Helpful Questions to Determine Legal CPT Base Rate Codes for Ambulance Billing
Legal Ambulance Billing
Before getting started with the how-to of determining the correct base rate CPT code for an ambulance claim, let me first establish that every ambulance claim should first be examined to ensure all legally required elements have been met. For example, the ambulance patient care report (PCR) should have a patient's name, date of service, and all required signatures from the time of service. In addition, the transport should have actually occurred. Fraudulent billing is considered illegal by all government agencies, especially the Centers for Medicare and Medicaid Services (CMS), and is punishable by law with prison, fines, or both. If these basic requirements on the PCR are not met, make sure the claim is not billed to CMS without these requirements present.
All examples here are examples only. The advice herein is my own advice as someone with many years of experience in ambulance billing. If any issues arise, CMS or the ambulance service's attorney should be contacted.
Emergency versus Non-emergency?
One of the first questions to ask is whether the transport is an emergency transport or a non-emergency transport. What is the origin? What is the destination? Many times (but not always) these two questions will guide you in your quest to provide the appropriate code. If the patient was transported from their home to a nearby hospital emergency room, this is probably an emergency. If the patient was transported from a hospital back to that patient's skilled nursing facility, it is more than likely a non-emergency transport.
Was the patient taken to a lower level of care (residence) to a higher level of care (hospital ER)? This may help support an emergency determination.
Was the patient transported from a higher level of care (hospital inpatient) to a lower level of care (nursing home)? This will help support a non-emergent determination.
What about scheduled versus non-scheduled transports? This may sound repetitive after reading that last paragraph, but to those in the ambulance billing community, they will know it is a related issue, but still separate. Was the transport scheduled in advance? If it was, how long ago was it scheduled? According to CMS's definition, a transport must have been scheduled (someone contacting the ambulance service and arranging a time and date for pick up while giving patient-identifying information) at least 24 hours in advance of the transport. This means it can be scheduled for a week in advance, which is seen many times in the case of a hospice respite care transport.
If the ambulance service is contacted on Monday at 10:00 AM and they are notified of a transport on the following day at 11:00 AM, that is a scheduled transport since the transport is 25 hours away. However, if that same phone call schedules a transport for that same Monday afternoon at 3:00, that transport, according to CMS, is a non-scheduled transport since only five hours' notice was provided.
In the case of the scheduled transport, that is a non-emergent transport. If the transport does not meet the requirements for being a scheduled transport, then it is considered to be an emergency when determining the correct CPT base rate.
BLS versus ALS
Basic Life Support (BLS) and Advanced Life Support (ALS) is different and they have different CPT codes and reimbursement amounts. This part of the evaluation is just as important in determining the correct CPT code. If the code is partly right and partly wrong, it's still the incorrect code for that transport and makes your entire claim to be in error.
When evaluating the PCR, it should be determined which interventions have been made that were required for the patient at the time of transport as well as which certified healthcare provider made those interventions. Different states have different guidelines that define the scope of practice for ambulance crew members, so be sure to familiarize yourself with the correct information for your area.
Each type of licensed healthcare provider on that call has a certain scope of practice they are legally allowed to operate within and the interventions are matched to the licensure of that provider.
For example, the patient's condition required the EMT to provide oxygen therapy and for the paramedic to perform IV therapy, that claim is legal to be filed as an ALS claim.
For example, EMTs are allowed to provide oxygen therapy, but are required to have extra training (such as becoming licensed as a Intermediate EMT) to perform interventions outside the EMT's scope of practice.
Paramedics are allowed to start IVs and perform cardiac monitoring within their scope of practice. But, as with EMTs, extra training is required for that provider before they can legally operate and/or monitor an IV pump or a CPAP machine.
I said all that to say this. To put much more simply, EMTs perform BLS interventions, Intermediates can perform BLS and certain ALS interventions and paramedics perform BLS and ALS interventions, as well as ALS II interventions (these require extra training).
These questions can be used for every ambulance claim to select the appropriate CPT base rate code for the claim. Was it a scheduled transport according to the Medicare definition of "scheduled"? Was it an emergency or non-emergency? Is the claim considered BLS or ALS based on the patient's condition at the time of transport and the healthcare provider who performed that intervention?
I know this is all confusing and can be overwhelming if you are just beginning your career as a biller, but with time it will get easier for you. Just keep using what you've already learned to continue to build your knowledge base. I hope this has helped you just a little to clarify all the seeming mumbo-jumbo on CMS's website!
What are your thoughts or comments? If I can clarify something for you, I'd love to do that. Did this article help you or just confuse you further? Please let me know what your thoughts are so I can be of more use to you in future articles because I really love ambulance billing! Thanks!
This content is accurate and true to the best of the author’s knowledge and does not substitute for diagnosis, prognosis, treatment, prescription, and/or dietary advice from a licensed health professional. Drugs, supplements, and natural remedies may have dangerous side effects. If pregnant or nursing, consult with a qualified provider on an individual basis. Seek immediate help if you are experiencing a medical emergency.
© 2017 Diana Majors