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Medical Necessity PowerPoint Presentation

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Medical Necessity Presentation Transcript

Slide 1 - Medicare Coverage Requirements for Medically Necessary Non-emergency and Emergency transports
Slide 2 - The Why This education is required as part of Cone Health Compliance for ambulance services.
Slide 3 - Medicare Ambulance Coverage Medicare covers ambulance services via ground transportation only if they are provided to a patient whose medical condition is such that other means of transportation is contraindicated. The patient’s condition requires both the ambulance transportation and the level of service provided for the billed service to be considered medically necessary.
Slide 4 - Eligibility Requirements To be eligible for Medicare ambulance services: An approved supplier of ambulance services transported the patient to and/or from a proper location The patient suffered from an illness or injury, which contraindicated transportation by other means, and medically required ambulance services. Bed confinement is not the sole criterion in determining the medical necessity of ambulance transportation.
Slide 5 - Scenarios where Medicare would presume medical necessity for both emergent & non-emergent ambulance services You transported the patient in an emergency, i.e., as a result of an accident, injury, or acute illness You needed to restrain the patient to prevent injury to the patient or others Patient required oxygen or other emergency treatment during transport to the nearest proper facility Patient was unconscious or in shock Patient showed signs and symptoms of acute respiratory distress or cardiac distress, such as shortness of breath or chest pain Patient showed signs and symptoms that show the possibility of acute stroke Patient needed to stay immobile due to fracture that had not been set or the possibility of a fracture Patient experienced severe hemorrhage Patient could only be moved by stretcher Patient was bed-confined before and after the ambulance trip
Slide 6 - Reasons for Denial for Ambulance Service in the 2020 reporting period – 23.5% related to errors in medical necessity documentation
Slide 7 - Medicare Learning Network Medicare Fee-for-Service improper payment rate for ambulance services for the 2020 reporting period is 7.2%, a projected improper payment amount of $349 million.
Slide 8 - Medical Necessity/Physician Certification Statement (PCS) All transports being billed to Medicare for payment must meet medical necessity and be reasonable and necessary. Medical Necessity/PCS forms must be obtained on all transports in which the patient is under the direct supervision of a physician. This includes transports to and from a hospital, SNF, or ECF when the patient is under the direct supervision of a physician. “Emergency” transports are excluded from the medical necessity/PCS requirement. Note: Most interfacility hospital-to-hospital transports are considered non-emergent transports.
Slide 9 - Medical Necessity Forms May be signed by and RN, NP/PA, MD, or case manager/MSW. Must be signed by a physician if the transport is repetitive (or a medical necessity form must be completed for each leg of the transport). Repetitive scheduled services are regularly provided transportation for the diagnosis or treatment of a pt’s medical condition, e.g., transportation for dialysis or radiation.
Slide 10 - Medical Necessity (Con’t) Bed confinement Is not synonymous with “bed rest,” “non-ambulatory,” or “stretcher-bound.” A patient’s bed confinement status may change. Transports must also include a reason for transport (Why are you transporting this patient)…bed confinement is not an automatic qualifier for payment under the Medicare Fee Schedule. A patient need not be bed confined in order to for a provider to bill the Medicare program…the transport notes must include the reason(s) for ambulance transport. What makes it medically necessary?
Slide 11 - Bed confinement criteria The patient can’t get up from bed without help. The patient can’t ambulate. The patient can’t sit in a chair or wheelchair. ALL three must be met to determine bed confinement. Note: Bed confinement is 1 factor in medical necessity determinations.
Slide 12 - Billing Levels
Slide 13 - Responses (Emergency) An emergency response is an immediate response at the BLS or ALS 1 level of service in response to a 911 or equivalent call. An immediate response is one in which the ambulance provider begins as quickly as possible to take the steps necessary to respond to the call. IMPORTANT: Interfacility transports are mostly non-emergent. (Exceptions include, but not limited to: STEMI, acute stroke to tertiary care center, acute trauma or surgical need). Your PCR documentation is key.
Slide 14 - Responses (Non-emergency) Responses to a call that do not require an immediate response. If a call could otherwise be scheduled. Transport returns, to SNF or LTACH, etc. Most interfacility transports.
Slide 15 - BLS Non-emergent Basic Life Support given as determined by state laws by an EMT-Basic (minimum). These calls can generally be delayed to handle another call. Examples: patients on oxygen, no IV drips, no cardiac monitor
Slide 16 - BLS-Emergency The provisions of BLS services in the context of an emergency response Examples: patients on oxygen, no IV drips, no cardiac monitor
Slide 17 - ALS 1 Non-emergent Transportation by an ALS ambulance (EMT-I or EMT-P), medically necessary supplies and services and an ALS assessment by ALS personnel or the provision of at least one ALS intervention (i.e. cardiac monitor). These are NOT immediate responses.
Slide 18 - ALS 1 Emergent The Advanced Life Support, Level 1…in the presence of an emergency response. Ex. Response for Code STEMI transport to the cath lab or Code Stroke transport to interventional radiology ALS is used for patients on the cardiac monitor, for example.
Slide 19 - ALS 2 Does not require an emergency response. Must have either at least one (1) of the following ALS2 procedures OR at least three (3) separate administrations of one or more medications by intravenous (IV) push/bolus or by continuous infusion. Medications do not include D5W, NS, or LR. IM, PO, SL, or nebulized meds do not qualify for ALS 2.
Slide 20 - ALS 2 (Procedures) Manual defibrillation/Cardioversion. Endotracheal intubation Central Venous Line Cardiac pacing Chest decompression Surgical airway Intraosseous line. Endotracheal Intubation is covered at the ALS-2 level even if we just monitor during transport.
Slide 21 - Specialty Care Transport (SCT) Specialty Care Transport means interfacility transportation of a critically injured or ill beneficiary by a ground ambulance, including medically necessary supplies and services, at a level of service beyond the scope of an EMT-Paramedic. This is state specific. 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, nursing, emergency medicine, respiratory care, cardiovascular care, or a paramedic with additional training. Examples of SCT: Managing ventilator settings, monitored arterial lines, IABP use
Slide 22 - Signature Requirements The signature of the patient, or that of a person authorized to sign on behalf of the patient, is REQUIRED for every transport. If the patient can’t sign because of a mental or physical condition, the following individuals may sign on behalf of the patient. Patient’s legal guardian A relative or other person who receives social security or other governmental benefits on behalf of the patient A relative or other person who arranges for the patient’s treatment or exercises other responsibility for their affairs A representative of an agency or institution that didn’t provide the services for which claims payment, but provided other care, services, or help to the patient. A representative of the provider or of the nonparticipation hospital claiming payment for services it has provided.
Slide 23 - Signature Requirements In Zoll Tablet PCR: Go to the “Outcomes” tab, then click the “Signatures” tab on the left column. Click “Add” in the lower left of the screen. Select a signature type: For the patient to sign: choose the “Patient Signature” form. For a relative or other patient representative: choose the “Representative Signature” form. If the patient is unable to sign and there is no relative or other patient representative, then a CareLink crew member may sign. Select the “Crew Signature-Patient Incapable of Signing” form. Note: If the patient is unable to sign, you must document the reason why in your PCR.
Slide 24 - What does this mean for you? Obtain a medical necessity/PCS form for each transport. For transports between Cone Health facilities, obtain a copy of the medical necessity form that was completed in Epic. For transports from non-Cone Health facilities, complete the paper CareLink medical necessity form. IMPORTANT: Return all medical necessity forms to the CareLink mail room bin to the left of the copier by end of shift. Your PCR documentation is a key component! Document the reason why the patient is being transported to their destination. Document the reason why ambulance transport is necessary. Document this information in your narrative. Obtain the signature of the patient, or that of a person authorized to sign the claim form on behalf of the patient. Document with the appropriate signature form in Tablet PCR.
Slide 25 - Paper CareLink Medical Necessity Form
Slide 26 - Expectations for Documentation and Paperwork All CareLink PCRs are expected to be completed and saved to the server by the end of your shift. Note: If you have IT issues preventing you from completing your PCR, please notify the Director via email with the specific issue(s). Medical necessity forms are expected to be placed in the bin to the left of the copier in the CareLink mail room by the end of your shift. Patient records that are no longer needed for your PCR documentation must be placed in the shred bin by the end of your shift.
Slide 27 - References Medicare Learning Network, Provider Compliance Tips for Ambulance Services, MLN909409 December 2020 Provider Compliance Tips for Ambulance Services (cms.gov) Medicare Learning Network, MLN Matters Number MM9761 Revised, 9/12/2016
 

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