Trailblazer Posts Notice Regarding Ambulance Dialysis Transport

Today, Trailblazer issued a notice the the ambulance supplier community regarding transports to and from dialysis.  Basically, Trailblazer is stating that based on alleged over utilization of ambulance transportation services for a residence to dialysis center transport (RJ and JR modifiers), they will pay the first 12 claims of the year without documentation.  After that, they will deny the transports and the supplier will have to respond via the Medicare appeals process.

New for this year is that Trailblazer will treat SNF and nursing home patients (NJ, JN, EJ and JE modifiers) being transported to dialysis in the same way they treated residence-based patients last year.  The difference here is that especially for the SNF patients because of the global payments that SNF units receive to treat these patients, the individual may not be responsible for the charges – the facility may be responsible.  This opens up tow issues – first, will SNF units even accept dialysis patients that require transport to dialysis and second, will they be willing to pay the medicare allowable charges to avoid implication of the Anti-Kickback Statute.

If you do not have a Compliance Plan in place for your Ambulance Service, it is very likely that issues like this will cause you problems in the new fiscal year.  Stay tuned for an announcement of a webinar covering the coming requirements for compliance plans tenatively scheduled for mid-July!

The notice from Trailblazer is after the jump (links are active):

June 27, 2011
TrailBlazer Health Enterprises® is issuing this listserv to notify the Part B community of important updates concerning ambulance services.
The links contained in this listserv may direct you to sites other than TrailBlazer®.

« Part B

Texas Ambulance Transports

Automated Denials for Non-Emergency Ambulance Transports in Texas: Modifiers RJ and JR – TrailBlazer has identified a potential overutilization of HCPCS code A0428 (non-emergency ambulance transport services), billed with modifiers RJ and JR, and its associated services (e.g., A0425) across the provider community in Texas.

We will implement the “Utilization Guidelines” in the Ambulance LCD for transports billed with RJ and JR modifiers effective on or about July 1, 2011, for services rendered January 1, 2010, and after. We will allow the first 12 trips (per year) without documentation if the medical necessity in the Ambulance LCD is met. Starting with the 13th trip, transports will be denied. If the supplier disagrees with the denial and has the documentation to support the medical necessity of the transport, a redetermination will need to be submitted. For information and guidelines on submitting appeals, refer to the TrailBlazer Redeterminations Web page and the Redetermination Request Form.

Note: Please do not send documentation with the initial claim. Documentation should only be sent with the redetermination.

For additional information, refer to the “Utilization Guidelines” section in the Ambulance Services (Ground Ambulance) LCD posted on our Web site.

TrailBlazer Will Implement a Service-Specific Audit

Non-Emergency Ambulance Transport Billed With Modifiers JN, NJ, EJ and JE Medical Review Results – TrailBlazer has identified a potential overutilization of HCPCS code A0428 (non-emergency ambulance transport services), billed with modifiers JN, NJ, EJ or JE, and its associated services (e.g., A0425) across the provider community in Texas. A widespread probe review was conducted recently to verify if this perceived overutilization was actual. Complete details of the review are available in the notice linked above.

Based on the results of this review, TrailBlazer will implement a service-specific audit for ambulance services in Texas billed with modifiers EJ, JE, JN and NJ. This audit will be effective on or about July 1, 2011. Education will be provided based on medical review results.

TrailBlazer could request documentation for ambulance claims filed with modifiers EJ, JE, JN and NJ. Once we receive the documentation, a determination will be made to pay or deny.

Note: Please do not send documentation with the initial claim; if we need the documentation, we will request it.

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