BILLING CHANGES

What is an ICD code? ICD (International Statistical Classification of Diseases and

Related Health Problem) or better known by its short-form (International Classification of Diseases).

ICD is maintained by the World Health Organization with in the United Nations Systems.

ICD is used to track morbidity and mortality statistics and also used in reimbursement systems and automatic decision support health care systems.

ICD codes are used as a standard diagnosis tool for epidemiology, health management, and clinical purposes.

ICD-10 is the 10th revision of the ICD codes.

ICD-10 Why the change?

The practice of medicine has changed dramatically in the last 25 years or so. There have been many new conditions discovered, treatments developed, and many new types of medical devices placed into service. The ICD-9 code set was not designed to capture all of this progress and has become bogged down.

ICD-10 is a mandated change enacted by the Federal Government.

The change allows for more than 14,400 different codes and permits the tracking of many new diagnoses. The codes can be expanded to over 16,000 codes with sub classifications.

ICD-10 ICD-9 previously consisted of 3-5 characters

that were a mixture of alphabetical and numerical values.

ICD-10 codes are normally a mixture of 3-6 characters of alphabetical and numerical values, with a 7th spot saved for subcategories.

                                                                                                                                                                            

Why is this important to you?

ICD-10 will require specificity in report writing and documentation. Providers will need to be very detailed in their

report writing when describing the patients medical condition. Mnemonics such as OPQRST are going to become an integral part of report writing with anyone complaining of pain.

Descriptions of injuries including location, bruising, swelling etc. will need to be clear and detailed when written in the documentation.

Examples ICD-9 Previously if a provider wrote

an assessment of “Right ankle sprain” an ICD-9 search would provide the following options.

845.09 – other sprains and strains of ankle

ICD-10 Now if a provider writes an

assessment of “Right ankle sprain” an ICD-10 search would provide the following options. No Code found

The provider would need to provide more information such as, “right lateral ankle sprain with no contusion” S93.401A - Right ankle sprain,

laterally, unspecified ligament of right ankle, initial encounter

National EMS Information System(NEMSIS)

NEMSIS is a national data base that was developed in the late 1970’s to collect data on EMS and patient outcomes.

NEMSIS requires each State to develop their own reporting system. Agencies first report to the State (WEMSIS) and the then State forwards the information on to NEMSIS.

NEMSIS 3.0 will be launched 1/1/2016 and all States are mandated to comply with the new reporting requirements and software upgrades.

National EMS Information System(NEMSIS)

The data collected is used in: Developing Nationwide EMS Training Curriculum Evaluating Patient and EMS System Outcomes Facilitating Research Efforts Determining National Fee Schedules and

Reimbursement Rates Addressing Resources for Disaster and Domestic

Preparedness Providing Valuable Information on Other Issues or

Areas of Need Related to EMS Care.

What does this mean to you?

With the NEMSIS mandated changes on 01/01/2016, all EPCR software vendors are working towards changing their programs to be compliant before the deadline.

This means we will be seeing changes in ERS, right now they are still beta testing their latest version with an unknown launch date at this time.

Currently we are also researching companies for a possible software change to help providers complete reports easier and faster.

The NEMSIS changes affect many aspects of EMS reporting and billing software.

What does this mean to you? In response to changes we are already seeing changes in software. As

of June 1st we will no longer have a “billing portal” to review and submit billing claims.

Runs for services will be dumped directly to the billing company with no review or oversight other than the initial provider writing the report, and the officer review.

This means that we will need to be spot on with our reporting processes.

This includes proper documentation, Billing Service Levels, Addresses, Mileage, medical necessity/reasonability, and reporting if the patient is a resident, non-resident, mutual aid partner resident, or a BCFD#4 employee.

It will also be the responsibility of the provider writing the report to notify the EMS Officer of any abnormal event that may pose a billing concern.

Service Levels

Before selecting any service levels we have to make sure that certain criteria is met. Emergency response, means responding immediately at the BLS or

ALS level of service to a 911 call or the equivalent. An immediate response is one in which the ambulance entity begins as quickly as possible to take all steps necessary to respond to the call.

Medically necessary, The patients condition must require both ambulance transportation itself and the level of service provided in order for the billed service to be considered medically necessary.

Reasonableness, The patient must require and it must be documented that the patient requires an upgrade in care for higher billable levels of service.

Service Levels

BLS Emergency

ALS 1 Emergency

ALS 2

Service Levels

BLS EmergencyMeans transportation by ground ambulance

vehicle and medically necessary supplies and service, plus the provision of BLS ambulance services. The ambulance must be staffed by an individual who is qualified in accordance with State and local laws as an EMT-B.

Service Levels ALS 1 Emergency

Transport by ground ambulance vehicle and medically necessary supplies and services, and either an ALS assessment by ALS personnel or the provision of at least 1 ALS intervention.

ALS assessment An assessment 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 initial assessment. An ALS assessment does not necessarily result in a determination that the patient requires an ALS level of billable service.

Service Levels ALS 1 cont.

Original dispatch criteria affects billable service levels, since our dispatch provides criteria based dispatch. If the rip and run alludes to this being a BLS call at the time of dispatch, the provider must document clearly why/if the call service is above a BLS level and the patient’s condition also warranted the upgrade in the level of service.

ALS procedures must also be medically necessary based on the patients reported condition. Starting an IV because the hospital prefers it, or the “gut” feeling of a provider does not meet medical necessity.

ALS procedures must also follow protocol. If you deviate from the protocol and skip a step it must be documented as to why this occurred.

Service Levels ALS 2, ground transport by ambulance, medically necessary

supplies and services, and the administration of at least three medication via IV push, bolus, or by continuous infusion (at the correct dosages). This excludes crystalloids, hypotonic, isotonic, and hypertonic solutions such as Dextrose, NS, Ringer’s Lactate.

Or transportation medically necessary supplies and services, and the provision of at least on of the following ALS procedures, Manual Defibrillation/cardioversion

ET intubation

Central venous line

Cardiac pacing

Chest decompression

Surgical airway

Interosseous line

Medical necessity must also be clearly documented.

Service Levels ALS 2 Cont.

Original dispatch criteria affects billable service levels, since dispatch provides criteria based dispatch. If the rip and run alludes to this being a ALS1 call at the time of dispatch, the provider must document clearly why/if the call service is above a ALS 1 level and the patient’s condition but also warrant the upgrade in the level of service.

ALS 2 procedures must also be medically necessary based on the patients reported condition. Performing a procedure must be medically necessary and follow standard of care practices.

ALS 2 procedures must also follow protocol. If you deviate from the protocol and skip a step it must be documented as to why this occurred.

Service Levels

If you are ever in doubt it is always better to select a lower service level rather than over bill. Overbilling for services that are not warranted can

enact the False Claim Act which is now monitored by the FBI.

False Claims Act now includes the provider as part of continuum for accountability. It is very important that the provider is trained and understands the billable service levels.

Resident status With losing the ability to have the billing portal, the provider will

now be required to complete the residency selection box in ERS under the billing tab. Resident- A patient with a physical address that is inside district

boundaries (includes anyone that is renting an apartment, house, RV space etc.).

Non-Resident – A patient with a physical address that is outside of the district boundaries. Example: a car accident patient that was driving on Bombing Range but lives in Pasco.

BCFD#4 Employee – any member that meets the criteria outlined in policy #302 Ambulance Billing section 3.2.

Mutual Aid Resident – A patient that meets the MOU reciprocity agreement with RFD, KFD, PFD, BCFD#2 and us. Example: dispatched mutual aid to RFD due to their units unavailable for dispatch, this patient would classify as a mutual aid resident.

Resident Status

Signature compliance

Health and Human Services (HHS), along with the Medicare Administration Centers are taking special interest in patient signatures. They have found that this is where they can reject a lot of claims for incorrect signatures. Any payment on a wrongfully obtained signature can enact the False Claim Act.

HHS has put a great deal of emphasis on signatures that are contemporaneous. Meaning obtained at the time of service. Signatures must be obtained from the patient at all times unless they are physically or mentally incapacitated and unable to sign. Your PCR must also reflect this physical or mental incapacitation to trigger signatures in box 2 or 3 of the signature form.

Signature rule

The general rule is that the beneficiary’s own signature is required unless the patient has died, 42CFR424.36

Patient must sign unless they are physically or mentally incapable of signing.

They are placing a very large emphasis that the signature must be contemporaneous, meaning at the time of service.

Signature rule (box 2)

If the patient is truly physically or mentally unable to sign, then there is a list of other signers that may sign on behalf of the patient.

The beneficiary’s legal guardian

A relative or other person who receives social security or other governmental benefits on the beneficiary's behalf.

A relative or other person who arranges for the beneficiary’s treatment or exercises other responsibility for his/hers affairs.

A representative of an agency or institution that did not furnish the services for which payment is claimed but furnished care, services, or assistance to the beneficiary.

Signature rule (box 3)

Applies only if: Patient is physically or mentally incapable of

signing No authorized signer is available or willing to sign

at the time of service. Requires 3 types of additional documentation to utilize

this exception and this documentation must be maintained for a minimum of 4 years from the date of service.

Signature rule (box 3) additional documentation

A contemporaneous statement, signed by an ambulance employee present during the trip to the receiving facility, that, at the time the service was provided, the beneficiary was physically or mentally incapable of signing the claim and that none of the authorized signers were available or willing to sign on behalf of the beneficiary.

Documentation with the date and time the beneficiary was transported, and the name and location of the facility that received the beneficiary.

A signed contemporaneous statement from the representative of the facility that received the beneficiary, which documents the name of beneficiary and the date and time the beneficiary was received by that facility.

Signature rule (box 3) additional documentation

New 4th rule that is set forth by the OIG An OIG exclusionary request must be completed on

the health care provider who is signing on the behalf of the hospital. This must be printed and scanned in with the report.

The OIG exclusionary information must be maintained for 10 years from the date of service.

Signature Rule

If the patient refuses to sign (but is mentally and physically capable of signing) we may not bill Medicare/Medicaid.

We will bill the patient for the full charge of the ambulance services provided.

If the patient later changes his/her mind and signs, we can then submit the payment to Medicare/Medicaid as long as it is timely.

****Please notify the EMS officer in the event that a patient is unwilling to sign so that we can make the proper billing arrangements.

Signature compliance

Power of Attorney statements/agreements. Most all POA agreements state they are only

enacted when/if the patient is unable to make their own decisions for their care. If the patient is able to speak and discuss their care then technically the POA is not enacted and the patient still has legal authority. There are several different types of POA’s and we will be working to provide further training in recognition of these POA’s.

False Claim Act

Whoever knowingly presents or causes to be presented a false or fraudulent claim for payment or approval, or

Knowingly makes, uses or causes to be made a false record or statement to get a false or fraudulent claim paid.

With the Affordable Care Act, power has now been granted to the FBI in regards to investigations, along with the Federal and State Office of Inspector Generals. Any new investigations the Federal investigators are now automatically inviting the State and Local investigators, Department of Health and any other vested entity to the investigation or inquiry.

False Claims – Risk Areas Up coding

Medical Necessity

Mileage inflation

Failing to obtain PCS forms when required

Duplicate Claims (repeat patients)

Billing for services or items not actually documented.

Failing to refund overpayments

Failure to maintain confidentiality of information

Signature form

Computer defaults

False Claim Act Penalties

Penalties for a False Claim. Civil penalty not less than $5,500 or not more than $11,000 for each

false claim

Plus an addition assessment of up to three times the amount of each false claim

Criminal penalties are now being placed upon providers, and agency administrations.