I hope you don't mind a biller visiting your board

[TBS]

And I hope you don't mind helping a biller semi-new to transport billing...

I have billed ambulance before, so the territory isn't totally foreign, but I only collected TX Medicaid for an emergency tranport company.

Now I am doing collections for commercial and TX Medicaid, but this environment is such that I really need a familiarity with Medicare, too, and also coding/billing. The women here have no desire to help me out (since they fear, wrongfully so, that once I learn their jobs they will likely lose theirs).

I need to know how to tell the difference between ALS and BLS. From posts on a general billing board I frequent I figure it's probably dictated by state laws, but since googling has not turned up a usefull website for Texas I need some general guidelines.

Also, even though we are non-emergency, apparently we will on occasion make an emergency run. I need to know how I can look at the run sheet and determine what is an emergency transport and what is a non-emergency transport.

Lastly, if anyone has done a study on this, I would like to know approximately how many Medicare claims, by percentage, do you get denied for medical necessity - particularly if you are doing non-emergency transports. How many of these (again, by percentage) do you estimate to be valid, and how many do you appeal? If anyone has similar figures for Texas Medicaid, I would appreciate those, too.

Thanks for any and all insight.

[flight-lp]

TBS,

First and foremost, welcome to the city. I hope you find your stay informative and enjoyable, but I have concerns about your first posting here.................

Billing is an entity that REQUIRES sound knowledge of all applicable state, local, and federal laws concerning reimbursement and collections. Such information is not soundly obtainable from an online message forum. You need to make contacts with the agencies involved in such activities. Here are three links you definitely will want to become familiar with...........

http://www.cms.hhs.gov/home/medicaid.asp

http://www.hhsc.state.tx.us/medicaid/med_info.html

http://www.medicare.gov/

I'd start here. The opinions of the people here is just that, opinions. You need facts, rules, and regulations. This is not the place to get them. Opinions given here will not hold water in any legal action and it will discredit your reputation with clientele. If its opinions you want for your own information, then post away. But if your looking for definitive answers to assist you in your collection activities, you need to go elsewhere. If you have an ulterior motive to gain information you seek for purposes of collection pursuits, then you will quickly see that people on this board are not going to help you. I'm not trying to insinuate anything, but there have been several occurrences before where people attempted to obtain information for litigation purposes and have been shut down real quick! Honesty is paramount here! Fail to have it and the wrath of EMT City shall ensue. Good luck with your endeavor.................

[bandaidpatrol]

We don't mind...

We love billers!

We point the finger at you, when the patient bitches at us!

[Doczilla]

TBS- welcome to the board. I think your perspective here is a welcome addition, as we don't get to see much of it.

Presence of a paramedic does not automatically mean that the ride is ALS. An ALS run is any run where the following is done:

IV line or IO line started

dialysis port, picc line, mediport or other central line ACCESSED (flushed with saline, IV line hooked up, or meds administered), not just assessed

medications administered, with the notable exception of aspirin (ASA), nitroglycerine (NTG), epinepherine 1:1000 via epipen, or albuterol by metered dose inhaler (MDI, not nebulizer). Anything given IV, IO or by a nebulizer makes it ALS.

endotracheal intubation, LMA or combitube placement attempted, whether successful or not

defibrillation (except with an AED)

cardioversion

transcutaneous pacing

EKG monitoring

chest decompression

Also, if the patient already has IV's running, chest tube in place, is on a ventilator, is in an incubator (neonatal transports), it is an ALS run, even if the medic doesn't do anything but monitor them. These things are common on interfacility transports. And generally if there is a nurse on board, it's ALS.

Emergency transport codes vary by agency. Some will refer to it as "emergency traffic", "code 3", "priority", or some such. I would contact a supervisor at the EMS agency directly to find out which they use. Some agencies use priority codes, so Priority 1 would be emergency transport, and priority 3 would be non-emergency (though others use the reverse). Others will use the term "scheduled transport" or "NET" for "non-emergency transport". And if it says "911 request", then it's emergency (I don't know if you back up the local 911 service or not). If the destination was the ER, it's an emergency run.

Others refer to it as NAB transport (non-ambulatory body) or lizard-hauling, but hopefully you won't see that on anyone's run report.

In order to be billable for medicare for a non-emergency transport, there needs to be a "statement of medical necessity" completed, often by a physician or his/her designee. Usually this is a little form that has the patient's diagnosis and why they need an ambulance. You may be able to make a good case for this if the patient has the following conditions:

bed-ridden, non-ambulatory

fractures of the legs, pelvis, back, or multiple extremities

unresponsive

bilateral leg amputations

requiring ANY medical intervention besides oxygen. Any medications administered, IV lines or EKG monitored, etc.

For emergency transport, it's easier. Essentially, anyone who calls 911 gets a ride that's paid for by medicare/medicaid.

'zilla

[TBS]

An ALS run is any run where the following is done:

IV line or IO line started

dialysis port, picc line, mediport or other central line ACCESSED (flushed with saline, IV line hooked up, or meds administered), not just assessed

medications administered, with the notable exception of aspirin (ASA), nitroglycerine (NTG), epinepherine 1:1000 via epipen, or albuterol by metered dose inhaler (MDI, not nebulizer). Anything given IV, IO or by a nebulizer makes it ALS.

endotracheal intubation, LMA or combitube placement attempted, whether successful or not

defibrillation (except with an AED)

cardioversion

transcutaneous pacing

EKG monitoring

chest decompression

Also, if the patient already has IV's running, chest tube in place, is on a ventilator, is in an incubator (neonatal transports), it is an ALS run, even if the medic doesn't do anything but monitor them. These things are common on interfacility transports. And generally if there is a nurse on board, it's ALS.

Thanks, Doczilla! That and this

If the destination was the ER, it's an emergency run.

were EXACTLY what I was looking for!

flight-lp, I appreciate your concerns...maybe I should have mentioned in my post that I have 16 years billing experience, am a certified biller, belong to 5 professional billing associations, have had no fewer than three jobs in which I managed the reimbursement of multi-provider facilities and organizations. I am familiar with Medicare guidelines, but if you will re-read my post, and then look at the general urls you posted, you will see that your information was absolutely useless. In fact, your Texas link was not even to the Medicaid contractor's website, which is where program rules and regulations are listed.

Furthermore, each one of those professional associations I belong to have message boards like this one - because, nowadays, "networking" is done mostly online, and because medical reimbursement is such a complex issue that NO ONE can know EVERYTHING, no matter how much education and experience they have. Furthermore, many things are up to interpretation, and before making any decisions, some people like to hear everyone's interpretations and then form there own opinions. This networking, via the internet message boards, are a valuable tool for this purpose.

Unfortunately, most of those boards have small memberships, and, in fact, only on the largest board are there any ambulance billers. Since none of them are from Texas, and you will see one of my biggest concerns were what TEXAS considers ALS or BLS, I decided to seek other routes for educating myself.

Thank you for taking the time to answer my post.

And, again, thank you, Doczilla, for clarifying things for me once and for all.

[flight-lp]

Well that definately clears up any questions. No harm or insult intended, sorry the info wasn't beneficial for you.........

[xselerate]

i don't mind billing people... funny enough but i coulda sworn i had a job cause of them....

[emtI4now]

We are a municipal-owned BLS service that does 911 response, and it's been my experience that just because someone dials 911 and gets transported to the ER doesn't mean that Medicare/Medicaid will pay for it. If the symptom/chief complaint doesn't indicate medical necessity of ambulance transport, the claim usually comes back patient responsibility. We are a BLS service, with no ALS available, other than the hospital, and sometimes, let's face it, it's just not truly classifiable as an emergency that is considered medically necessary.

I know this probably isn't helpful to you as we are not strictly a non-emergency transport service, as you are, although we do do non-emergency transports between facilities occasionally, but just thought I'd share my experiences.

[clbcpc]

Hi TBS

I too am a coder, biller; my certification is in physicians/clinics - however, I taught all facets of medical records management and billing/coding at the community college level. I am helping local EMS with their billing in an extremely remote, rural area in Texas. Our only hospital is more than 80 miles away.

When it was time to for my renewal CEUs, I compiled a training manual for our team here. I found precious few resources and ended up investing about 30 hours in searching. I did find a wonderful chart called the "Medical Conditions List", created by CMS. The chart includes - ICD9 Primary Code ICD9 Alternative Specific Code Condition (General) Condition (Specific) Service Levels (ALS/BLS) Comments and Examples (not all-inclusive) and a HCPCS Crosswalk. We are non-par with Medicare, but I have always found the "Feds" do give good basic guidelines and tools for the rest of the world. I tried to cut and paste a sample page, but table didn't come through. you should be able to locate it using this information:

January 4, 2006

FROM: Medicare Communications

SUBJECT: Ambulance Fee Schedule - Medical Conditions List: Manualization

Change Request (CR) #: 4221

Related CR Release Date: December 23, 2005

Effective Date: March 27, 2006

Implementation Date: March 27, 2006

Background

This document furnishes you with the Ambulance Medical Conditions List and its instructions.

Changes in Manual Instructions

Chapter 15 - Ambulance

30.3 – Ambulance Fee Schedule – Medical Conditions List and Instructions

(Rev. 789, Issued: 12-23-05, Effective: 03-27-06, Implementation: 03-27-06)

What I really need now, is someone to advise me in the setup of a realistic fee schedule. Anybody out there?

clbcpc

[MightyMee]

HI!

I am in Tx, I have over 20 yrs specializing in EMS billing. I have several certifications and have went one on one with the heads of Medicare, and BCBS for not paying as they should. I have also gotten claims paid that others would have written off as lost.

My word of advice is simple: Don't let them (insurance companies) scare you into thinking you are wrong and they don't have to pay! Know how to code properly is the key to getting claims paid, as well as knowing you are right from the time you receive the patient information to the point where it is paid PROPERLY. Do not take any deals with insurance companies, such as we'll pay within 10 days if you agree to this amount! Always follow-up and appeal as needed any unpaid claims. DO NOT make a telephone call to the insurance company without ALL information in front of you --document, document document all calls and work you do on a claim!

Marilyn

Specialist in EMS Billing