In prior urgent message we discussed some of the changes to your documentation in support of non-emergency and/or frequent flyers.

What is a frequent flyer?  Repetitive transports of same patient.  In an unofficial statement made at various conferences within this past week it has been defined as such:

ANY patient transporting more than 12 transports within one year to and from dialysis will result in facility providing transport to process an AUDIT.

ANY patient transporting more than 8 combined non emergency and/or emergency transports within one year will result in facility providing transport and exponentially ,facilities providing care to process an AUDIT as to why this patient requires so many transports and how it can be resolved.

IF any facility transports a gross percentage of all transports submitted to Medicare as frequent flyer you are being notified by letter of audit requirements, time frames and resulting responsibilities. In addition information received would indicate that any patient under audit will not be paid until audit is complete.  At that time, and only at that time, will facility be notified of paid or denied?  Following existing Medicare guidelines for auditing or review of medical necessity you, the facility, could be looking at 30-180 days depending on depth needed for review.

What does this mean for many non-emergency transport facilities?  YOU WILL BE OUT OF BUSINESS

Because you made a choice to provide transport services to a single population, you have effectively shut yourselves out of many valid populations.

For facilities that did not put their eggs into one basket but made sound business practice decisions, you are still going to process audits but only those audited will be held, you will still maintain a semblance of revenues.

In disclaimer, this information is not in print anywhere.  Medicare has not made any attempt to notify anyone in writing as of yet.  EFFECTIVE DATE:  APRIL 12, 2012.  Surprise Surprise!! This information has, again, been gathered from a variety of resources, people in the industry, seminars, meetings, conventions within just this past week.  This information was also gathered from multiple states.

You will be kept informed as information becomes available.  MAXimize will do everything possible to assist you with your audits but these audits are the FULL responsibility of facilities providing transport.

Who is going to be affected?   BILLING AGENCIES, HOSPITALS, NURSING FACILITIES, MEDICAL SUPPLIERS, VEHICLE LEASING AGENCIES, THE JOB MARKET, EMS PROGRAMMING SUPPLIERS, CLEARINGHOUSES and many more.

The last 10 years of rushing to get the Medicare money given freely for dialysis and other non-emergency transportation is now at an end.  Frequent flyers as these non-emergency transports are affectionately known as, will now have to utilize other means of transport.

The hospital discharge will no longer be able to go by BLS/stretcher transport just because they were called.

The statement “but I have a medical necessity” will not hold water.  No longer will EMS be used like a taxi service.

Everyone must share in the responsibility, and everyone will share.  The trickle down effect will take hold very shortly.

Emergency transports are not being left out of these changes!  Medicare and other carriers (Medicare is in the lead on these issues) are now wondering why particular patients must be taken to the ER by stretcher and discharged by stretcher so many times in one year?  What care is not being provided or what service is not being performed at nursing facilities that is causing this patient to be transported so often.  Now that is a real trickle down!

How are you going to be affected?

For example:  patient was reviewed head to toe patient has open leg wounds and heel wounds, complains of extreme pain level 7 of 10 requires special positioning to alleviate pain.

Critique:  while this brief narrative clearly indicates sufficient documentation for stretcher transport I would give this scenario a C in grade.  Why?  Exactly WHY does this patient have extreme pain 7/10; leg wounds and heel wounds do not preclude chair van transport; insufficient explanation of pain.

Same scenario:  Miss Mary complains that her pain level is high today 7 of 10.  We noticed her open leg wounds and heel wounds appear to be healing but are still weeping with a noticeable odor.  It is noted in past medical history that Miss Mary is mrsa positive, special wound precautions are taken.  When we moved Miss Mary to the stretcher she exhibited increase in pain and needed to be transported with special positioning with pillow between knees to alleviate some of pain.  Joints appear to be swollen and warm.  Miss Mary appears to be alert and aware of her surroundings at this time.

Nothing different, just in story form and humanized.

Medicare is asking that you transfer a sense of your transport so that they can see what you see; feel what you feel; and understand a situation that they cannot see.

Medicare is not asking you to DIAGNOSE your patients.  The billing office is not asking you to DIAGNOSE your patients.  Medicare and your billing office ARE asking you to give enough information to make an informed decision to allow appropriate coding of that transport to current guidelines.

Medicare has clearly indicated that the need for transport TO medical care is different than the need for transport FROM medical care.  This is requiring you to be even more explicit in your information on return transports; discharge transports and hospital to hospital transfers.

If you have any further questions or require additional information, please call for open discussion.

We ask that you open your mind to change; we ask that you consider making these minor changes to assist in appropriately coding your transports.

In the last seven months Medicare has made so many changes that you are overwhelmed; completely understood.  Now Medicare is trying to tighten up the drawstrings on your livelihood even more to the point that you are questioning your business viability.

Medicare is asking you to go against everything you have ever been taught regarding medical documentation for stretcher transportation.

Change is difficult.  These changes pertain to emergency and non-emergency and transports, including BLS, ALS and SCT.

Because emergency services are most likely mandated to transport and treat we will address non-emergency transports here.  MAXimize is happy to work with emergency transport agencies as well.

You currently are operating off a basic SOP for documentation of transports emergency and non-emergency.

Effective April 12^th, these transports are being denied in massive numbers, disabling your business to the point of layoffs, inability to meet payroll, taxes, and growth expectations.

Let’s look at this in a different way.  We are not asking you to delete your SOP for documentation.

You still need to have head-toe, vitals, patient medical history, medications and transport method, treatment during transport and transfer to end location notes.  It’s all about the HEAD to TOE!

Let’s face it: the notes you are providing do not relate to the reason for stretcher transport at that moment.

How do these words reflect what you are seeing, with your own eyeballs, at any given particular moment:  may, could, potential, possibly, due to past med hx, history of and, the very worst statement, see prior notes on file.

Your transport today must reflect what you and your patient are doing today.

Let’s separate the two issues here.

(1)  Your need to support standard operating procedures for transport notes

(2)  Medicare’s need to prove the need for stretcher transport to maximize expenditure of funds

It is STRONGLY SUGGESTED that you change your transport note format slightly:

(a)   Do your standard transport note, including everything BUT your head to toe and vitals.

(b)   Keep your vitals ONE LINE; past medical hx to ONE LINE; medications to ONE LINE

(c)   Keep your actual transport notes to a 3-4 line space at the end of NARRATIVE

(d)   Put your HEAD TO TOE as your narrative giving definitive current information regarding your patient.

(e)   And above all RE-HUMANIZE your patient.

Items (a) and (c) would include patient pick up description, movement description, transport and treatment during transport and transfer to end location information.

Item (b) include three lines for vitals, past med hx and medications, self explanatory

Item (c) is your current problem, and one you need to look at very, very closely.  If you have a completely innocuous, no issues seen head to toe why are you transporting this patient by stretcher?  Because you have a medical necessity?

A medical necessity is a piece of paper, many times given to you blank with a scribbled or photocopied signature.  This medical necessity is invalid.  Medicare and many carriers following Medicare guidelines now require PRINTED NAME, LICENSURE (ie MD RN NP etc) and a PHONE NUMBER  of person who is signing the medical necessity.  The medical necessity does not absolve you or prevent you from using your own judgement!

You are a professional and as such, have been well-trained in observation skills.  Use those skills.

Your head to toe statement is your narrative.  This narrative must tell a story of why your patient requires skilled transport levels.  Build this narrative as a story, starting at the top explain why your patient must be transported by stretcher to destination.  Talk to your patient not just your visual observation but also use your ears and listen.  Listening is observation as well.  Skimming over this narrative and writing a standardized blurb is not going to work.

The reality is you are going to give up some of your patients.

The reality is you are going to lost some of your round trip transports and only transport on the return service.

 IMPORTANT NOTICE FROM:

Page Wolfberg & Wirth

Novitas, the Medicare Administrative Contractor (“MAC”) for Jurisdiction 12 (covering Pennsylvania, Maryland, New Jersey, Delaware and Washington DC), released a new “Local Coverage Determination” (“LCD”). This “LCD” went into effect on April 12, 2012. It is available <HERE.  The LCD establishes new payment procedures that now require ambulance services to use Novitas-approved ICD-9 codes in order for the claim to be paid.

Included in this LCD is a list of about 100 “approved” ICD-9 codes.  At least one of these must appear on the claim for the claim to be considered “medically necessary.”  Claims submitted since April 12, 2012 without one of these ICD-9 codes are being denied.  Click <HERE to find out how to address this with your organization.

We are urging Novitas to eliminate their local list of ICD-9 codes and rely solely on the published Medicare Ambulance Condition Codes which have worked well over the years and were established to provide a consistent standard for processing ambulance claims.

Remember, this LCD only affects ambulance providers and suppliers in MAC Jurisdiction 12. However, note that later in 2012, Novitas Solutions will be replacing TrailBlazer as the Medicare Administrative Contractor for Jurisdiction H (Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma and Texas). Additionally, other MACs covering other Jurisdictions are always able to adopt Local Coverage Determinations that may affect your billing practices.

Additional questions:

MAXimize Inc

Toll free: 877-731-5464

Toll free fax: 800-234-1627

Email Us Directly: Maxbilling@verizon.net

MAXimize integrates iTech’s expEDIum

After many months of research MAXimize has made the decision to go with iTech’s expEDIum Medical Billing Solution; a web based billing and cash posting program.  We have found this programming to be malleable to our needs which is crucial when changing over from our in-house proprietary programming.  MAXimize will now be able to offer many new services to our EMS and Fire Clients, achieving multiple goals within the next 30-60 days.  As we integrate our clients into the new billing systems, we will be able to allow clients to directly log in to their own facility, review, search, set up checks and balances within their internal system base.   We are very excited!

Working with iTech’s expEDIum programming has been remarkably seamless.  The expEDIum team is there for us, understands the specific needs of EMS and Fire billing and revenue flows.

ITech and our business partner emsCharts are now beginning a working relationship.  How is this news important to you and our clients?  emsCharts is the premier electronic data collection and management solutions for the emergency medical field.  With this correlation of services, not to mention the fact that MAXimize covers client expense for data collection and storage, you will soon be hearing about a huge triple threat in the EMS and Fire industry.

To go one step further, MAXimize is using Office Ally as our new clearinghouse strengthening services offered to our clients by correlation of cash posting and pre-send scrubbing of all claims.  Claims go out once, and are paid lowering the denial rate, already the lowest in the industry, at 1.8%, even more.  More claims are going out electronically dramatically lowering days to pay for more carriers.

MAXimize is excited about these many changes, with this team in place, and adding the skills of our loyal employees, we see great things happening in our future!

Highmark Medicare Part B has been taking back mileage for any patient transported to, or from, a nursing facility in error stating that mileage was billed to incorrect contractor, and requesting you to re-bill.

This is a know program issue at Highmark Medicare Part B for ambulance services, and is being worked on.

Do not re-bill.

Do not write off this money.

Do not bill the facility.

Corrections will be forthcoming.

WEBCAST ~ 01/18/2012 01:00 PM Eastern Standard Time REGISTER

This webcast from JEMS will be presented by Steve Wirth and Doug Wolfberg and will focus on essential documentation points you need to cover with no-transport situations.  Whenever you don’t transport a patient, it’s essential to follow an established protocol to ensure that your biases and other subjective factors don’t take over when you’re dealing with the patient. And the quality of your documentation may be what helps save you in the event of a lawsuit.

Doug and Steve have years of experience in the field and in dealing with these situations from the legal side as well. Their firm represents hundreds of EMS agencies of all types across the nation. Don’t miss this valuable and practical webcast!

Register today and learn what has become easier for field providers and what you still need to be diligent about as an EMS professional.

Doug Wolfberg and Steve Wirth are attorneys with Page, Wolfberg & Wirth LLC, a national EMS-industry law firm. Visit the firm’s website at www.pwwemslaw.com for more EMS law information.

MAXimize Ambulance Billing Inc.

During the most recent holiday season — the season of giving — the Centers for Medicare & Medicaid Services (CMS) actually gave what could be construed as a holiday gift by taking something away.

On Dec. 28, 2011, CMS announced that it was delaying what many thought would be a contentious issue — the prepayment review demonstration. In the same announcement, CMS said it also was delaying the implementation of the Prior Authorization of Power Mobility Devices (PMDs) demonstration. The agency hastened to add that the Part A-to-Part B rebilling demonstration would remain as scheduled and would begin on Jan. 1, 2012.

Citing the fact that it had received many comments about both demonstration programs, the agency said that it would “consider these comments carefully” and that it would provide “at least 30 days notice before the demonstrations begin.”

The Pile-on

Among those who were challenging CMS on the two issues were 24 members of Congress, including veteran U.S. Reps. Charles Rangel (D-NY) and physician Michael C. Burgess (R-TX). In a Dec. 15, 2011 letter to acting CMS Administrator Marilyn Tavenner, the representatives cited efforts Congress made last year to reduce pricing for powered mobile devices (PMD) while at the same time increasing program integrity requirements for Medicare suppliers.

“On January 1, 2011, Congress mandated that all Medicare Group 2 standard power wheelchairs be converted to a 13-month rental item requiring businesses to obtain substantial outside capital,” the representatives wrote. “Including a demonstration project to the requirements in place could harm seniors that depend on durable medical equipment to live independently in their own homes.”
“We encourage you to halt the prepay review demonstration project due to the potential threats to businesses, jobs and seniors’ access care,” the letter read.
The correspondence appeared to lump the PMD prepayment demonstration with the inpatient Recovery Audit Prepayment Review demonstration.

On Dec. 29, 2011, the American Association of Homecare posted a news alert stating that, as a result of “intensive collaboration” with CMS and its organization (AAHomecare), CMS elected to delay the PMD demonstration. In its news alert, AAHomecare’s vice president of government affairs, Walt Gorski, was quoted as saying “we are pleased that CMS has taken a deep breath to better understand the power mobility sector and the impact that any widespread prepayment review would have on Medicare beneficiaries and homecare providers.”

The news alert stated that, when the program was announced by CMS on Nov. 15, 2011, the association began working with its members, physicians, consumers and members of the Complex Rehab and Mobility Council (CRCM) who would have been affected by the demonstration.

Prior Authorization for PMDs

According to CMS, the Prior Authorization would affect scooters and power wheelchairs for Medicare beneficiaries in seven states the agency previously has identified as having large numbers of fraud- and error-prone providers: California, Illinois, Minnesota, New York, North Carolina, Florida and Texas. This demonstration, CMS noted, would have helped to ensure that a beneficiary’s medical condition would warrant their medical equipment falling under existing coverage guidelines. Moreover, the program would assist in preserving a Medicare beneficiary’s right to receive quality products from accredited suppliers, the agency said.

Prepayment Review Demonstration

As described by CMS, the Recovery Audit Prepayment Review would have allowed the RACs to review claims before they were paid to ensure that providers had complied with all Medicare payment rules. The RACs then would have conducted prepayment reviews on certain types of claims that historically have resulted in high rates of improper payments.

In addition to the aforementioned California, Illinois, New York, Florida and Texas, CMS noted that these reviews also would have focused on the state of Louisiana. The agency also identified four states with high claims volumes of short inpatient hospital stays, naming Pennsylvania, Ohio, North Carolina and Missouri. A total of 11 states had been targeted for the demonstration, which since has been delayed until further notice.

“Considering the amount of time it takes to get to the Administrative Law Judge (ALJ) level of appeal — well over a year— it is good that the program is delayed,” Andrew Wachler, Esq., principal of Wachler & Associates, told RACmonitor. “And that’s because (of) the effect that prepayment review has on a hospital’s cash flow.”

This article was written by Chuck Buck    and other articles like it can be found on RAC Monitor.

CMS Will Delay Enforcement of 5010 Standards Compliance

Update courtesy of Page, Wolfberg & Wirth

On November 17, 2011, CMS announced a 90-day enforcement “grace period” for compliance with the new HIPAA 5010 transaction and code set standards.  This means that CMS will not initiate enforcement action against providers that are not in compliance with the 5010 standards until Saturday, March 31, 2012.

This is welcome news for many providers that are rushing to ensure they are ready for the transition at the end of this year.  Ambulance services that engage in covered electronic transactions, like claim submissions, are required to begin using the new 5010 standards as of January 1, 2012.  The new standards will enable providers to transition from the current ICD-9 codes to the new ICD-10-CM codes in October of 2013.

Despite the enforcement delay, CMS emphasizes that the official compliance date for use of the new standards remains Sunday, January 1, 2012.  At our upcoming spring abc3 conferences, PWW will discuss what the transition to ICD-10 codes will mean for the ambulance condition codes and discuss effective solutions your service will need to prepare for the switch to ICD-10 .

Click HERE to discover what late-breaking topics will be covered at spring abc3 and to register for this exciting event.