BILLING MEDICARE FOR EMERGENCY CALLS: MYTHS AND REALITIES
There are two commonly-held beliefs regarding the appropriate billing of emergency calls for Medicare patients:
- If an advanced life support skill is utilized or performed on scene or during transport, it is always proper to bill Medicare at the ALS emergency level; and
- Unless an ALS skill is performed, it is not proper to bill Medicare at the ALS emergency level.
While each of these statements are accurate in the majority of cases, further discussion is required in order to truly understand the Medicare rules and regulations that impact upon these two situations and how services can utilize these rules to bill appropriately and legally.
(1) Let’s look at the first statement. It makes sense to assume that if a provider places a patient on a cardiac monitor, starts an IV or administers a medication, billing at the ALS level would be proper. In most cases this will be true and the reviewers at Medicare will pay the claim without question.
In recent years, however, CMS (Center for Medicare and Medicaid Services) has been carefully scrutinizing ALS emergency calls. As a result of this heightened scrutiny, many services around the country have been required to refund payments on the ground that the ALS service performed was not medically necessary under the circumstances. In most of these cases, the use of a cardiac monitor or an IV were identified as being unnecessary interventions. A large municipal service in the Midwest was required to refund more than $200,000.00 when a review of several hundred runs revealed that a cardiac monitor was used on almost every patient over the age of 60 without any medical justification. A service in Texas was heavily fined for billing at the ALS level based on its routinely starting IVs that did not appear medically necessary.
We all know that the practice of emergency care is as much an art as it is a science and that not every provider will treat every patient in the exact same manner but we also have to recognize that we operate under protocols that for the most part define and direct the nature of the care that we provide. In most cases our interventions will be based either upon these written protocols or the direction of online medical control. Whenever an ALS intervention is performed, it is strongly recommended that the reason for the intervention be clearly set forth in the narrative. The failure to do so might result in a denial of a claim and/or a request for reimbursement if the claim has already been paid. When a patient requests an ambulance because he fell and hurt his knee, it might not appear to be a situation that would require the use of a cardiac monitor and a Medicare reviewer might deny the claim. But if your narrative includes a statement that the patient has a cardiac history and that prior to your arrival the patient felt light-headed or experienced a moment of chest pain, these facts might well justify the use of a monitor and billing at the ALS level.
The message here, as in so many other cases, is to thoroughly document what you do and the reason for your actions.
(2) Our second point is a little more complicated. Our instincts tell us that a run should not be billed at the ALS level unless some ALS intervention takes place. Generally, this is a good rule to follow but Medicare rules, in certain circumstances, permit billing at the ALS level even when no ALS intervention is performed and even if an ALS provider does not accompany the patient to the hospital. This is known as the ALS assessment rule.
The ALS rule is found at 42CFR 414.605. It defines ALS assessment as “an assessment performed by an ALS provider 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.” Nowhere in the rule does it describe what an ALS assessment should consist of: the only guideline is that the assessment is one that requires a level of knowledge beyond that of a BLS provider.
The key to the Rule is dispatch information but there is no guidance in the Rule as to what type of dispatch information would justify an ALS assessment. But common sense and good judgment would certainly dictate that calls involving chest pain, an unresponsive patient, serious trauma, difficulty breathing or suspected CVA, among others, would qualify as requiring assessment by an ALS provider. In order to effectively take advantage of the ALS assessment rule a number of things must occur:
- development of a service policy that describes your ALS assessment procedure including guidelines that set forth the type of dispatch information that will trigger the use of an ALS assessment;
- entering into an agreement with dispatch that describes those circumstances under which ALS will be dispatched for purposes of a possible ALS assessment or intervention;
- developing a policy that requires the ALS provider performing the assessment to document the nature of the assessment. It is not sufficient for a BLS provider to document that an ALS assessment was performed by an ALS provider. The ALS provider must document the assessment whether or not he or she accompanies the patient to the hospital.
Use of the ALS assessment rule can be an effective method of increasing revenue but it must be done carefully in order to avoid scrutiny and potential penalties.
Alan J. Azzara, Esq., EMT-P