November 2017 Professional Claims Review *CONFIDENTIAL ...

November 2017

Professional Claims Review *CONFIDENTIAL*

Final Report

El Paso Fire Department 416 N Stanton Suite 200

El Paso, TX 79901

FITCH & ASSOCIATES, LLC

2901 Williamsburg Terrace #G ▪ Platte City ▪ Missouri ▪ 65079

816.431.2600 ▪ www.fitchassoc.com

CLAIMS REVIEW

http://www.fitchassoc.com/

El Paso Fire Department i ©Fitch & Associates, LLC Professional Claims Review November 2017

Professional Ambulance Claims Review for El Paso Fire Department

Table of Contents STATISTICAL SAMPLING METHODOLOGY _______________________________________________________________ 2

Sampling Unit _____________________________________________________________________________ 2 Claims Review Population ___________________________________________________________________ 2 Sampling Frame ___________________________________________________________________________ 2

STATISTICAL SAMPLING DOCUMENTATION ______________________________________________________________ 2 Source of Data ____________________________________________________________________________ 3 Claims Review Objective ____________________________________________________________________ 3 Review Protocol ___________________________________________________________________________ 4

CLAIMS REVIEW FINDINGS _________________________________________________________________________ 5 Spares ___________________________________________________________________________________ 5 Mileage __________________________________________________________________________________ 6

Figure 1. Inaccurate Mileage_________________________________________________________________________ 6 Figure 2. Mileage Rounding Errors ____________________________________________________________________ 6 Figure 3. Mileage Accuracy __________________________________________________________________________ 7

Medical Necessity __________________________________________________________________________ 7 Figure 4. Medical Necessity _________________________________________________________________________ 7 Figure 5. Medical Necessity Percentage ________________________________________________________________ 8

Reason for Transport _______________________________________________________________________ 8 Figure 6. No Reason for Transport/Generic Reason for Transport ___________________________________________ 8 Figure 7. Reason for Transport _______________________________________________________________________ 9

Modifiers _________________________________________________________________________________ 9 Figure 8. Original Modifiers _________________________________________________________________________ 9 Figure 9. Modifiers _______________________________________________________________________________ 10

Coding of Charges ________________________________________________________________________ 10 Figure 10. Original Base Rate Comparison _____________________________________________________________ 11 Figure 11. Inaccurate Base Rates ____________________________________________________________________ 11 Figure 12. Coding of Charges Percentage ______________________________________________________________ 12

Diagnosis and Condition Coding _____________________________________________________________ 12 Figure 13. Diagnosis and Condition Coding Percentage __________________________________________________ 13 Figure 14. Inaccurate Diagnosis and Condition Coding ___________________________________________________ 13

Beneficiary Signatures _____________________________________________________________________ 14 Figure 15. Beneficiary Signature Error Percentage ______________________________________________________ 14

Receiving Facility Signatures ________________________________________________________________ 15 Figure 16. Receiving Facility Signature Section _________________________________________________________ 15 Figure 17. Receiving Facility Signature Error Percentage _________________________________________________ 16

Crew Signatures __________________________________________________________________________ 16 Figure 18. Crew Missing Signatures __________________________________________________________________ 17 Figure 19. 2 Crew Member Signatures vs 1 Crew Member Signature ________________________________________ 18

FINDINGS SUMMARY ___________________________________________________________________________ 19 Overall Quantified Results __________________________________________________________________ 20

Figure 20. Error Rate Quantification __________________________________________________________________ 20 CONCLUSION _________________________________________________________________________________ 21 CREDENTIALS ________________________________________________________________________________ 21

El Paso Fire Department ii ©Fitch & Associates, LLC Professional Claims Review November 2017

Attachments A. Compliance Review Worksheet B. RAT-STATS printout C. MLN Matters CMS Fractional Mileage D. 2.2.5.7 Not Medically Necessary Texas Medicaid Provider Procedure Manual E. 1.6.9.1 Client Acknowledgement Statement F. Curriculum Vitae

El Paso Fire Department 1 ©Fitch & Associates, LLC Professional Claims Review November 2017

Purpose Fitch & Associates, LLC (FITCH) was engaged by El Paso Fire Department (El Paso) to conduct a Professional Ambulance Claims Review of ambulance transports billed to and paid by Federal health care providers, to include Medicare and Medicaid. FITCH serves in this capacity as an external auditor of the billing functions of El Paso Fire Department’s EMS services. Fitch & Associates, LLC is a professional emergency services consulting firm, not a legal entity, and this report is not provided as legal counsel, rather it is an interpretation of the applicable rules, regulations, and laws governing the billing of medical transport services to Federal health care providers, commercial insurance companies, contracted payers, patients and beneficiaries, and/or other parties identified by El Paso Fire Department and its contracted billing agent, as responsible parties for reimbursement of services provided. This report is the property of El Paso Fire Department, and is private and confidential.


Statistical Sampling Methodology

Sampling Unit

The Sampling Unit consists of Items reviewed by FITCH for this professional claims review. For the purposes of this review, an Item is defined as an ambulance transport claim filed for payment with a Federal health care program including Medicare and Medicaid, for medical transports provided by El Paso Fire Department. Each claim may have multiple charges including ambulance base rates and mileage. The sampling unit for the claims billed to Federal health care providers was drawn from a total population of claims billed to and paid by these payers and was provided to FITCH by El Paso’s contracted billing agent, Intermedix, for a defined time frame agreed upon by the FITCH & the City of El Paso’s compliance department.

Claims Review Population The Claims Review Population consisted of all items for which El Paso reportedly received reimbursement from a Federal payer (defined as Medicare or Medicaid) during the period of September 1, 2016 to October 31, 2016. The review was based on a population of 1,635 items for which Medicare and Medicaid reimbursement was received.

Sampling Frame The Sampling Frame for the Medicare and Medicaid claims selected is identical to the Claims Review Population and represents all items for which El Paso received reimbursement from Federal health care programs for the time-period September 1, 2016 to October 31, 2016. In this case, the Sampling Frame for the Medicare and Medicaid claims represents 1,635 medical transports. The process to identify the Sampling Frame included a request for El Paso to provide, in electronic format, a list of all calls for which reimbursement was received from Medicare and Medicaid during the identified period. A sample size of 50 Medicare and Medicaid claims was pulled from the Population to be the Discovery Sample. The Discovery Sample of 50 claims was identified using the Office of the Inspector General’s (OIG) RAT-STATS statistical sampling software. Ten (10) spares were identified in order to allow for claims that may have been included in the Claims Review Population, and selected for the Discovery Sample, that were not reimbursed by Medicare, Medicaid, or other Federal health care payers.

Statistical Sampling Documentation A copy of the RAT-STATS printout of randomly selected items containing the Discovery Sample is included as Attachment B. As stated, the Sample contains 50 randomly selected items from the list of 1,635 claims filed with Medicare and Medicaid and for which payments were received. Of the 50 claims


in the initial Medicare and Medicaid sample, all 50 qualified for inclusion in the Discovery Sample and none of the Spares were utilized in the review.

Source of Data El Paso provided all documentation requested by Fitch related to each Item identified for the Claims Review. For secure transfer of these documents in electronic format, a ShareFile folder was created and access was provided to the El Paso’s contracted billing agent, Intermedix, for upload of the documents for this review. The request for documents included: Dispatch documents/notes Patient Care Reports Copies of Claims Forms and Invoices (primary and secondary) Copies of Proof of Payment (EOBs, RA, R&S, etc.) Signature Forms Prior Authorization and PCS Forms (as applicable) ABN (as applicable) Any other relevant documents that are related to the transport and/or bill

Claims Review Objective FITCH has developed an evaluation process to analyze each item submitted to ensure accuracy in billing and compliance with Federal healthcare rules and regulations. Special focus is placed on risk areas identified by the Office of the Inspector General (OIG) in their Compliance Program Guidance for Ambulance Suppliers and in their annual Work Plan (https://oig.hhs.gov/reports-and-publications/workplan/index.asp). Particular attention was paid, but not limited, to the following risk areas: Appropriateness of Destination Documentation of Medical Necessity Service Level (HCPCS) Coding Appropriateness of Patient/Beneficiary Signature Mileage Modifiers ICD-10 Coding Alteration of Documentation

The specific objective of the review was to determine if claims submitted to Federal health programs for reimbursement are accurate, provided proper documentation, and were correctly billed and paid. Each claim was examined and a compliance review worksheet was completed, included as Attachment A. The reviewer(s) then examined all submitted documentation for each ambulance transport. The review was designed to answer the following questions:

1. Does the patient transport meet the defined medical necessity criteria?


2. Is the reason for the ambulance transport documented? 3. Are appropriate modifiers used to identify origins and destinations? 4. Is the patient going to a covered destination for a medically necessary service? 5. If relevant, is the service for which the patient must be transferred to another facility

documented in the patient care report? 6. Is the mileage properly documented? 7. Are the appropriate codes used for charges and are those charges supported by documentation

in the patient care report? 8. Are beneficiary signatures obtained or does the documentation meet Medicare’s beneficiary

signature requirements? 9. Were the appropriate ICD-10 codes used to report the patients’ condition(s) at the time of

transport and are they based on information provided in the patient care report? 10. Was the amount reimbursed by the federal healthcare programs appropriate?

Review Protocol Each claim in the random sample identified through the RAT-STATS process, was assigned an Item number which corresponds to the El Paso account number. The Item and all information received for the corresponding claim(s) were entered into a spreadsheet, included with this report as Attachment A, and titled Compliance Review Worksheet. A comprehensive analysis of elements was performed and recorded in the review of each claim to determine accuracy and appropriateness. While there were variations in the information provided from claim to claim, all documents were thoroughly inspected to identify and examine the required elements. The bulleted list below captures the key aspects of the data components examined for each account to determine the accuracy and appropriateness of the charges assigned by El Paso and the corresponding payments from the Federal health care provider: Assigned Item Number Patient Name Run Number/Account Number Health Insurance Claim Number Federal Program(s) Billed Date of Service Origin and Destination Submitted Modifiers Identifying Origin and Destination Loaded Miles Filed for Reimbursement Determination of Mileage Supported by Documents Determination of Reason for Transport Supported by Documents Procedure Codes Submitted (HCPCS) and Reimbursed Description of Procedure Codes Determination of Appropriate HCPCS if Different from Claims Determination of Whether Charges are Supported by Documentation Determination of Whether Documents Support Medical Necessity Determination of Whether Ambulance Transport is Covered by Medicaid


ICD-10 Codes Appropriateness Notation of Patient Signature Requirements Fulfilled Physician’s Certification Statement (PCS) Appropriate and Complete When Required Total Charges Federal Health Program that Reimbursed Primary Payer Payments Reimbursed Procedure Code if Different Than Filed Allowed Amount for Each Procedure Code Determination of Correct Allowed Amount Dollar Difference Between the Allowed Amount and Fee Schedule Calculated Allowed Amount

(Overpayment or Underpayment) Secondary Payer Appropriateness of Secondary Payer Payments

FITCH staff members reviewed the information, including the procedure codes submitted from the claims and billing files and compared them to the procedure code reimbursed based on the remittance advice and explanation of benefits. Also reviewed were the allowable amounts and payments, as well as review of the appropriate payer fee schedules for the period reviewed. The reviewers examined the claims in the order of the sequential selection from the RAT-STATS program, to determine if any claims were not paid by a federal health program. Of the initial 50 Medicare/Medicaid claims identified in the sample, all 50 items met the criteria for inclusion in the review. No spares were utilized in this review. Each claim was reviewed and compared to the patient care report and other supporting and relevant documentation provided to determine if the procedure codes (HCPCS) assigned accurately reported the level of service provided.

Claims Review Findings FITCH reviewed 50 paid claims, submitted by El Paso to Medicare and Medicaid as the primary payers. The following paragraphs summarize the findings regarding the key questions to be answered by the Claims Review.

Spares

Ten (10) spare claims were randomly selected from the population for the claims review. No spares were utilized for this report.


Mileage

Google maps was the mapping program used to confirm the miles for this claims review. The reviewer utilized this program to verify the shortest distance between the origin and destination for the claims examined. The shortest route between pick up and destination can vary, which such should be explained in the narrative of the patient care report if such is found to be more than what might be reasonably acceptable. To support billing for distances that may appear to vary from the shortest distance between the two locations, it would be considered best practice to provide supporting information for the variances in the patient care report, for example, accidents and road construction. This claims review confirmed one inaccuracy, due to incorrect origin and destination information in the patient care report. Item 19, was a scene to hospital transport with the origin and destination address being identical. Two miles were billed to Medicare for reimbursement. Figure 1 below provides the account number of the inaccurate mileage billed. Figure 1. Inaccurate Mileage

Item # Account # PCR Billed Comments 19 40026146 2 2 Origin and Destination address the same, but 2 miles was billed to Medicare

Medicare requires that patient loaded mileage be reported in fractional units and billed to the nearest 1/10th of a mile for trips up to 100 miles. The claims reviewed were found to have mileage reported on the PCR to the hundredths place. MLN Matters Number MM7065 states that “contractors shall truncate mileage units with fractional amounts reported to greater than one decimal place, e.g., 99.99 will become 99.9 after truncating the hundredths place”. MLN Matters Number MM7065 is provided as Attachment C in this report. Of the 39 Medicare claims reviewed, 16 claims did not round to the nearest 1/10th place appropriately or did not truncate the number after the tenth place. Figure 2 below provides the list of claims that did not properly provide the nearest tenth of a mile and Figure 3 provides the error percentage. Figure 2. Mileage Rounding Errors

Item # Account # PCR Billed Correct Mileage 3 40312529 1.93 2. 1.9 6 40075324 3.98 4.0 3.9 7 40076608 1.21 1.3 1.2 8 40338584 9.96 10.0 9.9 9 40403541 6.22 6.3 6.2

12 39979073 1.51 1.6 1.5 15 40032187 8.81 8.9 8.8 27 40247872 4.41 4.5 4.4 29 40338877 0.44 0.5 0.4 30 40127082 2.74 2.8 2.7 32 39978562 8.82 8.9 8.8 33 40110563 3.83 3.9 3.8 38 40302650 7.41 7.5 7.4 41 40054537 1.99 2.0 1.9


42 39763711 2.72 2.8 2.7 48 40437877 3.31 3.4 3.3

Figure 3. Mileage Accuracy

Medical Necessity

Chapter 10, Section 10.4.1 (Necessity for the Service) of the Medicare Benefit Policy Manual outlines medical necessity for ambulance services. Medical necessity is only recognized when the patient’s condition is such that use of any other method of transportation is contraindicated. In any case in which some means of transportation other than an ambulance could be used without posing a danger to the patient’s survival or seriously jeopardizing the patient’s health, then no reimbursement will be made for the ambulance services. Documentation to support the medical necessity of an ambulance transport needs to provide a detailed description of the patient’s condition at the time of transport, along with descriptions of interventions and the patient’s responses to those interventions. Any additional documentation to support medical necessity and to validate that the patient could not be safely transported by ground ambulance would be appropriate for inclusion in the patient care report and is recommended as a best practice to ensure accuracy and mitigate risk. Of the claims reviewed, 48 met the medical necessity guidelines. Figure 4, provides a list of the claims that did not meet medical necessity and Figure 5 below, provides the error percentage. Figure 4. Medical Necessity

Item # Account # Comments

5 39745139

Per PCR, patient states having anxiety and fever because she had “the flu”. Upon being loaded into ambulance, patient stated feeling fine and just wanted to be taken to receive a flu shot. No information supports the need for transport or confirms that the patient could not have gone by other means without contraindication to health.

65%

35%

Mileage Accuracy Percentage

Accurate Mileage Billed

Inaccurate Mileage Billed


25 40199924

PCR states swelling in left leg for a month, no pain, uses walker to ambulate. Not being transferred due to an emergency situation – requested evaluation, no information in the PCR indicates a medically necessary reason for the ambulance and/or that the patient could not have gone by other means without contraindication to health.

Figure 5. Medical Necessity Percentage

Reason for Transport

Transports from one facility to another require documentation of the reason the patient must be moved from one hospital to another. This requires that the patient care report clearly indicate the precise treatment, procedure, or medical specialist that is available and required at the receiving hospital. Non-specific or vague statements (patient needs cardiac care, patient needs higher level of care, etc.) do not provide adequate information to support the transfer of the patient. One claim in this review was for a hospital to hospital transport. Item 10 provided the medical diagnosis (uncontrolled hematemesis) but no specific reason the patient was being transferred to another facility. This equals an error rate at 100% for this category of transport. Figure 6 displays the claim that did not offer details as to the services or reason for the patient transfer and Figure 7 illustrates the percentage of accurate verses inaccurate reason for transports. Figure 6. No Reason for Transport/Generic Reason for Transport

Item # Account # Reason for transport Comments

10 40260069 Due to Uncontrolled Hematemesis PCR did not provide details as to the services patient was being transferred to another hospital for that were not available at sending facility.

96%

4%

Medical Necessity

Accurate

Inaccurate


Figure 7. Reason for Transport

Modifiers

Claims filed for reimbursement by most all insurers, including Medicare and Medicaid, require that claims be filed with specific modifiers to identify both the point of origin and the destination of the ambulance transport. The first single digit modifier indicates the point of origin and the second single digit modifier indicates the destination. It is a requirement of both Medicare and Medicaid that transports be from and to a covered destination in order to be eligible for reimbursement. As an example, transports “to” a doctor’s office are not considered a covered destination (with limited exception as outlined in the CMS rules and regulations), however, a transport “from” a doctor’s office “to” a hospital may be covered if other conditions and requirements are met for the purposes of identifying the medical necessity of transport by ambulance to that destination and that the services to be received at the hospital are also medically necessary. Modifiers may not directly influence payment of a claim, however, they should be used to accurately support the origin and destination documented in the patient care report. Inaccuracy in the use of modifiers can be an identifier of other documentation problems or errors that could cause billing errors and/or put the service at risk. In Texas, Medicaid claims must be submitted with an ET modifier, preceding the origin and destination modifier, for each procedure code submitted for emergency transports. Any emergency transport procedure code without the ET modifier will be subject to prior authorization requirements. All Texas Medicaid claims reviewed accurately provided the ET modifier on both procedure codes. Figure 8 provides a breakdown of the original modifiers provided on the CMS 1500 forms. Figure 8. Original Modifiers

Modifier Quantity Modifier Quantity Modifier Quantity HH 0 SH 4 RH 32 EH 1 NH 1 ETPH 1

ETRH 7 ETEH 1 ETSH 2

98%

2%

Reason for Transport

Accurate

Inaccurate


ETHH 0 QL 1

Of the 50 claims reviewed, four claims were found to have incorrect modifiers. The claim submitted for Item 10 provided an original modifier of ETPH (Physician’s Office to Hospital), however, the PCR indicated that the pickup location was a hospital emergency room. The correct modifier would have been ETHH. The claim for Item 16 provided an original modifier was ETRH (Residence to Hospital) when the PCR indicates that the pickup location was at a park (scene). The correct modifier would be ETSH. Item 5 and 25 were deemed not medically necessary transports as outlined in medical necessity section of this report, the GY modifier should have accompanied the origin and destination modifier to indicate that the services were non-covered for Medicare and Medicaid. 2.2.57 of the Texas Medicaid Provider Procedure Manual provides information on the appropriate modifiers to use for claim submission for not medically necessary transports which is provided at the end of this report in Attachment D. Figure 9, below, graphically illustrates the percentage of correct modifiers verses the percentage of claims having an incorrect modifiers for this claims review. Figure 9. Modifiers

Coding of Charges

The claims reviewed for this report provided 99 charges associated with the 50 transports. The breakdown of charges were 50 base rates, and 49 mileage rates. No mileage was billed for Item 23 due to the patient passing away after dispatch but before patient was loaded into the ambulance. Medicare does allow for billing for deceased patients with a BLS base rate, no mileage, and a specific modifier of QL. Figure 10 below, graphically illustrates the original base rates.

92%

8%

Modifiers

Accurate

Inaccurate


Figure 10. Original Base Rate Comparison

CMS and the Office of the Inspector General (OIG) have placed special focus on claims that are billed for reimbursement at levels of service higher than that required by the patient at the time of transport and/or are contradictory to the information provided in the Patient Care Report and the supporting documents. Figure 11, provided the claims that did not provide adequate documentation to support the level of service billed. Figure 11. Inaccurate Base Rates

Item #

Account # HCPCS Billed

Correct HCPCS

Comments

2 40384440 A0427 A0429 Threat to self is a BLS service.

27 40247872 A0429 A0427 Abdominal pain with other symptoms (vomiting) is an ALS service.

Figure 12, provides the coding of charges percentage out of the 50 codes provided.

010

20

30

40

ALS 2(A0433) ALS-E

(A0427) BLS-E(A0429)

1

32

17

Base Rate Comparison


Figure 12. Coding of Charges Percentage

Diagnosis and Condition Coding

Effective October 1, 2015 all Medicare ambulance transports require dual diagnosis codes. The primary diagnosis code should reflect the patient’s condition at the time of transport and the secondary code must report the patients need for the ambulance service and personnel at the time of transport. Medical necessity and coverage of ambulance transport is not based merely on the presence of a specific diagnosis. When billing, the code that best describes the patient’s condition at the time of transport, should be selected based on information provided in the patient care report. It is important to report specific codes related to a diagnosis only when provided by a physician, otherwise signs/symptoms as observed and recorded by the transport crew at the time of transport or unspecified codes are the best choice to accurately reflect the health care encounter. The patient care report should be reviewed and the claim coded based on each health care encounter and the level of certainty of the patient’s condition known for that transport. Information received at the time of dispatch (reason for response) is also important and may be relevant in support of the billing of claims. A total of 87 condition/diagnoses codes utilized in the billing of the 50 claims analyzed in this review. The use of appropriate diagnosis/condition coding is demonstrated for 78 of those 87 codes. As shown in Figure 13 below, based on the population of codes used, this is a 10.3% error rate in the assignment of those condition codes for the claims examined for this report.

96%

4%

Coding of Charges

Accurate

Inaccurate


Figure 13. Diagnosis and Condition Coding Percentage

Figure 14 summarizes the claim with incorrect primary diagnosis and condition codes. Figure 14. Inaccurate Diagnosis and Condition Coding

Item # Account # Comments

7 40076608 K29.90 (Gastroduodenitis, unspecified without bleeding) is a diagnosis, the symptom/sign stated in the PCR was vomiting of blood which is K92.0 (Hematemesis).

10 40260069 R41.82 (Altered mental status) would not be a specific primary code. The PCR states the interfacility transfer is due to uncontrolled hematemesis, K92.0 (Hematemesis) would be the appropriate primary code.

13 40267190 A generic ICD-10 code R10.84 (Generalized abdominal pain) was used, but the chart provided specific details of abdominal pain to right upper quadrant, R10.11 (Right upper quadrant pain) would have been a more appropriate code.

17 40338534 R58 (Hemorrhage, not elsewhere classified) was information provided from the doctor’s visit earlier in the day, the reason for the transport was kidney pain. N23 (Unspecified renal colic) is a type of abdominal pain usually caused by kidney stones.

25 40199924 E11.65 (Type 2 diabetes mellitus with hyperglycemia) is a diagnosis, the information provided in the chart states swelling to left leg, a more appropriate primary code would be R60.0 (Localized Edema).

32 39978562 I67.89 (Other cerebrovascular disease) was selected as primary, the sign/symptoms provided in the chart was R53.1 (Weakness).

35 40206252 A generic code of R52 (Pain, unspecified) was provided but the chart provide specific information. M25.52 (Pain in right hip) would be a more appropriate code.

36 40364123 A generic code of R52 (Pain, unspecified) was provided but the chart provide specific information. M79.672 (Pain in left foot) would be a more appropriate code.

41 40054537 S49.92XA (Unspecified injury of left shoulder and upper arm – initial encounter) was coded as primary, but the chart states that pain was in the left hip. M25.552 (Pain in left hip) would be the correct code.

89.7%

10.3%

Diagnosis and Condition Coding

Accurate ICD-10 Code

Inaccurate ICD-10 Code


Beneficiary Signatures

Chapter 10, Section 20.1.2 (Beneficiary Signature Requirements) of the Medicare Benefit Policy Manual outlines the specific requirements that must be met for obtaining appropriate patient signatures for billing ambulance claims to Medicare. The signature of the beneficiary is required for Medicare for the purposes of accepting assignment and for submitting claims for transport services. If the patient is unable to sign, the specific mental or physical reason must be documented in the Patient Care Report, or on the Signature Form, specifically stating that the condition prevented the patient from signing, and an appropriate alternate signature must be obtained. Thirty-nine (39) claims in this review were for transport of Medicare beneficiaries, and 39 contained appropriate patient or acceptable alternate signatures. However, 3 of these claims, Items 4, 18 and 29 although having an acceptable alternate signatures had no specifically stated reason that the patient was unable to sign other than “patient care transferred”. This is not an acceptable reason for the patient being unable to sign the assignment of benefits and HIPPA acknowledgement form. Item 4 was a Medicaid claim and does not technically have the same signature requirements, as participation in the Medicaid program constitutes the agreement of assignment and allowance for claims submittal for services. However, as a best practice, FITCH recommends getting a signature for all claims, no matter the payer source. Medicare claims, on the other hand, which Items 18 and 29 were, require appropriate signatures to be on file prior to sending a claim from reimbursement to Medicare. Figure 15 below provides the error percentage for the beneficiary signatures. Figure 15. Beneficiary Signature Error Percentage

92%

8%

Beneficiary Signature Error Percentage




Receiving Facility Signatures

Medicare has implemented the legibility rule which requires that all signatures be legible or have an accompanying printed version of the signors name and any applicable credentials. The Patient Care Report provides a signature section for the hospital/receiving agent to verify the transfer of care from the ambulance provider to the facility. This claims review showed a consistent error in this process for obtaining credentials from receiving facilities personnel. Of the 50 claims reviewed, 14 did not provide all three items for the person signing or that delivered the information, and 1 provided no information at all. It is best practice to constantly obtain the first and last name and credentials of the receiving representative. Figure 16. Receiving Facility Signature Section

Item # Incident # Comments

6 40075324 No credentials of the receiving representative





18 40324304 No signature or credentials of the receiving representative










Additional training is recommended to the crew members concerning the significance of getting complete documentation, including first and last names with credentials. Figure 17 below emphasizes the error percentage for receiving facility signatures.


Figure 17. Receiving Facility Signature Error Percentage

Crew Signatures

Novitas Solutions states in their Ambulance Trip/Run Sheet Record Documentation article that “Signatures, including credentials, from the provider(s), who renders the services documented: Services provided/ordered must be authenticated by the author.” Review of the claims provided by El Paso show significant inconsistency in the requirements being met for recording of crew member signatures. Of the 50 claims reviewed, 20 claims only provided 1 crew member signature. The crew members typed name is provided on each page of the patient care report, but that does not replace the signature or meet the Medicare signature requirements. The error rate in this sample for not obtaining both crew members signatures is 40%. Signature logs which include the typed and printed name of the crew member along with the usual signature of that person, on file and regularly maintained at the department are a good practice in the event a signature is not legible. As of the writing of this report it was not determined if such a log is on file and updated at El Paso Fire Department. This, however, does not absolve crew members from signing their charts. Best Practice, to meet the requirements of the rule, is to have both crew members sign each patient care report when the transport and documentation of such is completed, providing attestation to the events and accuracy of the information recorded in the chart. Figure 18 reflects the claims that only provided 1 crew member signature and Figure 19, graphically illustrates the percentage of one crew member signatures verses the percentage of claims having two crew member signatures for this claims review.

71%

29%

Receiving Facility Signature Error Percentage




Figure 18. Crew Missing Signatures

Item # Incident # Comments

2 40384440 Only one crew members signature provided on PCR.





















Figure 19. 2 Crew Member Signatures vs 1 Crew Member Signature

60%40%

Signature Percentage

2 Crew Signatures

1 Crew Signature


Findings Summary In the event of an actual audit, and when services have been placed under corporate integrity agreements, the regulating agencies focus on areas with greater than 5% error rates, as well multiple error rates across the various areas reviewed. This report acknowledged that medical necessity and modifiers were less than the 5% error rate used as a benchmark that would indicate the possibility of more serious issues which might require an increased evaluation of the population of claims. Several other areas reviewed, however, had higher than 5% error rates. This does suggest that El Paso could be at risk for making errors that could result in inappropriate billing of claims to Federal health care providers. It is recommended that El Paso management review, assess and make process improvements to the areas identified in this report discussed below. These areas may require additional training of staff to improve and ensure compliance with Federal health care provider guidelines. Six areas are identified for improvement.

Mileage: Medicare requires that patient loaded mileage be reported in fractional units and billed to the nearest 1/10th of a mile. Standard academic and statistical principles dictates that rounding decimals to the nearest 1/10th is dependent on the number in the 1/100th place, if such exist. Example: 9.15 is rounded to 9.2. If the number in the 1/100th position is less than 5, the number in the 1/10th place does not round up. Example: 9.14 is 9.1. A recommendation would be to have the mileage tracking system automatically round, leaving less human error for the calculations. The CMS document related to this topic has been included with this report as Attachment C.

Coding of Charges: While this is below 5%, it is suggested to be monitored and seek to continuously improve. A recommendation would be to continually provide training to the crews to create a patient care report that is a thorough, accurate, and objective description of all signs and symptoms exhibited by the patient at the time of pick up, during the transport, and at hand off to the receiving entity, as well as any treatments or therapies and the outcomes of each, and finally to use the narrative to “paint a picture” of the patient’s condition that may not otherwise be able to be ascertained from the other information in the report. Additionally, this information should be reviewed with the person(s) responsible for assigning the codes and charges in order to ensure all parties are clear as to the responsibility to accurately report the level of service.

Diagnoses and Condition Coding: Medical necessity and coverage of ambulance transport is not based merely on the presence of a specific diagnosis. When billing, the coder should be able to assign a code or codes that best describes the patients’ condition at the time of transport, reporting the signs and symptoms observed and reported in the patient care report by the crew. With the implementation of ICD-10, more specific codes are to be utilized when coding claims. This requires a thorough description be provided by the transport crews in order to allow the billing team to assign the most accurate code(s) available. While this field of coding does not currently impact reimbursement directly, it does often provide necessary support for other critical elements such as support of medical necessity and assignment of charges based on service level. Errors here can increase El Paso’s risk of non-compliant billing.

Beneficiary signatures: The signature of the beneficiary is required for Medicare for the purposes of accepting assignment and for submitting claims for transport services. When a patient is unable to sign, the specific mental or physical reason must be documented on the signature form and should be supported in the patient care report. When the patient is


unable to sign an appropriate alternate signature must be obtained. If a patient refuses to sign the form, although they are physically and mentally capable, this should be documented as a refusal to sign. An appropriately completed Signature Form must be obtained prior to a bill being submitted to Medicare for reimbursement.

Receiving facility signatures: Medicare has designed the legibility rule that requires that all signatures be legible or have an accompanying printed version of the signors name and any applicable credentials. The signature section for the hospital/receiving agent on the Patient Care Report is provided to verify the transfer of care from the ambulance provider to the facility. This claims review displayed discrepancy in this process for obtaining credentials from receiving facilities. El Paso should stress the importance of obtaining signatures and legible, full names and credentials, of the persons accepting the patient at the receiving facilities. Failure to do so puts the service at risk for non-compliance of this rule.

Crew signatures: Only 60% of the PCRs provided had both crew members’ signatures on the form. Medicare requires that all medical records be authenticated by the author, this requirement is met by having all crew members that rendered services to the patient sign the PCR. Each crew member participating in a patient transport has responsibilities including attesting to the duties they performed and the facts reported in the patient care report. Failure on behalf of all crew members to review the patient care report for accuracy and signing as to their role and responsibility puts the service at risk for non-compliance with Federal health care provider rules and regulations.

Overall Quantified Results

Figure 20. Error Rate Quantification

Claims Review Findings Error Percentages

Mileage 35%

Medical Necessity and Coverage 4%

Reason for Transport 2%

Modifiers 8%

Coding of Charges 4%

Diagnoses and Condition Coding 10.3%

Beneficiary Signature 8%

Receiving Facility Signature 29%

Crew Signature 40%


Conclusion The claims review identified multiple areas of concern and risk for El Paso Fire Department as related to the accuracy of charging and coding ambulance claims. These include mileage billing, ICD-10 diagnoses, and receiving facility and crew member signatures. It is important to understand that whether deliberate or accidental, negligence in any area can result in non-complaint billing practices, putting the organization at risk for fraud, overpayments and penalties, both monetary and civil. The OIG is concerned with compliance error rates 5% and greater. Additionally, errors in multiple areas of review, even when quantified to be lower than 5% can be a sign of other issues and should give rise to concern and necessitates need for prompt address. It is recommended that El Paso Fire Department make process improvements to the areas detailed in this report and provide additional training on particular aspects of the charting and billing process.

Credentials Anthony Minge, EdD, Fitch & Associates Partner, designed the original plan for the full sampling and reviewed the findings. The curriculum vitae for Anthony Minge is included in attachment C. A certified ambulance coder, Melissa Coons, reviewed the claims including codes used for diagnosis and compared them with the documentation. Mrs. Coons’ curriculum vitae is also included in attachment C.


Attachment A

Compliance Review Worksheet

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1 16-059747 40073510 2817034341010 CARE 9/23/2016 3.00 3.0 Y NA A0427 ALS 1 Emerg Y Y NA NH Y NA Y $785.00 $403.84 $403.84 Y S01.90XA

A0425 Ground Mileage $45.00 $21.72 $21.72 Y Z74.3

2 16-0565014 40384440 2816294495190 CARE 10/17/2016 3.25 3.3 Y NA A0427 ALS 1 Emerg N Y NA RH Y NA Y $785.00 $403.84 $340.07 Y F29


3 16-063769 40312529 3216291509980 CARE 10/12/2016 1.93 2.0 N NA A0427 ALS 1 Emerg Y Y NA RH Y NA Y $785.00 $403.84 $403.84 Y R10.13


4 16-054699 39744761 1000200302016290000 CAID 9/1/2016 14.28 15.0 Y NA A0427 ALS 1 Emerg Y Y Y ETEH Y NA Y $785.00 $306.75 $306.75 Y R06.89


5 16-054755 39745139 5759LF839743139 CAID 9/1/2016 5.42 6.0 Y NA A0429 BLS Emerg Y N N ETRH N NA Y $785.00 $228.22 $0.00 Y R68.89

A0425 Ground Mileage $90.00 $26.85 $0.00

6 16-060002 40075324 2817020733020 CARE 9/24/2016 3.98 4.0 N NA A0427 ALS 1 Emerg Y Y NA RH Y NA Error $785.00 $403.84 $340.07 Y M25.50


7 16-060148 40076608 2916278058670 CARE 9/25/2016 1.21 1.3 N NA A0427 ALS 1 Emerg Y Y NA RH Y NA Error $785.00 $403.84 $403.84 N K29.90


8 16-064235 40338584 2816293800450 CARE 10/14/2016 9.96 10.0 N NA A0429 BLS Emerg Y Y NA RH Y NA Y $785.00 $340.07 $340.07 Y R11.0


9 16-065295 40403541 3216298173260 CARE 10/19/2016 6.22 6.3 N NA A0427 ALS 1 Emerg Y Y NA RH Y NA Y $785.00 $403.84 $403.84 Y M54.9

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10 16-062065 40260069 1000200302016286801 CAID 10/4/2016 5.98 6.0 Y N A0433 ALS 2 Y Y NA ETPH N N Y $785.00 $443.98 $443.98 N R41.82

A0425 Ground Mileage $90.00 $20.36 $20.36

11 16-060439 40104514 2816279890350 CARE 9/26/2016 12.25 12.3 Y NA A0427 ALS 1 Emerg Y Y NA RH Y NA Y $785.00 $403.84 $403.84 Y K92.0


12 16-058282 39979073 2916273574030 CARE 9/17/2016 1.51 1.6 N NA A0427 ALS 1 Emerg Y Y Y RH Y NA Error $785.00 $403.84 $403.84 Y M54.5


13 16-063047 40267190 2816287448270 CARE 10/8/2016 3.50 3.5 Y NA A0427 ALS 1 Emerg Y Y NA RH Y NA Y $785.00 $403.84 $403.84 N R10.84


14 16-061497 40170100 2816334433950 CARE 10/1/2016 6.80 6.8 Y NA A0429 BLS Emerg Y Y NA SH Y NA Error $785.00 $340.07 $340.07 Y S99.911A


15 16-055428 40032187 3216270369080 CARE 9/5/2016 8.81 8.9 N NA A0429 BLS Emerg Y Y NA RH Y NA Error $785.00 $340.07 $340.07 Y M54.9

A0425 Ground Mileage $135.00 $64.44 $63.71 Z74.3

16 16-058379 39986180 57XV9CG39986180 CAID 9/17/2016 1.30 2.0 Y NA A0429 BLS Emerg Y Y NA ETRH N NA Y $785.00 $228.22 $228.22 Y F29

A0425 Ground Mileage $30.00 $8.95 $8.95

17 16-064231 40338534 2000200302016290000 CAID 10/14/2016 3.79 4.0 Y NA A0429 BLS Emerg Y Y Y ETRH Y NA Y $785.00 $258.31 $258.31 N R58

A0425 Ground Mileage $60.00 $20.24 $20.24

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18 16-064015 40324304 2816292724740 CARE 10/13/2016 1.00 1.0 Y NA A0427 ALS 1 Emerg Y Y NA RH Y NA N $785.00 $403.84 $403.84 Y R06.02


19 16-059102 40026146 126167882600 CAID 9/20/2016 2.00 2.0 N NA A0429 BLS Emerg Y Y Y ETSH Y NA Error $785.00 $228.22 $228.22 Y R73.09

A0425 Ground Mileage $20.00 $8.95 $8.95

20 16-067582 40544776 2916320789030 CARE 10/29/2016 2.74 2.7 Y NA A0427 ALS 1 Emerg Y Y Y RH Y NA Error $785.00 $403.84 $403.84 Y R10.84


21 16-059031 40022638 3216277451710 CARE 9/20/2016 11.75 11.8 Y NA A0427 ALS 1 Emerg Y Y Y RH Y NA Y $785.00 $403.84 $403.84 Y S49.92XA


22 16-066393 40481764 28163026944550 CARE 10/24/2016 6.70 6.7 Y NA A0429 BLS Emerg Y Y NA RH Y NA Y $785.00 $340.07 $340.07 Y R10.819


23 16-067844 40559587 2916320789090 CARE 10/31/2016 0.00 0.0 NA NA A0429 BLS Emerg Y Y NA QL Y NA NA $785.00 $340.07 $340.07 Y I46.9

$0.00 $0.00 $0.00

24 16-061586 40171575 3816286013370 CARE 10/2/2016 1.58 1.6 Y NA A0427 ALS 1 Emerg Y Y NA SH Y NA Y $785.00 $403.84 $403.84 Y R11.0


25 16-062130 40199924 2216286728320 CARE 10/4/2016 15.06 15.1 Y NA A0429 BLS Emerg Y N NA RH N NA Error $785.00 $340.07 $0.00 N E11.65


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26 16-061097 40164287 136298156700 CAID 9/30/2016 3.00 3.0 Y NA A0427 ALS 1 Emerg Y Y Y ETSH Y NA Y $785.00 $271.02 $271.02 Y T50.904A

A0425 Ground Mileage $45.00 $13.42 $13.42

27 16-062691 40247872 2816287447940 CARE 10/7/2016 4.41 4.5 N NA A0429 BLS Emerg N Y Y RH Y NA Y $785.00 $340.07 $403.84 Y R10.9


28 16-058701 40000954 2816274720500 CARE 9/19/2016 3.90 3.9 Y NA A0427 ALS 1 Emerg Y Y NA RH Y NA Y $785.00 $403.84 $403.84 Y S39.82XA


29 16-064258 40338877 2816293800490 CARE 10/14/2016 0.44 0.5 N NA A0427 ALS 1 Emerg Y Y NA RH Y NA Y $785.00 $403.84 $403.84 Y T50.904A


30 16-060811 40127082 2816280544790 CARE 9/28/2016 2.74 2.8 N NA A0427 ALS 1 Emerg Y Y NA RH Y NA Error $785.00 $403.84 $403.84 Y R07.9


31 16-058370 39986046 2916273574070 CARE 9/17/2016 3.38 3.4 Y NA A0427 ALS 1 Emerg Y Y NA EH Y NA Y $785.00 $403.84 $403.84 Y T07


32 16-058268 39978562 2916273573980 CARE 9/17/2016 8.82 8.9 N NA A0427 ALS 1 Emerg Y Y NA RH Y NA Y $785.00 $403.84 $403.84 N I67.89


33 16-060423 40110563 2816279890280 CARE 9/26/2016 3.83 3.9 N NA A0427 ALS 1 Emerg Y Y NA RH Y NA Y $785.00 $403.84 $403.84 Y R07.9


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34 16-056831 39879831 2817033714140 CARE 9/10/2016 2.26 2.3 Y NA A0427 ALS 1 Emerg Y Y NA RH Y NA Y $785.00 $403.84 $403.84 Y R06.00


35 16-062206 40206252 136361635300 CAID 10/4/2016 1.95 2.0 Y NA A0429 BLS Emerg Y Y Y ETRH Y NA Error $785.00 $228.22 $228.22 N R52

A0425 Ground Mileage $30.00 $8.95 $8.95

36 16-064603 40364123 2816293800680 CARE 10/16/2016 8.18 8.2 Y NA A0429 BLS Emerg Y Y NA RH Y NA Error $785.00 $340.07 $340.07 N R52


37 16-055665 39798847 135799396200 CAID 9/6/2016 2.86 3.0 Y NA A0427 ALS 1 Emerg Y Y Y ETRH Y NA Y $785.00 $271.02 $271.02 Y F29

A0425 Ground Mileage $45.00 $13.42 $13.42

38 16-063659 40302650 2816293800350 CARE 10/11/2016 7.41 7.5 N NA A0429 BLS Emerg Y Y NA SH Y NA Y $785.00 $340.07 $340.07 Y F29




40 16-062136 40213657 58K2FZ-40213657 CAID 10/4/2016 8.90 9.0 Y NA A0427 ALS 1 Emerg Y Y Y ETRH Y NA Y $785.00 $271.02 $271.02 Y R41.82

A0425 Ground Mileage $135.00 $40.27 $40.27

41 16-059581 40054537 2816295605320 CARE 9/22/2016 1.99 2.0 N NA A0429 BLS Emerg Y Y NA RH Y NA Y $785.00 $340.07 $340.07 N S49.92XA


42 16-055005 39763711 2917003542560 CARE 9/3/2016 2.72 2.8 N NA A0429 BLS Emerg Y Y NA SH Y NA Y $785.00 $340.07 $340.07 Y S09.90XA

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44 16-060396 40110860 2816279890430 CARE 9/26/2016 0.87 0.9 Y NA A0427 ALS 1 Emerg Y Y NA RH Y NA Error $785.00 $403.84 $403.84 Y R55


45 16-064583 40364355 2816293800750 CARE 10/15/2016 0.90 0.9 Y NA A0429 BLS Emerg Y Y NA RH Y NA Y $785.00 $340.07 $340.07 Y T07




47 16-064883 40374864 136573745900 CAID 10/17/2016 6.82 7.0 Y NA A0427 ALS 1 Emerg Y Y Y ETRH Y NA Y $785.00 $271.02 $271.02 Y R73.09

A0425 Ground Mileage $105.00 $31.32 $31.32

48 16-065515 40437877 2816301485720 CARE 10/20/2016 3.31 3.4 N NA A0427 ALS 1 Emerg Y Y NA RH Y NA Y $785.00 $403.84 $403.84 Y T14.90


49 16-067817 40556082 2917037094340 CARE 10/31/2016 6.90 6.9 Y NA A0427 ALS 1 Emerg Y Y NA RH Y NA Error $785.00 $403.84 $403.84 Y R06.02


50 16-066258 40462384 2816357220920 CARE 10/23/2016 2.60 2.6 Y NA A0427 ALS 1 Emerg Y Y NA RH Y NA Error $785.00 $403.84 $403.84 Y R06.02



Attachment B

RAT STATS Printout

Windows RAT-STATS Statistical Software Random Number Generator

Date: 5/17/2017 Time: 11:44Audit:Order Value Account Number Seed Number Frame Size

1 1059 40073510 42254.27 1,6352 1090 403844403 974 403125294 683 397447615 130 397451396 1166 400753247 912 400766088 896 403385849 1355 40403541

10 1349 4026006911 1558 4010451412 928 3997907313 543 4026719014 417 4017010015 836 4003218716 29 3998618017 147 4033853418 885 4032430419 30 4002614620 1043 4054477621 1544 4002263822 808 4048176423 168 4055958724 452 4017157525 1351 4019992426 254 4016428727 311 4024787228 1150 4000095429 854 4033887730 1041 4012708231 1098 3998604632 1453 3997856233 1152 4011056334 1006 3987983135 34 4020625236 827 4036412337 246 3979884738 819 4030265039 1070 3989554440 442 4021365741 630 40054537

El Paso Sept-Oct 2016 Claims Review

42 668 3976371143 497 4032457344 876 4011086045 575 4036435546 1523 4009464047 395 4037486448 105 4043787749 1388 4055608250 1034 40462384

Order Value Account Number51 1479 4042257452 711 3986205953 1256 4036414054 1055 4001291955 947 4015524456 1375 4027485157 456 4032429158 495 3979569159 1597 4018182960 265 40447401


Attachment C

MLN Matters CMS Fractional Mileage

Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2009 American Medical Association.

Page 1 of 3

News Flash – If you are a Medicare Fee-For-Service physician, provider, or supplier submitting claims to Medicare for payment, this is very important information you need to know. Effective immediately, any Medicare Fee-For-Service claim with a date of service on or after Jan 1, 2010, must be received by your Medicare contractor no later than one calendar year (12 months) from the claim’s date of service – or Medicare will deny the claim. For additional information, see MLN Matters® Articles MM6960 at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM6960.pdf and MM7080 at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7080.pdf on the CMS website. You can also listen to a podcast on this subject by visiting http://www.cms.gov/Outreach-and-Education/Outreach/CMSFeeds/index.html on the same site.

MLN Matters® Number: MM7065 Revised Related Change Request (CR) #: 7065

Related CR Release Date: November 19, 2010 Effective Date: January 1, 2011

Related CR Transmittal #: R2103CP Implementation Date: January 3, 2011

Fractional Mileage Amounts Submitted on Ambulance Claims

Note: This article was updated on August 8, 2012, to reflect current Web addresses. Previously, it was revised on December 7, 2011, to add a reference to MLN Matters® article MM7557 (http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7557.pdf) to alert ambulance billers that use the UB04 that the fractional mileage requirements apply (effective August 1, 2011) to paper billing. All other information remains the same.

Provider Types Affected

This article is for providers and suppliers of ambulance services who bill Medicare contractors (carriers, fiscal intermediaries (FIs), or Part A/B Medicare Administrative Contractors (A/B MACs)) for those services.

What You Need to Know

Change Request (CR) 7065, from which this article is taken, provides a new

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM6960.pdf�




http://www.cms.gov/Outreach-and-Education/Outreach/CMSFeeds/index.html�

http://www.cms.gov/Outreach-and-Education/Outreach/CMSFeeds/index.html�



MLN Matters® Number: MM7065 Related Change Request Number: 7065


Page 2 of 3

procedure for reporting fractional mileage amounts on ambulance claims, effective for claims for dates of service on or after January 1, 2011. Prior to that date, mileage is reported by rounding the total mileage up to the nearest whole mile. Be sure billing personnel are aware of this change that requires ambulance providers and suppliers to report to the nearest tenth of a mile for total mileage of less than 100 miles on ambulance claims as of January 1, 2011.

Background

Currently, the Medicare Claims Processing Manual, Chapter 15, Sections 30.1.2 and 30.2.1 require that ambulance providers and suppliers submitting claims to Medicare contractors use the appropriate Healthcare Common Procedure Coding System (HCPCS) code for ambulance mileage to report the number of miles traveled during a Medicare-reimbursable trip for the purpose of determining payment for mileage. According to these instructions from the Centers for Medicare & Medicaid Services (CMS), providers and suppliers are required to round the total mileage up to the nearest whole mile, including trips of less than one whole mile. For example, if the total number of round trip miles traveled equals 9.5 miles, the provider or supplier enters 10 units on the claim form or the corresponding loop and segment of the ANSI X12N 837 electronic claim. For ambulance suppliers submitting claims to the Medicare carriers or A/B MACs, the Medicare Claims Processing Manual, Chapter 26, Section10.4 additionally states that at least one (1) unit must be billed in Item 24G on the CMS-1500 claim form or the corresponding loop and segment of the ANSI X12N 837P electronic claim. Therefore, if a supplier travels less than one mile during a covered trip, the supplier would enter 1 unit on the claim form with the appropriate HCPCS code for mileage. In the CY 2011 Medicare Physician Fee Schedule (MPFS) final rule, CMS established a new procedure for reporting fractional mileage amounts on ambulance claims to improve reporting and payment accuracy. The final rule requires that, effective January 1, 2011, all Medicare ambulance providers and suppliers bill mileage that is accurate to a tenth of a mile.

NOTE: Currently the hardcopy UB-04 form cannot accommodate fractional billing, therefore, hardcopy billers will continue to use previous ambulance billing instructions provided in effect prior to January 1, 2011, that is, providers that are permitted to file paper UB-04 claims will continue to round up to the nearest whole mile until further notice from CMS.

Effective for claims with dates of service on and after January 1, 2011, ambulance providers and suppliers must report mileage units rounded up to the nearest tenth of a mile for all claims (except hard copy billers that use the UB-04) for mileage totaling less than 100 covered miles. Providers and suppliers must submit

MLN Matters® Number: MM7065 Related Change Request Number: 7065

Page 3 of 3

fractional mileage using a decimal in the appropriate place (e.g., 99.9). Medicare contractors will truncate mileage units with fractional amounts reported to greater than one decimal place (e.g., 99.99 will become 99.9 after truncating the hundredths place). For trips totaling 100 miles and greater, suppliers must continue to report mileage rounded up to the nearest whole number mile (e.g., 999). Medicare contractors will truncate mileage units totaling 100 and greater that are reported with fractional mileage; (e.g., 100.99 will become 100 after truncating the decimal places). For mileage totaling less than 1 mile, providers and suppliers must include a “0” prior to the decimal point (e.g., 0.9). For ambulance mileage HCPCS only, Medicare contractors will automatically default “0.1” unit when the total mileage units are missing in Item 24G of the CMS-1500 claim form.

NOTE: The remittance advice for provider-based ambulance services will indicate whole units, rather than fractions, for providers that have not transitioned to the 5010 format. However, the payment reported on the remittance advice may be paid based off fractional mileages as reported on the institutional claim.

Additional Information

The official instruction, CR 7065, issued to your Medicare contractor regarding this change may be viewed at http://www.cms.hhs.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2103CP.pdf on the CMS website. If you have any questions, please contact your Medicare contractor at their toll-free number, which may be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/provider-compliance-interactive-map/index.html on the CMS website.

News Flash - Each Office Visit is an Opportunity. Medicare patients give many reasons for not getting their annual flu vaccination, but the fact is that there are 36,000 flu-related deaths in the United States each year, on average. More than 90% of these deaths occur in people 65 years of age and older. Please talk with your Medicare patients about the importance of getting their annual flu vaccination. This Medicare-covered preventive service will protect them for the entire flu season. And remember, vaccination is important for health care workers too, who may spread the flu to high risk patients. Don’t forget to immunize yourself and your staff. Protect your patients. Protect your family. Protect yourself. Get Your Flu Vaccine - Not the Flu. Remember – Influenza vaccine plus its administration are covered Part B benefits. Note that influenza vaccine is NOT a Part D covered drug. For information about Medicare’s coverage of the influenza vaccine and its administration, as well as related educational resources for health care professionals and their staff, please visit http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Flu_Products.pdf and http://www.cms.gov/Medicare/Prevention/Immunizations/index.html on the CMS website.


http://www.cms.hhs.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2103CP.pdf�

http://www.cms.hhs.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2103CP.pdf�

http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/provider-compliance-interactive-map/index.html�



http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Flu_Products.pdf�

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Flu_Products.pdf�

http://www.cms.gov/Medicare/Prevention/Immunizations/index.html�


Attachment D

2.2.5.7 Not Medically Necessary Transports

AMBULANCE SERVICES HANDBOOK AUGUST 2017

8CPT ONLY - COPYRIGHT 2016 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

2.2.5.2 Air or Specialized Vehicle Transports

Air ambulance transport services, by means of either fixed or rotary wing aircraft, and other specialized emergency medical services vehicles may be covered only if one of the following conditions exists:

• The client’s medical condition requires immediate and rapid ambulance transportation that could not have been provided by standard automotive ground ambulance.

• The point of client pick up is inaccessible by standard automotive ground vehicle.

• Great distances or other obstacles are involved in transporting the client to the nearest appropriate facility.

Claims for air ambulance transports procedure codes A0430 and A0431 must be submitted with the corresponding air mileage procedure code A0435 or A0436.

2.2.5.3 Specialty Care Transport (SCT)

SCT (procedure code A0434) is the interfacility transport of a critically injured or ill client by a ground ambulance vehicle, including the provision of medically necessary supplies and services, at a level of service beyond the scope of the emergency medical technician (EMT) or paramedic. SCT is necessary when a client’s condition requires ongoing care that must be furnished by one or more health profes-sionals in an appropriate specialty area, for example, emergency or critical-care nursing, emergency medicine, respiratory care, cardiovascular care, or a paramedic with additional training.

2.2.5.4 Transports for Pregnancies

Transporting a pregnant woman may be covered as an emergency transfer if the client’s condition is documented as an emergency situation at the time of transfer.

Claims documenting an emergency home delivery or delivery en route are considered emergency transfers. Premature labor and early onset of delivery (less than 37 weeks gestation) may also be considered an emergency. Active labor without more documentation of an emergency situation is not payable as an emergency transport.

If the pregnant client is transported in an ambulance for a nonemergency situation, all criteria for nonemergency prior authorization must be met.

2.2.5.5 Transports to or from Prescribed Pediatric Extended Care Centers (PPECC)

Non-emergency ambulance transports between a client’s home and a PPECC are not covered.

2.2.5.6 Transports to or from State Institutions

Ambulance transports to or from a state-funded hospital for admission or following discharge are covered when nonemergency transfer criteria are met. Ambulance transfers of clients while they are inpatients of the institution are not covered. The institution is responsible for routine nonemergency transportation.

2.2.5.7 Not Medically Necessary Transports

Providers must use the GY modifier to submit claims for instances when the provider is aware no medical necessity existed. When billing for this type of transportation, ambulance providers must maintain a signed Client Acknowledgment Statement indicating that the client was aware, prior to service rendered, that the transport was not medically necessary. The Client Acknowledgment Statement is subject to retrospective review.

Refer to: Subsection 1.6.9.1, “Client Acknowledgment Statement” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information).


1.6.9.1 Client Acknowledgement Statement

Attachment E

Texas Medicaid & Healthcare PartnershipCPT only copyright 2014 American Medical Association. All rights reserved.

December 2016 Texas Medicaid Provider Procedures Manual

Section 1: Provider Enrollment and Responsibilities : 1.6 Provider Responsibilities : 1.6.9 Billing Clients : 1.6.9.1 Client Acknowledgment Statement

1.6.9.1 Client Acknowledgment StatementTexas Medicaid only reimburses services that are medically necessary or benefits of special preventive and screening programs such as family planning and THSteps. Hospital admissions denied by the Texas Medical Review Program (TMRP) also apply under this policy.

The provider may bill the client only if:

• A specific service or item is provided at the client’s request.

• The provider has obtained and kept a written Client Acknowledgment Statement signed by the client that states:

• “I understand that, in the opinion of (provider’s name), the services or items that I have requested to be provided to me on (dates of service) may not be covered under the Texas Medical Assistance Program as being reasonable and medically necessary for my care. I understand that the HHSC or its health insuring agent determines the medical necessity of the services or items that I request and receive. I also understand that I am responsible for payment of the services or items I request and receive if these services or items are determined not to be reasonable and medically necessary for my care.”

• “Comprendo que, según la opinión del (nombre del proveedor), es posible que Medicaid no cubra los servicios o las provisiones que solicité (fecha del servicio) por no considerarlos razonables ni médicamente necesarios para mi salud. Comprendo que el Departamento de Salud de Texas o su agente de seguros de salud determina la necesidad médica de los servicios o de las provisiones que el cliente solicite o reciba. También comprendo que tengo la responsibilidad de pagar los servicios o provisiones que solicité y que reciba si después se determina que esos servicios y provisiones no son razonables ni médicamente necesarios para mi salud.”

A provider is allowed to bill the following to a client without obtaining a signed Client Acknowledgment Statement:

• Any service that is not a benefit of Texas Medicaid (for example, cellular therapy).

• All services incurred on noncovered days because of eligibility or spell of illness limitation. Total client liability is determined by reviewing the itemized statement and identifying specific charges incurred on the noncovered days. Spell of illness limitations do not apply to medically necessary stays for Medicaid clients who are 20 years of age and younger.

• The reduction in payment that is due to the Medically Needy Program (MNP) is limited to children who are 18 years of age and younger and pregnant women. The client’s potential liability would be equal to the amount of total charges applied to the spend down. Charges to clients for services provided on ineligible days must not exceed the charges applied to spend down.

• All services provided as a private pay patient. If the provider accepts the client as a private pay patient, the provider must advise clients that they are accepted as private pay patients at the time the service is provided and responsible for paying for all services received. In this situation, HHSC strongly encourages the provider to ensure that the client signs written notification so there is no question how the client was accepted. Without written, signed documentation that the Texas Medicaid client has been properly notified of the private pay status, the provider cannot seek payment from an eligible Texas Medicaid client.

• The client is accepted as a private pay patient pending Texas Medicaid eligibility determination and does not become eligible for Medicaid retroactively. The provider is allowed to bill the client as a private pay patient if retroactive eligibility is not granted. If the client becomes eligible retroactively, the client notifies the provider of the change in status. Ultimately, the provider is responsible for filing timely Texas Medicaid claims. If the client becomes eligible, the provider mustrefund any money paid by the client and file Medicaid claims for all services rendered.

A provider attempting to bill or recover money from a client in violation of the above conditions may be subject to exclusion from Texas Medicaid.

Important: Ancillary services must be coordinated and pertinent eligibility information must be shared. The primary care provider is responsible for sharing eligibility information with others (e.g., emergency room staff, laboratory staff, and pediatricians).

Page 1 of 1Client Acknowledgment Statement

8/2/2017http://www.tmhp.com/Manuals_HTML1/TMPPM/Archive/2016/Vol1_01_Provider_Enroll...


Curriculum Vitae

Attachment F

Anthony Minge, EdD Page 1

Anthony W. Minge, EdD 2901Williamsburg Terr., Ste G Partner, Fitch & Associates Platte City, Missouri 64079

SUMMARY Mr. Minge is a proven managerial executive with extensive experience in financial, operational, and

personnel management as well as planning, leadership and business development. His dynamic management and leadership characteristics combined with strong teaching, training, outreach, management, and marketing skills provide for market growth and development.

CAREER

Present Partner Fitch & Associates Platte City, Mo.

2007 -2012 Senior Associate / Director of Patient Accounts Fitch & Associates / MedServ International Platte City, Mo. Provides business and financial management of patient accounts department responsible for

processing more than 60,000 ground and air medical transport claims per year. Corporate Compliance Officer Develops accounts receivable management, policy and procedure, and protocol design for

multiple ground and air services Developed electronic “dashboard” style reporting product.

2006 – 2007 Manager of Business Services Northwest Medstar Spokane, Wash. Provided business and financial leadership and management of the air-medical transport system

of Inland Northwest Health Services Established and managed annual company strategic, operational and financial goals and

objectives. Carried out operation/strategic objectives Responsible for expense management and cash flow including oversight of MedStar's patient

accounts and multiple business service projects Established budgetary controls and implemented new business objectives that were

instrumental in turning organization into a profit center within less than one year

2001-2005 Business Manager Transport Services Children’s Medical Center of Dallas Dallas, Texas Assisted in program development, clinical, competitive and fiscal performance of the

department Provided leadership to ensure success in analyzing and monitoring the internal and external

environment effecting the department Designed and managed inter-department billing and collections team for all transports,

significantly increasing department contributions to the hospital. Redesigned departmental operations creating a profit center from a cost center becoming

second largest revenue generating center in the hospital Oversaw installation of new healthcare information management and billing system


1999-2001 Supervisor, Patient Financial Services Children’s Medical Center of Dallas Dallas, Texas Supervised Medicaid/Medicare collections team for hospital patient financial services unit. Developed strategic alliances with outpatient clinics and operations to educate each resulting in

better billing and collection outcomes Developed working relationship between hospital and State/Government provider relations

resulting in enhancement of billing operations and greater collections

1995-1999 Supervisor/Interim Manager Olsten Health Services Irving, Texas Designed and supervised first Medicaid and Medicare billing and collections team for Texas Developed training programs for infusion billing and collections Supervised and managed multi-state home health and infusion services 100+ person billing,

collections and audit team Increased revenue and collections for home nursing and home infusion service divisions through

education of staff, realignment of duties and process improvements EDUCATION

Argosy University; Dallas, Texas 2016 Doctorate of Education Organizational Leadership Amberton University; Garland, Texas 2002 Master of Business Administration Strategic Leadership Midwestern State University; Wichita Falls, Texas 1994 Bachelor of Business Administration Marketing

MEMBERSHIPS

Association of Critical Care Transport American Ambulance Association Association of Air Medical Services Texas Ambulance Association (Supporting Member) Deep in the Heart of Texas Pediatric Neonatal Critical Care Transport Conference Committee

Member and Faculty 2001 through 2005 Member of 2005 Texas Medicaid/Texas Department of Health workgroup supporting hospital

based transport programs and air medical programs Eastern Washington Trauma Advisory Council - Northwest MedStar Representative 2006/2007

Eastern Washington Trauma Advisory Council - Injury Prevention Committee Member 2007


PUBLICATIONS “Healthcare Reform: “Is Your Agency the Coyote or the Road Runner?” EMS Insider January

2013 “How Can I Increase Our Billing Receipts and Decrease Our Collection Time?”, Best Practices in

Emergency Services, August 2010 Vol. 13 No. 8, p. 9 Co-authored, with Dr. Thomas Abramo, “2005 International Transport” Chapter for American

Academy of Pediatrics “EMS leaders must treat employees equitably, not equally”, The Leadership Edge – EMS1.com

August 2015 “Scrutiny of ambulance operations highlights need for compliance”, Compliance Today,

September 2016 (co-authored with Matthew Streger)

Melissa Dawn Coons 2901 Williamsburg Terr., Ste G Fitch & Associates Platte City, Missouri 64079

SUMMARY

Mrs. Coons has excellent organizational, project management and analytical skills. These skills facilitate strong

team work and customer service. Her administrative skills have facilitated success while leading internal teams

as well as assisting external customers manage their high level workloads while meeting strict deadlines. These

skills and her attention to detail along with her past experience in high volume medical billing make her

proficient in the medical claims review processes.

CAREER

Present Claims Review Specialist

Fitch & Associates Platte City, Mo.

2013 – 2015 Assistant Director Patient Accounts

Fitch & Associates / MedServ International Platte City, Mo.

Primary responsibility to oversee billing for more than 60,000 ground and air medical transport claims

per year.

Provided leadership to ensure success in day to day operations.

Developed training documentation to educate billing and collection teams to advance processes.

EDUCATION

National Academy of Ambulance Compliance

Certified Ambulance Coder

Northwest Missouri State University, Maryville Missouri

Bachelor of Science

Management and Marketing


www.fitchassoc.com

November 2017 Professional Claims Review *CONFIDENTIAL ...

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