Ambulance Coding & Billing: Emergency Medical Treatment and Labor Act

EMTALA (Emergency Medical Treatment and Labor Act) is inextricably intertwined with ambulance coding, billing and reimbursement, and the ambulance providers should keep up with EMTALA even though it has few minor problems like the time gap that occurs when the patient is offloaded from the ambulance and get into the hospital. Now, billing for ambulance services is complex, and the ambulance provider needs to take a stance when they’re filing documentation claim. In addition, the state laws is another area of concern to the ambulance provider, as the Medicare program at the national level will always require certain levels of equipment, certain levels of technical personnel and you may have state laws and even local regulations that will come into play. And this can affect what you do. The providers need to follow whatever rules and regulations there are. For instance, you are in an area that requires ALS response and the ALS will respond back but it may only be necessary to have a BLS service. And therefore, that's all you're going to get paid for. Ambulance coding and billing see many compliance issues such as medical necessity coverage ABNs, EMTALA. For any ambulance provider taking care of the patients is their first priority, apart from coding & billing, documentation, rules & regulations, and laws. So, no matter what you do, take good care of your patients rest will fall in place.

There are many types of ambulance services— BLS, the basic and then the advanced, emergency versus nonemergency, specialty care transport, mobile intensive care unit, and also the paramedic intercept. The paramedic intercepts always reach the spot first in case something happens, along with the fire folks, and then shortly behind, the hospital ambulance that will also go out and then do the transport. Hospital ambulance have different modalities— ground, water, air etc, the Air can be fixed wing or a rotary wing, and many hospitals have nice helicopters. Now, the ambulances also have other equipment that goes with the services, like the technicians, the EMTs which could be basic intermediate paramedic. Again, this depends a little bit upon state law and then of course Medicare will follow whatever the state laws mandate relative to their qualifications. And then we also have specialized nursing staff when you get into some of these very high level transport where we have to use specialty trained nursing staff.

It’s imperative to get understand the process of pickup to off-load. In other words, Medicare program will only pay you for a transport, an ambulance transport if you actually put the patient on the ambulance. You have to get them inside the ambulance, so, it's from pickup to offload—and that's what they're going to be paying for. Moreover, when it comes to ambulances, things are measured in statute miles, according to the latest medical audio conferences. It’s essential to know the miles used in land, water and air.
Another vital point in ambulance services is to understand the point of pickup, it’s important because of the certain real add-ons and this gets back in the zip code requirement. If you're an independent ambulance provider and you're billing the Medicare geographic carrier, you may also get into the fact that you driven out a ways, you pick up the patient and then you take them someplace else. You could cross jurisdictional lines. But just be aware of that point of pickup is not only important. But your home station may also be important. In addition, always remember the date of service should always be DOS— not SOS. Now, this can get a little complicated— suppose you're out there at an accident site and you're loading the patient, you better make sure you get them in there before midnight or definitely wait until after midnight, otherwise, you know, you could have some difficulty in determining exactly what the date of service is. Providers are always getting in trouble with DOS, hence it is crucial to be explicit about the date.

Acronyms Used in Ambulance Services
When it comes to ambulance services, it’s essential to know some acronyms – AFS, RVUs (relative value units), and more. The Ambulance Fee Schedule is based upon relative value units. Also, there is Geographic Adjustment Factors. Interestingly enough, the ambulance fee schedule uses what's called GPCIs. And this is part of RBRVS, the Resource Based Relative Value System for physicians. And there are three different GPCIs. And we use the practice expense GPCI in order to adjust geographically the payment for ambulance services. And, then we Rural Adjustments, this year we have an inflation of 5%, which is pretty good. And then of course we have to have a conversion factor.

Ambulance service and fee schedule goes hand in hand; always remember with fee schedules, if your payment is lesser, lesser of the amount charged for the fee schedule amount. If for some weird reasons you don’t charge at the full level of the payment amount, they'll pay you the lesser. Hence, it’s important to make sure your charges are at level that is above the fee schedule payment amount. Now, particularly for hospital folks we become so accustomed to the perspective payment systems where we get paid the full amount no matter what we charge. This is a little bit different. The new ambulance fee schedule is generally inclusive of supplies. So a lot of these supply issues and re stocking issues and other things like that kind of go away at least relative to the Medicare ambulance fee schedule. There are two parts. There's a base rate depending upon the level of service being provided and also being medically necessary to be provided. And then there's a mileage rate. So it's divided into two parts. In addition, zip code is very important because that drives the possible application of the rural incentives and the geographic adjustment factor. The system requires as with most Medicare fee schedule is updated annually. And then we seem to constantly have congressional involvement. They keep throwing in little things about the latest of which came from MIPPH 2008, the Medicare Improvement for Participants and Providers Act of 2008. We have some changes there once again. So you'll have to keep up with the legislative mandates as well. Always remember that you can be paid for ambulance services depending on who you are either by the carrier or the fiscal intermediary. The orientation today will be a little more towards hospitals and the fiscal intermediaries. But same information is necessary for either claim filing process.

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