Top 5 Compliance Issues for Ambulance Biller As we are doing Ambulance Billing for years now, our clients can rest easy that they are protected by our informed knowledge at all levels. If that’s not the case in your world, then maybe it’s time to give us a call. You can reach us at 888-357-3226 or info@medicalbillersandcoders.com Click Here: https://www.medicalbillersandcoders.com/blog/top-5-compliance-issues-for-ambulance-biller/ #ambulancemedicalbilling #ambambulancemedicalbilling #medicalbillingforambulanceservices #ambulancemedicalbillingcodes #ambulanceserviceinmedicalbilling #ambulancebilling #ambulancebillingservices #ambulancebillingservice #ambulancebillingmedicare #medicareambulancebilling #ambulancebillingandcollections #cmsambulancebillingguide #medicareambulancebillingguide

1. Medical Billers and Coders

2. Ambulance service billing involves a host of unique
compliance challenges. The ambulance industry has seen a
significant number of false claim cases, fraud
investigations, Medicare audit activity, and other types of
billing-related cases. It is imperative that billers fully
understand the nuances of ambulance reimbursement to be
able to successfully sidestep these landmines.

3. The following are five of the most significant issues in
ambulance billing.
This is by no means an exhaustive list but includes some of the
most common and serious challenges in the world of compliant
ambulance billing.
1. Medical Necessity
2. Signatures
3. Advanced Life Support Billing
4. Interventions
5. Training

4. 1. Medical Necessity
Medical necessity is established when the patient’s condition is
such that the use of any other method of transportation is
contraindicated. In any case in which some means of
transportation other than an ambulance could be used without
endangering the individual’s health, whether or not such other
transportation is actually available, no payment may be made for
ambulance services. In all cases, the appropriate documentation
must be kept on file and, upon request, presented to the
carrier/intermediary. It is important to note that the presence (or
absence) of a physician’s order for transport by ambulance does
not necessarily prove (or disprove) whether the transport was
medically necessary. The ambulance service must meet all
program coverage criteria in order for payment to be made.

5. Medical necessity for ambulance services continues to be the
biggest compliance issue in ambulance billing. Like any other
type of healthcare service, ambulance transportation must meet
medical necessity guidelines in order to be covered. However,
when it comes to ambulance billing, the medical necessity
standards seem to be vague and less defined than in other medical
specialties.
In other words, if a patient could safely be transported by car,
wheelchair van, stretcher van, or any other means, then medical
necessity is not met, and reimbursement cannot be made. It is
important to note that when assessing medical necessity, only the
patient’s condition matters; it is irrelevant if those other means of
transportation are unavailable.

6. To put it another way, if the only reason a patient is being
transported by ambulance is that they don’t have a car, or that
the nursing home’s wheelchair van is out of service, that alone is
insufficient to establish medical necessity for ambulance
transport. The mere unavailability of other means of transport
does not mean that ambulance transport will be covered.
The medical documentation from the ambulance crew at the
time of service—the patient care report (PCR)—must clearly
establish that the patient required transport by ambulance. This
is vital, and ambulance billers will often find that ambulance
PCR documentation is not sufficiently detailed or complete to
allow for the level of specificity required under ICD-10 coding.

7. 2. Signatures
Medicare and other Payers require the signature of the
beneficiary, or that of his or her representative, for both the
purpose of accepting the assignment and submitting a claim. If
the beneficiary is unable to sign because of mental or physical
conditions authorized person may sign the claim form on behalf
of the beneficiary. Authorized person can be Beneficiary’s legal
guardian, a relative or other person who receives social security
on behalf of the beneficiary, a representative of an agency that
provides assistance to the beneficiary, a representative of the
ambulance provider or supplier who is present during an
emergency and/or non-emergency transport.

8. A provider/ supplier (or his/her employee) cannot request
payment for services furnished except under circumstances fully
documented to show that the beneficiary is unable to sign and that
there is no other person who could sign. Medicare does not
require that the signature authorize claim submission to be
obtained at the time of transport for the purpose of accepting
assignment of Medicare payment for ambulance benefits.
When a provider/supplier is unable to obtain the signature of the
beneficiary, or that of his or her representative, at the time of
transport, it may obtain this signature any time prior to submitting
the claim to Medicare for payment. (Note: There is a 12 month
period for filing a Medicare claim, depending upon the date of
service.) If the beneficiary/representative refuses to authorize the
submission of a claim, including a refusal to furnish an
authorizing signature, then the ambulance provider/supplier may
not bill Medicare but may bill the beneficiary (or his or her estate)
for the full charge of the ambulance items and services furnished.

9. If, after seeing this bill, the beneficiary/representative decides to
have Medicare pay for these items and services, then a
beneficiary/representative signature is required and the ambulance
provider/supplier must afford the beneficiary/representative this
option within the claims filing period, but this creates more work
for ambulance billers and can cause significant delays in the
ambulance revenue cycle.

10. 3. Advanced Life Support Billing
Another key compliance risk area in ambulance billing is the
use of higher-paying advanced life support (ALS) codes in
cases where lower-reimbursed basic life support (BLS) codes
should be used. ALS levels of service can be billed only when
the skills required to care for the patient exceed the scope of
practice of an EMT-Basic in that jurisdiction. Therefore, an
ambulance biller must know what the approved scope of
practice consists of for EMTs in that jurisdiction, and what
skills require licensing or certification above that level.

11. The biggest area of compliance risk with ALS services, however,
has been in the application of the so-called “ALS Assessment”
rule. Under this rule, Medicare allows the ALS-emergency level
of service to be billed when the nature of the ambulance dispatch
necessitates an assessment of the patient by an ALS crew, even if
the patient does not end up needing ALS interventions. While this
rule sounds straightforward on the surface, it has been the subject
of much compliance enforcement activity in the ambulance
industry in the past few years.

12. Some ambulance billers improperly conclude that all 911 calls
are billable at the ALS level whenever there is a paramedic or
other ALS provider responding on the ambulance. This results in
significant overbilling, or “upcoding,” of BLS claims to the ALS
level. It is not the mere presence of an ALS provider that triggers
the ALS assessment rule; an ALS-level emergency call is also
required under the EMS system’s dispatch protocols. So,
ambulance billers must not assume that every ambulance call
with a paramedic on board qualifies for an ALS level of billing.

13. 4. Interventions
Earlier, we discussed the medical necessity for the ambulance
transport itself. But the medical necessity for transport has a close
relative, and that is a medical necessity for the clinical
interventions performed by the crew.
Say, for instance, that an ambulance PCR documents a patient
with no complaints, and with normal and stable vital signs, who is
being transported to the hospital. The PCR indicates that the
patient is ambulatory and that she walked unassisted and without
difficulty to the stretcher. The PCR also indicates that the EMT
administered two liters per minute (LPM) of oxygen via nasal
cannula. A patient with no complaints and normal vital signs
would ordinarily not require the administration of supplemental
oxygen; though this particular intervention is often used by EMS
providers even when there is no clinical indication for it.

14. In a case such as this, where the documentation provides no
basis for the biller to establish medical necessity, the
performance of medical intervention—when there is no medical
justification for that intervention documented anywhere in the
record—should not be used to “confer” medical necessity on a
claim where it does not otherwise exist. In other words,
interventions themselves must be medically necessary, and it is
the job of the EMS providers to document the clinical need for
the interventions. It is not the job of the biller to “assume” that
medical necessity exists merely because an intervention was
performed.

15. In the event that there are no ALS interventions documented,
review the PCR and/or dispatch records to determine if ALL
of the following criteria have been met:
1. The initial dispatch required an emergency response; and
2. The dispatch center who handled the call stipulated that the
patient’s reported condition at the time of dispatch required an
“ALS level” response- based upon approved dispatch
protocols; and
3. An ALS Provider arrived on scene and conducted an “ALS
Assessment; and
4. The patient was transported to an approved destination such as
a hospital; and
5. The transport meets Medicare’s reasonableness and medical
necessity standards
Transports that meet all of the above criteria may be
appropriately billed to Medicare as an ALS1-Emergency even
though no ALS interventions were provided.

16. 5. Training
Finally, an important part of an ambulance billing operation is to
ensure that all billers are specifically trained in the unique world
of ambulance billing and coding. It is dangerous to assume that
billing and coding knowledge from other areas of healthcare is
automatically applicable to ambulance billing. Ambulance coding
and billing have their own quirks and idiosyncrasies, and billers
should receive ambulance-specific training to maximize billing
compliance.
Formalized and ambulance-specific coding and compliance
training can also help your agency overcome the “whisper
policies” that often occur in a billing office in the absence of
formalized and standardized training.

17. Accurate communication is the key to an effective ambulance
billing program. Patient care providers at all levels along with
ambulance company administrators, supervisory staff, and most
importantly the billing office itself must be prepared and well-
versed in sorting out these sometimes confusing scenarios.
As we are doing Ambulance Billing for years now, our clients can
rest easy that they are protected by our informed knowledge at all
levels. If that’s not the case in your world, then maybe it’s time to
give us a call.

18. Get in Touch
Medical Billers and Coders
Email : info@medicalbillersandcoders.com
Toll Free no: 888-357-3226