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MEDICARE PROVIDER ADVISORY GROUP MEETING
Wednesday, April 19, 2006 10:30 A.M.
Medicare Services Center, N. Little Rock

A summary of the PAG meeting will be posted here soon.

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Reminder--Health care providers are required by law to apply for a National Provider Identifier (NPI). To apply online, visit: https://nppes.cms.hhs.gov,

Announcing the new CMS web page dedicated to providing all the latest NPI news for Fee-For-Service (FFS) Medicare providers!  Visit http://www.cms.hhs.gov/providers/npi/default.asp on the web.  While this page is dedicated to the FFS community, it contains helpful information and links that may benefit all health care providers. 

Melissa Scarborough, MPH, CHES
Provider Outreach Specialist
Centers for Medicare & Medicaid Services
1301 Young Street, Suite 827
Dallas, Texas 75202
Phone: 214-767-4407
Fax: 214-767-0323

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Posted from PWW EMSLawlines January 2005 Edition
www.pwwemslaw.com

Medicare’s New Initiative to Reduce “Error Rates”:  Will You Be Ready for An Audit? . . .

 CMS recently announced that it plans to implement a comprehensive initiative over the next four years to reduce the provider compliance error rate in Medicare payments by 4%.  The initiative, which includes ambulance claims, is a result of an expanded program by CMS to collect more detailed and specific information from its contracted carriers.  Fiscal year (FY) 2004 was the first year for the new collection and analysis techniques.  It will likely lead to more Medicare audits of ambulance service claims as the federal government continues to scrutinize Medicare payments more closely.  

 This review was the most extensive ever, providing CMS with more accurate information about contractor-specific error rates, error rates by provider type, and error rates by service type, including ambulance.  According to the CMS announcement, this level of detail and accuracy (which is unprecedented in CMS history) will help CMS identify problem areas and target improvement efforts more effectively.  The review also revealed that the use of “best practices” by Medicare carriers significantly reduces error rates. 

 The CMS announcement comes on the heels of the Office of Inspector General (OIG) Semiannual Report, which details accomplishments from OIG activities and initiatives from April 1 through September 30, 2004. The OIG reported savings to taxpayers of almost $30 billion: $27.3 billion in implemented recommendations, $754.2 million in audit receivables, $8.3 million in additional audit recoveries, and $1.9 billion in investigational receivables.  These substantial numbers are ever increasing evidence of the government’s increased enforcement initiatives.  For the OIG report, go to:  www.cms.hhs.gov/CERT

 Under the error rate reduction initiative, CMS identified error rates for a wide range of billing codes, broken down by carrier.  For ambulance service claims, BC/BS of Rhode Island had the highest “error rate” in the continental United States at 14.4%.  The chart below gives an indication of the error rates of selected contractors for ambulance service claims:  

According to CMS Administrator Mark B. McClellan, M.D., PhD, CMS hopes to eventually identify individual providers who have a high incidence of billing errors.  What does that mean for ambulance services?  Make sure your “billing house” is in order!

The Best Practices initiative will focus on the new data techniques and provider education.  CMS discovered that provider and contractor education were the best current tool for reducing the error rate. 

             Another area of focus for CMS will be on the response rate of providers asked to supply additional information to CMS for “questionable” claims.  Many of these claims will deal with the age-old problem of documenting medical necessity.  When CMS asks for additional information, if the provider does not send it, CMS records the claim as an error and sends it back to the provider.  The new initiative will attempt to reduce the number of claims listed as errors because the requested information was never sent.  This will mean greater efforts by CMS to obtain the requested information.  As a first step, CMS is extending the time period for supplying additional information from 55 to 90 days.  CMS will also employ an “Error Rate Contractor” responsible for lowering the poor response rate. 

            CMS’s new efforts will likely have a large impact on ambulance providers throughout the country.  The attempt to reduce the error rate will no doubt mean more audits and reviews for individual providers as well as more scrutiny for routinely submitted claims.  Also, keep in mind that provider education has traditionally been a first step in CMS corrective procedures and any provider education resulting from errors identified by CMS may open the door to more severe corrective actions, such as pre-payment review, if errors persist. 

 Steps to Take Now

             Ambulance services should insure that their compliance practices and procedures are up to date and being enforced.  Additionally, increased training in the areas traditionally flagged by Medicare such as medical necessity and documentation will help insure that your ambulance service breezes through the increased scrutiny this error reduction effort is sure to bring. 

Emergency Calls.  We are already seeing increased audit activity by carriers with respect to ALS assessments and use of HCPCS Code A0427, ALS 1- Emergency.  Documentation that is critical to adequately evaluate a claim includes:  1) dispatch protocols; 2) call intake and dispatch information (especially nature of the call at dispatch); 3) evidence that the ambulance is staffed by an ALS crew; 4) evidence of a 911 type dispatch and an emergency response; and 5) evidence that an ALS assessment was performed by a paramedic.

Non-Emergency Calls. Ambulance field providers should be trained to make sure that in non-emergency transports Physician Certification Statements (PCSs) are completed by the sending facility and signed by the appropriate person.  The PCS should contain as much detail as possible about not just the patient’s mobility status, but also a description as to why transportation by ambulance service was medically required.  Billing personnel should be trained to look for incomplete or inaccurate PCS forms.  A procedure should be in place to ensure that incomplete PCS forms are completed by the appropriate person. 

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SNF Ambulance Services

(Rev.163, 4-30-04 )

SNF-516.2

The following ambulance transportation and related ambulance services for residents in a Part A stay are not included in the Part A PPS payment. Except for specific exclusions, consolidated billing includes those medically necessary ambulance trips that are furnished during the course of a covered Part A stay. Carriers are responsible for assuring that payment is made only for ambulance services that meet established coverage criteria.

In most cases, ambulance trips are excluded from consolidated billing when resident status has ended. The ambulance company then must bill the carrier directly for payment. Listed below are a number of specific circumstances under which a beneficiary may receive ambulance services that are covered by Medicare, but excluded from consolidated billing.

The following ambulance services may be billed as Part B services by the supplier in the following situations only.

• The ambulance trip is to the SNF for admission (the second character (destination) of any ambulance HCPCS modifier is N (SNF) other than modifier QN, and the date of service is the same as the SNF 21X admission date.);
• The ambulance trip is from the SNF after discharge, to the beneficiary’s home where the beneficiary will receive services from a Medicare participating home health agency under a plan of care (the first character (origin) of any HCPCS ambulance modifier is N (SNF)), and date of ambulance service is the same date as the SNF through date and the SNF patient status is other than 30;
• The ambulance trip is to a hospital based or nonhospital based ESRD facility (either one of any HCPCS ambulance modifier codes is G (Hospital based dialysis facility) or J (Non-hospital based dialysis facility) for the purpose of receiving dialysis and related services excluded from consolidated billing;
• The ambulance trip is from the SNF to a Medicare participating hospital or a CAH for an inpatient admission;
• The ambulance trip after a formal discharge or other departure from the SNF to any destination other than another SNF, and the beneficiary does not return to that or any other SNF by midnight of that same day; and
• Ambulance service that conveys a beneficiary to a hospital or CAH and back to the SNF, for the specific purpose of receiving emergency or other excluded services.

Note that ambulance trips associated with services provided in renal dialysis facilities (RDFs) are also excluded from SNF consolidated billing. Effective April 1, 2002 , payment shall be the amount prescribed in the ambulance fee schedule.

NOTE: A beneficiary’s transfer from one SNF to another before midnight of the same day, and ambulance transports to or from a diagnostic or therapeutic site other than a physician’s office or hospital (e.g., an independent diagnostic testing facility (IDTF), cancer treatment center, radiation therapy center, wound care center), are not excluded from consolidated billing. The first SNF is responsible for billing the services to the FI.

See Chapter 15 for Ambulance Services.

SNF BILLING

(Rev.163, 4-30-04 )

SNF-516.2, SNF QA Day4

The following ambulance transportation and related ambulance services for residents in a Part A stay are not included in the PPS rate. They may be billed as Part B services by the supplier in only the following situations.

• The ambulance trip is to the SNF for admission (the second character (destination) of any ambulance HCPCS code modifier is N (SNF) other than modifier QN, and the date of service is the same as the SNF 21X admission date.)
• The ambulance trip is from the SNF to home (the first character (origin) of any HCPCS code ambulance modifier is N (SNF)), and date of ambulance service is the same date as the SNF through date, and the SNF patient status (FL 22) is other than 30.)
• The ambulance trip is to a hospital based or nonhospital based ESRD facility (either one of any HCPCS code ambulance modifier codes is G (Hospital based dialysis facility) or J (Nonhospital based dialysis facility).
• The ambulance trip is from the SNF to another SNF (the first and second character (origin and destination) of any ambulance HCPCS code modifier is “N” (SNF)) and the beneficiary is not in a Part A stay.

Ambulance associated with the following outpatient hospital service exclusions payment is under the ambulance fee schedule:

• Cardiac catheterization;
• Computerized axial tomography (CT) scans;
• Magnetic resonance imaging (MRIs);
• Ambulatory surgery involving the use of an operating room;
• Emergency services;
• Angiography;
• Lymphatic and Venous Procedures; and
• Radiology therapy.

Finally, ambulance transportation for removal, replacement, and insertion of PEG tubes is an excluded service under consolidated billing for Part A and is not considered an SNF service. Therefore, that ambulance is also excluded from SNF consolidated billing (CB), and the service would be billed to the carrier under Part B.

When not subject to SNF CB, claims for drugs and EKG testing administered during a transport to or from a SNF are separately payable during the AFS transition period only in those carrier jurisdictions that allowed separate payment for J-codes and EKG testing prior to the implementation of the AFS. (Only Method 3 and Method 4 suppliers in carrier jurisdictions that allowed separate payment for these services prior to April 1, 2002 may bill separately for J-codes and EKG testing during the transition period.)

Carriers in those jurisdictions that allow separate billing for J-codes and EKG testing apply the appropriate reasonable charge percentage for the AFS transition year (40% in 2004) to the reasonable charge amount for these codes. (Because separately billable items are not recognized under the fee schedule, there is no FS portion for these codes.) In jurisdictions where separate payment for J-codes and EKG testing was not permitted prior to April 1, 2002 , carriers shall deny supplier claims for such services.

The following ambulance transportation and related ambulance services for residents in a Part A stay are included in the SNF PPS rate and may not be billed as Part B services by the supplier. In these scenarios, the services provided are subject to SNF CB and the first SNF is responsible for billing the services to the intermediary:

• A beneficiary’s transfer from one SNF to another before midnight of the same day. The first and second characters (origin and destination) of any HCPCS code ambulance modifier are “N” (SNF).
• A transport between two SNFs is not separately payable when a beneficiary is in a Part A covered SNF stay, and will result in a denial of a claim for such a transport. When billing for ambulance transports, suppliers should indicate whether the transport was part of a SNF Part A covered stay, using the appropriate origin/destination modifier (e.g., “NH” for a transport from a SNF to a hospital).
• Suppliers should bill with an “NN” origin/destination modifier when a SNF to SNF transport occurs. A transport between two SNFs is not separately payable when a beneficiary is in a Part A covered SNF stay, and will result in a denial of a claim for such a transport.