HI 225 Ch07 pp ts.ambulance.ab202017

1. © 2018 American Health Information Management Association© 2018 American Health Information Management Association
Principles of Healthcare Reimbursement
Sixth Edition
Anne B. Casto, RHIA, CCS

2. © 2018 American Health Information Management Association
Chapter 7
Ambulatory and Other Medicare-Medicaid
Reimbursement Systems
• Learning Objectives
– Describe the elements of the ambulance fee
schedule
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Ambulance Fee Schedule
• Covered Services
– Medicare Part B provides beneficiary coverage for
ambulance services
• Will provide transport service
– Only if other means are inadvisable, based on the beneficiary’s medical
condition
• Provided to the nearest facility that is able to provide services
for that patient’s condition
• Transported
– From one hospital to another
– To home
– To an extended care facility
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Types of Providers
• Providers
– Ambulance service entities associated with a
medical facility
• Hospital, CAH, SNF
• Suppliers
– Ambulance service entities not associated
with a medical facility
• Independent ambulance companies
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Ambulance Fee Schedule
• Reimbursement is based on the level of
service provided to the beneficiary
– Seven levels of service (table 7.9 in text)
• Specifies the emergency medical technician (EMT)
skill set necessary to provide services and care
– Two types of transports
• Ground
• Air
– Nine payment levels (table 7.11 in text)
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Nonemergency Transport
• Repetitive
– Physician certification in advance for the
services
• Nonrepetitive
– Physician certification within 21 days after the
transport
• Physician assistant, nurse practitioner, clinical
nurse specialist, registered nurse, discharge
planner
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Provisions
Immediate
Response
• Additional payment is provided for
the extra overhead expenses
incurred to stay prepared at all times
for emergency medical service
Reginal
variations
• Based on patient pick-up location
(zip code)
• PE GPCI
• Ground = 70% adjusted
• Air = 50% adjusted
• Mileage is not adjusted
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Provisions
Multiple
patients
• 2 patients: each is reimbursed at 75% of rate
• 3 or more: each is reimbursed at 60% of rate
• Mileage is split between patients
• Use modifier GM
Deceased
patient
• If patient is pronounced dead prior to call, no
payment is made
• If patient is pronounced dead after call, but
prior to arrival, BLS rate is paid, mileage is not
paid
• If patient is pronounced dead during transport,
payment rules are followed as if patient were
alive: Modifier QL is reported
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Modifiers
• HCPCS Level II modifiers
– Origin and destination modifier must be
reported for each trip (see table 7.13 in text)
– Additional modifiers are used (see figure 7.5 in text)
• Provided under arrangement of a provider of
services (QM)
• Furnished directly by a provider of services (QN)
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Medical Conditions List
• Numerous requests for medical condition lists to
help determine level of service
– CMS implemented a Medical Conditions List in
February 2007
• Condition list
• Transportation indicators
• Assist with determining the appropriate level
of service
• Conversion to ICD-10-CM
– Cross walk is provided so diagnoses can be
converted from ICD-10-CM to ICD-9-CM to work with
the Medical Conditions List
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