Often, neither nurses nor ambulance crew are knowledgeable regarding certain specific Medicare coverage requirements, and going forward their simple actions could lead to billing issues. Also medical billers when billing and referring to the documentation for clarification, need to be aware and back check the information so as to avoid denial claims that could cause harm to the revenue cycle management cycle process.

Below are some pointers to keep in mind for the medical billers, ambulance crew and healthcare providers:

1. Ambulance "run sheets" narrative documentation:

This is the most critical documentation in order to receive reimbursements. The ambulance crew has to note a beneficiary's appearance upon arrival. The "run sheets" need to have information on whether a beneficiary is found in a chair, or whether they were able to stand and move onto the stretcher. However, more often than not, their notes fail to note key facts such as whether the beneficiary was in a reclined position (not sitting upright), required total assistance for any transfers, or was unable to walk unassisted.

Moreover, added to this failure is the absence of specific communication by the discharging staff at the facility which often leads to the ambulance crew erroneously documenting that the transport was not medically necessary, all of which could lead to an eventual denial of the claim by Medicare.

2. Medicare Coverage of ambulance services:

Medicare Part B covers ambulance services only if the following prerequisites are met:

  • The supplier meets the applicable vehicle, staff, and billing and reporting requirements and the service meets the medical necessity and origin and destination requirements.
  • Medicare Part A payment is not made directly or indirectly for the services.

3. Billing and Reporting Requirements:

  • Bill for ambulance services using only certain CMS-designated procedure codes to describe origin and destination and must indicate on claims form that the physician certification is on file.
  • Upon a carrier's request, complete and return the ambulance supplier form designated by CMS and provide the Medicare carrier with documentation of compliance with emergency vehicle and staff licensure and certification requirements in accordance with State and local laws.
  • Upon a carrier's request, provide additional information and documentation as required.

4. Medically reasonable and Necessary:

When billing to Medicare, especially Part B, when using an ambulance service, it should be seen that the documentation clearly shows that it was medically necessary. The Medicare payment is subject to Part B deductible and co-insurance.

5. Billing to Hospital/SNF:

This can be covered only when and if the patient is an inpatient at a hospital or Skilled Nursing Facility (SNF) but should be done on the day of the ambulance transportation is carried out and not on the day of discharge.

6. Hospice Provider:

When the patient is enrolled in the hospice and if and when the ambulance transport is employed but only when related to terminal illness, then only can the ambulance service be arranged by the hospice and be billed to the hospice.

7. Documentation:

Often Ambulance transportation is inappropriately denied even though under Medicare coverage. In such circumstances, with all paper work that thoroughly documents the "medical necessity" the denial should be appealed. Hence, appropriate documentation on file and, upon request, present it to the contractor. Please note that, even though the signed certification statement or signed return receipt is present, this does not alone demonstrate that the ambulance transport was medically necessary. All other program criteria must be met in order for payment to be made.

8. Air Ambulance Service:

Medicare is also known to cover air ambulance services if certain conditions are met :

  • if the ambulance service is furnished to a beneficiary whose medical condition is such that other means of transportation are contraindicated
  • The beneficiary's condition must require both the ambulance transportation itself and the level of service provided in order for the billed service to be considered medically necessary

9. Non-emergent transportation:

This by ambulance is Medicare-coverable if either:

  • The beneficiary is bed-confined and it is documented that the beneficiary's condition is such that other methods of transportation are contraindicated; or
  • The beneficiary's medical condition, regardless of bed confinement, is such that transportation by ambulance is medically required.

Thus, bed confinement is not the sole criterion in determining the medical necessity of non-emergent ambulance transportation; rather, it is one factor that is considered in medical necessity determinations. Part B of Medicare will generally cover up to 80% of emergent and non-emergent ambulance transports when medically necessary and when transport by any other means could endanger your health

10. Medicare and Repetitive Ambulance Service:

Repetitive ambulance services, defined as medically necessary ambulance transportation for three or more round trips during a 10-day period, or at least one round trip per week for at least three weeks, are often needed by beneficiaries receiving dialysis or cancer treatment. Medicare may cover repetitive, scheduled, non-emergent transportation by ambulance if:

  • The medical necessity requirements are met; and
  • The ambulance provider/supplier, before furnishing the service to the beneficiary, obtains a written order from the beneficiary's attending physician certifying that the medical necessity requirements are met.

11. Physician Certification Statement:

If ambulance services are unable to obtain a signed physician certification statement from the beneficiary's attending physician, a signed certification statement should be obtained from any or either of the following: the physician assistant (PA), nurse practitioner (NP), clinical nurse specialist (CNS), registered nurse (RN), or discharge planner, who has knowledge of the beneficiary's condition at the time the ambulance transport is ordered.

Moreover, ant or either of these individuals must be employed by the beneficiary's attending physician or by the hospital or facility where the beneficiary is being treated and from which the beneficiary is transported. However, if unable to obtain the required certification within 21 calendar days following the date of the service, the ambulance supplier must document its attempts to obtain the requested certification and may then submit the claim.

12. Origin & destination Requirements:

Certain origin and destination requirements for coverage, Medicare will pay for ambulance transportation

13. Specific limits on coverage of ambulance services outside the United States:

If services are employed outside the United States, Medicare Part B covers ambulance transportation to a foreign hospital only in conjunction with the beneficiary's admission for medically necessary inpatient services as specified.

14. Updated with changing healthcare rules & regulations:

The healthcare industry is continually changing, and your billing must keep pace. Hence, outsourcing or hiring of trained financial professionals can benefit your ambulance services. Given that they are focused and constantly on top of new legislation, regulations and any other current rules, they can immediately raise flags which can affect your Revenue Cycle Management potential

Keeping the above pointers in mind, your denial claims will be decreased and provide a healthy Revenue Cycle.

Published By - Medical Billers and Coders
Published Date - Apr-08-2016 Back

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