Documenting Emergent Scenarios Post October 1

If you’re a regular reader of this space you are aware that we focus A LOT on medical necessity, especially as the definitions contained in the rules pertain to Medicare. With anywhere from 40% to 60% or upward of the average ambulance reimbursements being derived from Medicare Fee-for-Service or Medicare Advantage plans it is important to understand that there are strict guidelines on how to document the patient conditions in order to submit a claim for payment.

One of the largest Medicare Administrative Contractors (MACs), Novitas Solutions, has already published their Local Coverage Determination to begin on October 1, 2015 (ICD-10 implementation day.) In it, we see some key areas that all of us in the ambulance world must adhere to with the inception of the new coding initiative which provides payers to redefine justification for payment. We’ve said it before, but it all boils down, once again, to the level of detail in the documentation provided in the Patient Care Report.

Emergency Ambulance Services
While these rules have been in place, we see there has been some interesting focus placed in the actual wording of the guidance provided.

“The patient’s condition is an emergency that renders the patient unable to be safely transport to the hospital in a moving vehicle (other than an ambulance) for the amount of time required to complete the transport. Emergency ambulance services are services provided after the sudden onset of a medical condition. For the purposes of this LCD, acute signs and/or symptoms of sufficient severity must manifest the emergency medical condition such that the absence of immediate medical attention could reasonably be expected to result in one or more of the following:

  • Place the patient’s health in serious jeopardy.
  • Cause serious impairment to bodily functions
  • Cause serious dysfunction of any body organ or part”
Documenting Emergent Scenarios Post October 1
Let’s dig in and dissect…
Let’s dig in and dissect this portion of the definition and pull out the key areas and what we understand is the intent interwoven into the direction Novitas is providing (while Novitas lays claims to this document, other MACs all follow similar direction as derived from the CMS National Payment Policy.)
Emergency = unable to be safely transport in another moving vehicle
The first criterion for justifying payment is explaining why (or why not) the patient cannot be transported safely in another vehicle other than your ambulance. Your documentation should clearly spell out the medical necessity and the need for an ambulance. This is a very important point and we must be truthful. So if the patient called for convenience then we must represent it as such. But, if the patient truly is suffering from a condition that precludes any other transport to the hospital then be precise and detailed with your explanation that clearly demonstrates why your ambulance had to transport the patient to the hospital.

Sudden onset of a medical condition…
Criterion number two to explain is the patient’s condition was a sudden onset. Explaining that past medical history or a chronic condition contributed to the scenario is fine and certainly acute exacerbation of the existing condition may warrant the need for immediate ambulance treatment and transport, but EMS providers must be explicit in explaining this. It is fairly clear that a patient who has had chronic back pain for many months and activates 9-1-1 today should be representing an unexpected escalation of the chronic condition that goes beyond the daily baseline condition for the patient. Comparing and contrasting “before”, “during” and even “after” treatment and then transport is important. Describing the condition using qualifying words and pointing out the timetable of the event is also important to describe this “sudden onset.”

Acute signs and/or symptoms of sufficient severity…could reasonably be expected to result in…
…A patient in serious jeopardy with serious impairment to bodily functions and/or with serious dysfunction of any body organ or part.

This part of the definition is pretty easy to follow and quite frankly easy to document. If the patient is not seriously impaired, does not have serious dysfunction or a body organ or part nor is in serious jeopardy of losing his/her life, then the “emergency” probably isn’t an emergency at all and probably won’t be paid by Medicare.

Is this anything new? Nope!

But, is there a renewed focus placed on these criteria. You bet!

The read between the lines is we are about to be faced with tighter review and scrutiny as these newly defined boundaries are presented. It’s a challenge for you, in the field, and all of us in the billing office.

Let’s work together to insure that the true emergencies are explained and are paid. Of course, let’s also work together to insure that the bogus runs are represented for what they are, as well.

The Enhanced Ambulance Billing Services blog is brought to you as an educational outreach by Enhanced Management Services, Inc. At Enhanced we provide third-party, ground ambulance billing services to Fire/EMS agencies across the United States. To learn more about what we do, please visit our website at and click on the “Get Started” link located on any landing page.

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