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Widespread Review of Ambulance Services: Fourth Quarter of FY 2014

November 5, 2014
FROM:      Palmetto GBA (Railroad Medicare)
RE:           Widespread Review of Ambulance Services: Fourth Quarter of FY 2014

Railroad Medicare
Widespread Review of Ambulance Servcies: Fourth Quarter of FY 2014 

Palmetto GBA (Railroad Medicare) has completed a widespread review of specific ambulance service claims submitted between July and September 2014. The review sample included the HCPCS codes A0427 (Emergency Transport - ALS), and A0428 (Non-Emergency Transport - BLS). A total of 20,618 services were included in the sampling. Of the claims reviewed, 7,439 were denied and 13,179 services were allowed. The overall claim denial rate was 33.5 percent. An analysis of the results is provided below.

The Top Denial Reasons

Insufficient Documentation: 
Approximately 6200 services were denied due to insufficient documentation. The specific reasons were:

 • No Physician Certification Statement (PCS) submitted and/or documentation submitted to support medical necessity
 • The PCS date was not within the appropriate time frame
 • The PCS was not signed by the appropriate health care professional
 • No run sheet submitted as evidence the service was rendered
 • Run sheet submitted is for another patient or with incorrect date of service
 • Missing crew members information and/or credentials

Signatures: 
Approximately 3700 services were denied due to lack of signatures.

Provider Signatures - Medicare requires that services provided/ordered be authenticated by the author. The signature for each entry must be legible and should include the practitioner’s first and last name. The documentation should include applicable crew credentials. Providers can submit a valid signature attestation or log with any documentation that does not contain a signature or contains an illegible signature. Services billed as A0427 do not require a PCS, but like all ambulance services, the documentation must include crew signature and credentials. 

Beneficiary Signatures - Medicare requires the signature of the beneficiary, or that of his or her representative, for both the purpose of accepting assignment and submitting a claim. Please refer to the Medicare Benefit Policy Manual, Chapter 10, Section 20.1.2 for details regarding who may sign on the beneficiary’s behalf and the specific documentation requirements. In the event that the beneficiary is unable to sign and no representative is available, the crew may sign in the place of the beneficiary. A statement explaining the reason beneficiary is unable to sign must be included.

Claims that denied for lack of required signatures fell into these categories:

• PCS
• Illegible signature
• Missing appropriate person’s signature
 • Crew Member
• Missing or illegible crew member signature
 • Beneficiary
•  Lack of signature
• Documentation requirements for person signing on behalf of beneficiary were not present
• Beneficiary signature not dated

Requested Documentation Not Received: 
Approximately 2500 services were denied due to lack of provider response to Additional Documentation Requests (ADR). As part of the Medical Review process, claims are randomly selected for review, and ADRs are generated and sent to the providers or suppliers who submitted the claim. Providers have 30 days to respond to an ADR; if a response is not received, the claim will automatically deny on the 45th day.

Requesting medical records has statutory basis. Medicare contractors are authorized to collect medical documentation by the Social Security Act. Section 1833(e), which states “No payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.” These requirements are also outlined in Section 1815(a) of The Act.

Service Not Reasonable and Necessary: 
Approximately 700 services were denied because the services were not reasonable and necessary as the documentation did not support the patient’s condition was such that use of any other method of transportation was contraindicated.

The patient’s medical record must document the patient’s condition and all services rendered for each transport being billed. It is the responsibility of the ambulance supplier to maintain (and furnish to Medicare upon request) complete and accurate documentation of the beneficiary's condition to demonstrate the ambulance service being furnished meets the medical necessity criteria. The trip record should 'paint a picture' of the patient's condition at the time of transport. All documentation must be complete and legible.

Some ambulance transports are billed for patients who may be considered ‘bed confined’. However, bed confinement, itself, does not automatically justify an ambulance transport. In addition, the term 'bed confined' is not synonymous with 'bed rest' or 'non-ambulatory.' Bed confined is one factor to be considered but is not meant to be the sole criterion to determine medical necessity.

Bed confined requires all of the following criteria to be met:

• The beneficiary is unable to get up from bed without assistance
• The beneficiary is unable to ambulate
• The beneficiary is unable to sit in a chair or wheelchair

When a beneficiary was transported because of the need to remain immobile due to the possibility of a fracture or a fracture that had not been set, the involved bone and the date and time of the fracture or injury must be clearly documented.

For scheduled and non-scheduled non-emergency ambulance services, the ambulance supplier must obtain a PCS, certifying the need for an ambulance and retain the certificate on file, unless the beneficiary resides at home or in facilities in which he or she is not under the direct care of a physician.

Itemization of the Review Data:

HCPCS Code# of Services ReviewedServices AllowedServices DeniedDenial Rate % by Dollar Amount
 A0427 8,700 6,278 2,422 27.8
 A0428 11,918 6,901 5,017 42.1
Overall Totals  20,618 13,179 7,439 33.5

Future Plans 

Based on the claim denial rate, Palmetto GBA (Railroad Medicare) will continue the service-specific prepayment review of HCPCS A0428 (Non-Emergency Transport - BLS), and A0429 (Emergency Transport - BLS). However, due to the successful reduction in the denial rate of HCPCS code A0427 (Emergency Transport - ALS) it will no longer be reviewed on a pre-payment basis.  Results from the next widespread review will be published at the conclusion of the first quarter of FY 2015. If billing aberrancies are identified, a review of individual providers may be initiated in order to substantiate or disprove questionable billing patterns.

If you have questions, you may contact our Provider Contact Center at 888-355-9165. Representatives are available from 8:30 a.m. to 4:30 p.m. in all time zones with the exception of PT, which receives service from 8 a.m. to 4 p.m. PT.

Guidelines for the PCS: (PCS Not Required For A0427)

Type of Transport PCS Requirements

A0428 (Ambulance service, basic life support, non-emergency transport (BLS) Scheduled/Repetitive:

• Documentation or PCS from physician (signature requirements must be met). The documentation/ PCS must:

 • Be dated no earlier than 60 days before the date the service is furnished

 • Meet the medical necessity requirements*
 

• Must contain a valid signature of the author of the medical record, i.e. run sheet

 • Must be able to identify the name/employee ID and credentials of crew (BLS)

• Must contain a signature from the beneficiary or that of his/her representative for the purpose of accepting assignment and submitting a claim to Medicare (see IOM 100-02, Chapter 10, § 20.1.2 for details and a list of acceptable representatives. This signature does not need to meet the signature requirements (i.e. legibility).)

Unscheduled or Scheduled/Non-Repetitive:
• Documentation or PCS from physician, P.A., N.P., C.N.S., R.N., or discharge planner, who has personal knowledge of the beneficiary’s condition at the time of transport (signature requirements must be met)

• For a resident of a facility who is under the care of physician if the ambulance supplier obtains a written order from the beneficiary’s attending physician, with 48 hours after the transport, certifying that the medical necessity requirements have been met

• For a beneficiary residing at home or in a facility who is not under the direct care of a physician.  A physician certification is not required

• If the ambulance supplier is 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.  Acceptable documentation includes a signed return receipt from the U.S. Postal Service or other similar service that evidences that the ambulance supplier attempted to obtain the required signature.

• Must contain a valid signature of the author of the medical record, i.e. run sheet

• Must be able to identify the name/employee ID and credentials of crew (BLS)

• Must contain a signature from the beneficiary or that of his/her representative for the purpose of accepting assignment and submitting a claim to Medicare (see IOM 100-02, Chapter 10, § 20.1.2 for details and a list of acceptable representatives. This signature does not need to meet the signature requirements (i.e. legibility).)

References

• CMS guidance for ambulance suppliers regarding Advance Beneficiary Notice (PDF, 140 KB) 
• Medicare Benefit Policy Manual, Chapter 10, Ambulance (PDF, 162 KB) 
• Medicare Claims Processing Manual, Chapter 15, Ambulance (PDF, 496 KB)
• § 410.40 Coverage of Ambulance Services
• § 410.41 Requirements for Ambulance Suppliers 

Guaranteed cash flow during transition.