Provided by Coventry Health Care® ©2010 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission

Provided by Coventry Health Care®

©2010 Coventry Health Care. All rights reserved.Proprietary – Do not copy, distribute or disclose without permission of

Coventry Health Care.

California Medical Bill Reviewer Re-Certification

Unit 6: Other Fee Schedules

Module 1: Ambulance & DMEPOS Guidelines

2

March 2010CA Regulations RefresherTraining – AMB & DMEPOS

Overview Hi! In this module, you will learn about

two different fee schedules—

Ambulance and DMEPOS.

You will learn about ambulances

services, the crew requirements,

ambulance modifiers, and how these services are

reimbursed.

Then, you will learn about the DMEPOS

fee schedule and the guidelines for

reimbursement.

Part I: Ambulance Guidelines Ambulance Fee Schedule Crew Requirements Ambulance Services Supplies & Materials Modifiers Ambulance Reimbursement

Let’s start by discussing some

general ambulance guidelines...

Part I: Ambulance Guidelines Ambulance Fee Schedule

3


Ambulance Fee Schedule

Just like medical legal services, ambulance services are covered in a separate fee schedule.

Ambulance guidelines include

reimbursement for: Transportation Services Supplies & Materials

Let’s take a look…

4


Vehicle & Crew Requirements

The ambulance must be designed and equipped for transporting the sick, or injured, and include patient care equipment.

The ambulance crew must have two members, one of which has medical training equivalent to the standard and advanced Red Cross training.

Patient care equipment includes:

Stretchers Clean linens First aid supplies Oxygen equipment Lifesaving equipment

required by state and local authorities.

5


Ambulance Services

The ambulance fee schedule covers transportation services only if other means of transportation are contraindicated, or inadvisable, due to the patient’s medical condition.

Transportation services must be provided only to local facilities, unless necessary services are not available locally.

Transportation may also be provided:

From one hospital to another.

To the patient’s home. To an extended care

facility.

6


Air Ambulance Services

In addition to ground ambulance services, air ambulance services are included in the ambulance fee schedule.

Air ambulance services are covered when:

The point of pick-up is inaccessible by land vehicle.

The distances and/or other obstacles impede getting the patient to the nearest hospital with appropriate facilities.

7


Supplies and Materials

Some types of supplies are considered part of general ambulance services, and are included in the charge for the trip.

Reusable devices, not separately reimbursed

include devices such as: Back boards Neck boards Inflatable leg and arm

splints

8


Supplies and Materials

In contrast, a separate reasonable charge may be recognized for non-reusable items and disposable supplies.

Separate charges may be allowed for supplies,

such as: Oxygen Gauze IV Tubing

...that are required for patient care during the

trip.

9


Modifiers

For ambulance services, one-digit modifiers are combined to form a two-digit modifier.

Please refer to the state reference guide for a list of modifiers.

The first digit of the modifier identifies the ambulance’s place of origin.

The second digit identifies the ambulance’s destination.

Just like other types of

service, special modifiers are associated with

ambulance services.

10


Ambulance Reimbursement Now that you

understand the basics of ambulance services, let’s look at how these services are reimbursed...

Part I: Ambulance Guidelines Ambulance Fee Schedule Crew Requirements Ambulance Services Supplies & Materials Modifiers Ambulance Reimbursement Ambulance Reimbursement

11


Ambulance Reimbursement

Reimbursement is consistent across all providers of ambulance services.

The maximum reasonable fee for ambulance services shall not exceed 120% of the applicable fee as set forth in the CMS' Ambulance Fee Schedule.

Providers of ambulance services

include: Hospitals Private companies Fire departments

12



For services provided in the year 2007, Medicare announced ambulance fees must be increased by an Ambulance Inflation Factor (AIF) of 1.025.

To apply the new AIF, multiply the ambulance service fees in the CY 2007 Ambulance Fee Schedule by 1.025. As you can see, it is

important to check the website often for

updates!

13



The ambulance fee schedule amount is determined by the zip code of the point of pick-up, not the provider’s address.

Zip codes are divided into nine

Medicare localities:

03 05 06 07 09

17 18 26 99

14


Zip Code Localities

Within each of the nine localities, certain zip codes may be a rural area, which will have a different mileage rate than urban zip code areas in that same locality.

A zip code table lists the locality of the zip code and indicates whether it is a rural or urban area.

Different Mileage Rates

15


State Zip Code Carrier Locality

Urban (Blank)/Rural (R)/

Super Rural (B)CA 95568 31140 99 BCA 95569 31140 99 RCA 95570 31140 99 RCA 95571 31140 99 RCA 95573 31140 99 RCA 95585 31140 99 BCA 95587 31140 99 BCA 95589 31140 99 RCA 95595 31140 99 BCA 95601 31140 99 RCA 95602 31140 99CA 95603 31140 99CA 95604 31140 99CA 95605 31140 99CA 95606 31140 99

Zip Code Localities

The zip code table is located at the following link:

National Breakout of the Geographic Area Definitions by Zip Code

Remember, for a specific zip code, the table

indicates the: Locality Rural Indicator, if

applicable

16


Zip Code Localities

Each locality has several different associated values that you need to be familiar with.

These different values include:

Geographic Practice Cost Index (GPCI)

Conversion Factor (CF) Mileage Ground Rate (MGR) Relative Value Unit (RVU) for each

HCPCS code


17



You should be familiar with conversion factors and relative value units from your earlier studies of reimbursement calculations.

However, you may not be familiar with the GPCI and MGR.Geographic Practice Cost Index (GPCI):

Mileage Ground Rate (MGR):

A factor used to adjust for geographic

differences in the cost of maintaining a medical

practice.

The reimbursement rate per mile for ground ambulance services.

18



There are different reimbursement calculations for mileage and other types of service.

Mileage Reimbursement: (MGR x Mileage)(AIF) = Total Reimbursement

All Other Reimbursements: (RVU x CF x GPCI)(AIF) = Total Reimbursement

Suppose an ambulance picks up an injured worker in the 95605 zip code area and travels nine miles to the nearest facility. How should the services be reimbursed?


19


State Zip Code Carrier Locality

Urban (Blank)/Rural (R)/

Super Rural (B)CA 95568 31140 99 BCA 95569 31140 99 RCA 95570 31140 99 RCA 95571 31140 99 RCA 95573 31140 99 RCA 95585 31140 99 BCA 95587 31140 99 BCA 95589 31140 99 RCA 95595 31140 99 BCA 95601 31140 99 RCA 95602 31140 99CA 95603 31140 99CA 95604 31140 99CA 95605 31140 99CA 95606 31140 99


1. The first step is to identify the zip code locality from the zip code table.

2. For zip code 95605, the locality is 99. After identifying the zip code locality, reimbursement values can be calculated.

20



Ambulance reimbursement information is available at the following website:

http://www.dir.ca.gov/dwc/FeeSchedules/AMBULANCE_FeeSchedule/OMFS_Ambulance.pdf

There, you will find tables listed by state that provide information specific to different localities.

21



From the table you can get information for the following: Carrier #

Locality HCPCS Code Conversion Factor

Relative Value Unit GPCI Urban Mileage Rates Rural Mileage Rates

22



For the example we are working with, suppose the bill

shows HCPCS codes: A0425: Ground mileage, per

statute mile. A0426: Ambulance service,

advanced life support, non-emergency transport, level 1.

23



From the zip code table we found that 95605 corresponds to Locality 99 and an urban area, because the rural indicator is blank.

Zip Code Carrier LocalityRural

Indicator

95605 31140 99

HCPCS RVU CF GPCI MGR

A0425 1.0 1.0 1.265 6.87

A0426 1.20 209.65 1.265 333.58

Then, by locating the correct locality on the table in the fee schedule, we found the information in the table below.

24



Using the information in the table:


A0425 1.0 1.0 1.265 6.87

A0426 1.20 209.65 1.265 333.58

Mileage Reimbursement: (MGR x Mileage)(AIF) = Total Reimbursement

($6.87 X 9 miles) = $63.37(1.025)

Now let’s take a look at the reimbursement calculation for the other expenses...

25



Now, let’s calculate the reimbursement for the services related to A0426.


A0425 1.0 1.0 1.265 6.87

A0426 209.65 1.20 1.265 333.58

All Other Reimbursements: (RVU x CF x GPCI)(AIF) = Total Reimbursement

($209.65 X 1.20 = $326.19 (1.025)X 1.265)

Now that you have learned about ambulance services and how they are reimbursed, we will discuss DMEPOS guidelines.

26


DMEPOS Here, you will learn about DMEPOS

services, how they are differentiated, and how they are

reimbursed.

Let’s start by taking a look at some

general guidelines...

Part II: DMEPOS Guidelines DMEPOS Guidelines Asterisked Items Modifiers DMEPOS Reimbursement

Part II: DMEPOS Guidelines DMEPOS Guidelines

27


DMEPOS Guidelines

The DMEPOS Fee Schedule provides reimbursement guidelines for durable medical equipment, prosthetics, orthotics, and supplies. Prosthetics and orthotics

are appliances or supplies that: Restore function

Immobilize joints Protect joints Provide pain relief Correct & prevent deformity Replace body parts

28


DMEPOS Guidelines

Reimbursement for orthotic and prosthetic services accounts for more than the device itself.

Prosthetic and orthotic codes have a “L” or “X” prefix attached to a four digit numeric code.

Reimbursement accounts for: Evaluation & consultation

Construction Delivery Training on the proper use

of the device

29


Asterisked Items

Prosthetic and orthotic supplies can be designated by a single asterisk or a pair of asterisks in the fee schedule.

One Asterisk Two Asterisks

Items denoted by a single asterisk in the Maximum Reimbursement list may be billed by a provider only if the item falls within the provider’s scope of their practice.

Items denoted by a two asterisks may be

reimbursed if the item falls within the provider’s

scope of their practice, and if the pharmacy or

pharmacist is certified by the NARD Health

Support & Appliances Program.

NARD stands for National

Association of Retail

Druggists.

30


Modifiers Just like other types of services, DMEPOS

services can have associated modifiers. Let’s take a look...

Part II: DMEPOS Guidelines DMEPOS Guidelines Asterisked Items Modifiers DMEPOS Reimbursement

Modifiers

31


Modifiers

The DMEPOS reimbursement guidelines include three two-digit modifier supply codes.

51:This modifier

indicates a medical supply company with

certified orthotic personnel accredited by an organization recognized by the

National Organization for Competency

Assurance.

52:This modifier

indicates a medical supply company with certified prosthetic personnel accredited by an organization recognized by the


Assurance.

53:This modifier

indicates a medical supply company with

certified orthotic and prosthetic

personnel accredited by an organization recognized by the


Assurance.

32


Modifiers

In addition to the modifier supply codes, there are two digit alphabetical modifiers.

Most commonly these modifiers include:

NU: Purchase, New RR: Rented UE: Purchased, Used KM: Replacement

33


DMEPOSReimbursement Lastly, let’s take a

quick look at DMEPOS

reimbursement guidelines...

Part II: DMEPOS Guidelines DMEPOS Guidelines Asterisked Items Modifiers DMEPOS Reimbursement DMEPOS Reimbursement

34


DMEPOS Reimbursement

The maximum reasonable fees for durable medical equipment, prosthetics, orthotics, and supplies should not exceed 120% of the applicable California fees set forth in the Medicare calendar year 2007. It is important to realize that the

DMEPOS fee schedule is

updated quarterly.

Therefore, it is important to

check for updates!

To check for updates, you can find the DMEPOS fee schedule

at:http://cms.hhs.gov/DMEPOSFeeSched/LSDMEPOSFEE/list.asp

The most current version is: D07 JAN C.zip

35


Summary

Ambulance Guidelines

Ambulance Crew Requirements, Services, Supplies & Materials

Ambulance Modifiers & Reimbursement Guidelines

DMEPOS Guidelines

DMEPOS Modifiers & Reimbursement Guidelines

Asterisked Items in the DMEPOS Guidelines

Documents

Provided by Coventry Health Care® ©2010 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission