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Widespread Review of BLS Non- Emergency Ambulance Services: Second Quarter of FY 2017

May 05, 2017
FROM:     Palmetto GBA (www.palmettogba.com)
RE:         Widespread Review of BLS Non- Emergency Ambulance Services: Second Quarter of FY 2017

Palmetto GBA/Railroad Medicare has completed a widespread review of specific ambulance service claims submitted from January through March 2017. The review sample included the HCPCS code A0428 (Non-Emergency Transport - BLS). A total of 4,993 services were included in the sampling. Of the claims reviewed, 1,645 were denied and 3,348 services were allowed. The overall claim denial rate was 36.0 percent. An analysis of the results is provided here.

Itemization of the Review Data:

HCPCS Code
# of Services Reviewed
Services Allowed
Services Denied
Denial Rate % by Dollar Amount
A0428
4,993
3,348
1,645
32.6


The error rate of 32.6 is a decrease from the last quarter error rate of 36.0 percent.

The Top Denial Reasons 
Requested Documentation Not Received:
 
Non-response to Additional Documentation Requests (ADR) resulted in the denial of approximately 740 services. More than 45.0 percent of all denials for these codes are related to non-response to requests for documentation.

As part of the Medical Review process, claims are selected for review by a computerized system. Once a claim is selected, an ADR is generated and sent to the provider or supplier who submitted the claim. Providers have 45 days to respond to an ADR; if a response is not received, the claim will automatically deny on the 46th day. Please see article on Medical Review: Additional Documentation Requests (ADRs) for information on how to respond to a record request.

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.

Insufficient Documentation: 

Approximately 760 services were denied due to insufficient documentation.  About 46.2 percent of all denials are due to insufficient information to support the claim.

The specific reasons given for insufficient documentation were:

• Trip report was incomplete or omitted
• Trip report was for wrong date of service or wrong patient
• The documentation was illegible
• Trip report lacked sufficient documentation to support the medical necessity of the transport
• If required for the type of service, the PCS was incomplete or omitted

Decisions regarding whether services are medically reasonable and necessary cannot be made without all of the required information present. Thorough documentation of the required elements serves to create a clear picture of the patient's condition and the treatments provided. All documentation must be complete and legible.

Signatures: 
Non-conforming signatures resulted in the denial of approximately 90 services.  

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. Please refer to the Internet Only Manual (IOM) Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 for details regarding signatures of providers of a service.

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

PCS
• Repetitive transport PCS not signed by the MD or DO
• Repetitive transport PCS not signed prior to the transport
• Transport more than 60 days after the PCS signed
• Illegible signature
• Missing appropriate person’s signature/credentials

Crew Member
• Missing or illegible crew member signature
• Missing crew 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 IOM 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, with additional supportive information from the receiving facility.  (See the Code of Federal Regulations ambulance links in the resource list at the end of this article.) A statement explaining the reason beneficiary is unable to sign must be included.

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

Beneficiary
• Lack of signature
• Documentation requirements for person signing on behalf of beneficiary were not present
• Beneficiary signature not dated

Service Not Reasonable and Necessary: 
Approximately 20 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 trip report must contain a record of the patient’s condition and all services rendered for each transport. 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.

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. The PCS is one part of the documentation that supports the medical necessity of the transport. The information in the transport record and in the PCS should support the need for transport and should have similar findings for the reason for transport. Conflicting information in the PCS and the transport record may affect the outcome of the review.

The remaining denied claims fell into general categories not included in this Top Denial summary.

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). Results from the next widespread review will be published at the conclusion of the 3rd quarter of FY 2017. 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 or A0429)

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).)

Guaranteed cash flow during transition.