Transcript BILLING CHANGES - Fire Training Tracker - Tri

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 Emergency
 Means
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.