of the workings, then one can be assured that the Revenue Cycle Management (RCM) process will not be impacted. But this is all dependent on the meticulous documentation, or rather the First Patient Care Report (PCR) that forms the foundation upon which the billers and coders in the Ambulance Service sector rely on. You may well ask why is the Patient Care Report (PCR) that documents the process right from when the emergency call via 911 comes in to the time the patient is handed over into the care of the physician so important.
The definition "medical necessity" especially when it comes to applying for reimbursement from Medicare, of which 40-60 percent of ambulance reimbursements are derived via billing, is very crucial to understand when ambulance services are requested. The information noted should clearly spell out the medical necessity and demonstrate why the ambulance had to transport the patient to the hospital and its need.
Describing the condition using qualifying words like "sudden onset of a medical condition" and pointing out the timetable of the event is necessary to meet the conditions laid down in the Medicare rule book and its definition. Without knowing if it's a repetitive condition or a new condition- acute or otherwise, Medicare may refuse to pay, and thus the insurance may not pay too leading to denied claims and appeals for the billing service.
What constitutes an emergency? When documenting, even the 911 call, it should be noted if at all the call was an emergency or not upon arrival. This will help the medical coders and billers to properly assess the situation and provide substantial support to the billing of the level of service of the call and thus prevent abuse of the system. Emergency versus non-emergency billing along with ALS versus BLS is determined in large part by how the call came to be dispatched, by what agency and the protocol used by the dispatcher to determine the level or priority the call is when dispatched. So what's constitutes as an emergency, is very pertinent to be recorded in the PCR for the medical biller to bill the trip as an emergency. Use of lights or sirens may not be necessary to constitute it as an emergency. So knowing the elements and noting it down in the PCR is very essential.
Noting all details of the patient and their insurance information, verified and eligible, past history, helps the medical billers & coders properly assess when sending forth the bill to the payer. Remember to always get the PCR signed by the patient or representative of the patient, which provides authority to the billing office in various cases like permission to appeal claims, collects, and above all acts as proof that the service was actually provided.
Transportation details are important since this is where fraud and scams can creep into the system. To avoid legal suits, it is very necessary to record the origin and destination locations & the number of miles traveled when transporting the patient from Point A to Point B, as Medicare doesn't pay for many transportation services- so description and reasons mentioned in PCR documentation can bring support to the billers if and when claims are in the appeal process.
To prevent any incorrect documentation of the scenario or input of key elements, PCRs should be written on the go and soon after depositing the patient. If there is a time lapse, one may skip important elements that can miss out on the input of crucial codes that affect the billing. Time is money and the longer one takes to write the PCR, the more delayed will be the claim, finally affecting the billing sector from achieving their payment goal.
Remember that every PCR brings in reimbursements to pay for a host of administrative and operational overheads. The billers can succeed to bring in the dollars only if the PCR is detailed to help apply both a procedure and diagnosis code and thereby implement an effective Revenue Cycle Management.
Prepare a checklist of what needs to be noted right from when the call has come through requesting for an "emergency service" .Keep certain terms handy specifically what constitutes "medical necessity" so as to reiterate information when one is writing up the final PCR. Use recording devices if necessary to note down any minor observations, which could always bring the billers some support for the cause and reason. This will help when documenting the PCR covering all the vital points required by the medical billers and coders.
Best Billing and Coding Practices