Novitas Obviously Does Not Understand Modern EMS

Ok, this gem appeared in my mailbox today.

I will have a couple of comments after jump as well, but the problem with this policy bulletin is that it does not take into account what routinely happens in cardiac arrest scenarios, especially in progressive EMS systems.  Specifically, what happens when an ALS provider arrives on scene with a patient in cardiac arrest and the resuscitation is not successful in the field? Well, I was an EMS Supervisor for the Houston Fire Department for almost 6 years before I retired and a Paramedic my entire career. For the ENTIRE time I was a supervisor, we would work many cardiac arrest calls and NOT transport if the resuscitation was not successful in the field.  This is a generally accepted practice.

But reading this Bulletin, it appears that Novartis only believes that this should be paid at the provider’s BLS rate! I know that CMS defines the ambulance benefit as a “transport” benefit, but this is monumentally foolish with regards to a modern EMS system. And they don’t even address this issue in the bulletin as neither example provided  reflects the reality of a significant number of the cases actually occurring in the field.

The FULL text of the Bulletin after the jump:

Ground Ambulance Transport Services and Deceased Beneficiaries

Issued: April 15, 2013

Novitas Solutions, in concert with the Centers for Medicare & Medicaid Services (CMS), is continuing to focus on lowering the Comprehensive Error Rate Testing (CERT) claims paid error rate. Currently, one area of concern identified in the CERT data is the denial of ground ambulance transport in regards to a deceased beneficiary.  This has lead to the recoupment of overpayments by Novitas Solutions totaling over $1,949.27. More importantly, when CMS and CERT extrapolate these errors to the universe they will account for approximately $9,746,350 million, in claims payment errors for the November 2013 report.

Medicare defines ambulance services as:

The Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service.”

Medicare defines Ground Basic Life Support (BLS) Ambulance Service as:

transportation by ground ambulance vehicle and the provision of medically necessary supplies and services, including BLS ambulance services as defined by the State. The ambulance must be staffed by an individual who is qualified in accordance with State and local laws as an emergency medical technician-basic (EMT-Basic). These laws may vary from State to State or within a State. For example, only in some jurisdictions is an EMT-Basic permitted to operate limited equipment onboard the vehicle, assist more qualified personnel in performing assessments and interventions, and establish a peripheral intravenous (IV) line.”

Medicare defines Ground Advanced Life Support (ALS) as:

 ”transportation by ground ambulance vehicle and the provision of medically necessary supplies and services including the provision of an ALS assessment or at least one ALS intervention An advanced life support (ALS) assessment is an assessment performed by an ALS crew as part of an emergency response that was necessary because the patient’s reported condition at the time of dispatch was such that only an ALS crew was qualified to perform the assessment. An ALS assessment does not necessarily result in a determination that the patient requires an ALS level of service. An advanced life support (ALS) intervention is a procedure that is in accordance with State and local laws, required to be done by an emergency medical technician-intermediate (EMT-Intermediate) or EMT-Paramedic.”

Documentation of ambulance services must also provide the medical necessity of the service.  The CMS Internet Only Manual (IOM) directs the following:

Medical necessity is established when the patient’s condition is such that use of any other method of transportation is contraindicated. In any case in which some means of transportation other than an ambulance could be used without endangering the individual’s health, whether or not such other transportation is actually available, no payment may be made for ambulance services. In all cases, the appropriate documentation must be kept on file and, upon request, presented to the carrier/intermediary. It is important to note that the presence (or absence) of a physician’s order for a transport by ambulance does not necessarily prove (or disprove) whether the transport was medically necessary. The ambulance service must meet all program coverage criteria in order for payment to be made.”

CMS provides the following direction for the situation when the ambulance provider finds the beneficiary to be deceased upon arrival at the scene:

“Because the Medicare ambulance benefit is a transport benefit, if no transport of a Medicare beneficiary occurs, then there is no Medicare-covered service. In general, if the beneficiary dies before being transported, then no Medicare payment may be made. Thus, in a situation where the beneficiary dies, whether any payment under the Medicare ambulance benefit may be made depends on the time at which the beneficiary is pronounced dead by an individual authorized by the State to make such pronouncements.”

This is where the real problem is – considering the ambulance transport as a “transportation” function and not a “healthcare” function. This is why EMS is undervalued, IMHO, in the healthcare world and by CMS!

CMS gives guidance as to payment of an ambulance provider in the case of a deceased beneficiary.  Payment is dependent upon the timing of the beneficiary’s death and when the ambulance was dispatched.

  • If the beneficiary is pronounced dead prior to the ambulance dispatch, there is no payment by Medicare.
  • If the beneficiary is pronounced dead after the ambulance is dispatched, but prior to the beneficiary being loaded on the ambulance, then the provider’s Basic Life  Support rate, no rural or mileage adjustment, is paid and the ambulance provider is to use the QL modifier on the claim.
  • If the beneficiary is pronounced dead after the ambulance pick up and prior to the arrival at the receiving facility, then the ambulance services are paid at the medically necessary level of care furnished and supported in the documentation.

Upon clinician review, by the CERT contractor, the documentation supports that the beneficiary was already deceased at the time the ambulance provider was called.  In one such case example, the documentation noted that the beneficiary was pronounced dead two hours prior to the ambulance being dispatched.  The ambulance crew returned to their station and did not transport the beneficiary.  In this case, the ambulance provider cannot bill Medicare per the above stated guidelines.

In a second example, the ambulance provider was called and dispatched for a beneficiary who was unresponsive and having shallow breathing.  Upon arrival the ambulance crew finds that the beneficiary has a do not resuscitate order and that the attending physician was in agreement with the do not resuscitate orders and instructed that CPR not be performed.   The ambulance crew returned to their station and did not transport the beneficiary.   In this case, the ambulance provider can bill their Basic Life Support rate only and should append the QL modifier to the claim line.

This is the only examples that they could find? See above for an equally common, if not more expensive case. 

The key to proper billing of ambulance services in the situation of a beneficiary’s death is the timing of the pronouncement of the beneficiary’s death and the documentation to support whether or not this occurred prior to the ambulance being dispatched, after the ambulance was dispatched but prior to the beneficiary being loaded into the ambulance for transport, or after the beneficiary is loaded on the ambulance for transport but prior to the arrival at the receiving facility.

It is our goal at Novitas Solutions to have claims paid correctly and to lower the CERT rate.  If additional questions arise, providers can contact Novitas Solutions’ Provider Outreach and Education Department.


CMS Internet Only Manual, Publication 100-02, Chapter 10 *

I believe that my former employer, the City of Houston Fire Department, will lose more than $100,000 in reimbursement from CMS as a result of this bulletin. For 911 agencies already on the brink of financial solvency, this may be enough to send the companies over the edge. And from a healthCare perspective and a public safety perspective, it is truly not justified because it will cause more transports, because providers will adjust policy to chase that shrinking reimbursement dollar when it isn’t justified from a medical or (really more important) public safety standpoint.

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