Billing for ALS Assessments

Billing for ALS Assessments

Often misunderstood

EMS billing is a science all of its own.

One of the often misunderstood topics is when and how to properly bill for an ALS Assessment.

Today’s blog serves to educate our clients and friends who read this space regarding when and how to bill for an ALS Assessment.

The Product of Trusted Individuals

Because this subject of ALS Assessment has so many facets and has been kicked around so much by those of us who dissect all matters EMS on a regular basis; it doesn’t surprise us when we read communication that is published by other authors that sometimes serves only to create more confusion on the subject.

With so many different interpretations floating around, it is important that we take the time to clarify for the readers of this space, our friends and clients, the correct application of the rules when billing Medicare.

Please know, that this blog is the product of many different persons that combine to provide our readers with the most up-to-date educational information about ambulance billing that we can provide. Each blog we release is as accurate as possible using the best collection of knowledge and interpretation that we can put together prior to our posting to this space.

Not only do we rely on sources from within our own company, but we regularly network, communicate and solicit input from other nationally known and trusted ambulance industry experts.

Today’s Focus

Today, we will focus on the ALS Assessment definition as outlined in the Code of Federal Regulations (42 CFR §414.605.)

Advanced Life Support Assessment Definition

An advanced life support (ALS) assessment is an assessment performed by an ALS crew as part of an emergency response that was necessary because the patient’s reported condition at the time of dispatch was such that only an ALS crew was qualified to perform the assessment. An ALS assessment does not necessarily result in a determination that the patient requires an ALS level of service.

Application: The determination to respond emergently with an ALS ambulance must be in accord with the local 9-1-1 or equivalent service dispatch protocol. If the call came in directly to the ambulance provider supplier, then the provider’s /supplier’s dispatch protocol must meet, at a minimum, the standards of the dispatch protocol of the local 9-1-1 or equivalent service. In areas that do not have a local 9-1-1 or equivalent service, then the protocol must meet, at a minimum, the standards of a dispatch protocol in another similar jurisdiction within the State or, if there is no similar jurisdiction within the State, then the standards of any other dispatch protocol within the State. Where the dispatch was inconsistent with this standard of protocol, including where no protocol was used, the beneficiary’s condition (for example, symptoms at the scene determines the appropriate level of payment.)

Different Payers, Different Rules

First and foremost allow us to remind you that different payers have issued different rules regarding billing for ALS assessment. Some payers will not pay for ALS assessment while others have not addressed the subject at all!

Before we go any further we suggest that you determine what each insurance payer allows or disallows when it comes to billing for scenarios where the ALS provider arrives on the scene and provides an assessment but no ALS interventions (e.g.: IV, monitor, medication, etc.)

For our purposes today, we’ll primarily focus on what the Centers for Medicare and Medicaid Services (CMS) says and how those rules apply to the Medicare beneficiaries. This is important as Medicare and Medicare HMO’s typically account for a large percentage of an ambulance service’s payer mix.

Just because Medicare pays for a properly documented and coded ALS assessment does not mean that a State’s Medicaid program will pay using the same parameters. In addition, just because Medicare may pay for an ALS Assessment, that does not mean that a commercial insurer will allow payment based on the same criteria.

Know who you’re billing and bill accordingly!

There are several key areas which need to be thoroughly understood in order to properly bill for an “ALS Assessment.”

First Things-First!

One of the best techniques to properly determine which transports qualify for “ALS Assessment” coding is to first determine which transports already qualify for ALS level of reimbursement because an ALS intervention was performed.

We Suggest initial processing of a billable transport PCR by searching for any and all ALS interventions. Once an ALS intervention has been identified in the PCR, the transport should be properly classified as emergency or non-emergency and the proper ALS level HCPCS code can be assigned.

In the event that there are no ALS interventions documented, review the PCR and/or dispatch records to determine if ALL of the following criteria have been met”

1. The initial dispatch required an emergency response; and
2. The dispatch center who handled the call stipulated that the patient’s reported condition at the time of dispatch required an “ALS level” response- based upon approved dispatch protocols; and
3. An ALS Provider arrived on scene and conducted an “ALS Assessment; and
4. The patient was transported to an approved destination such as a hospital; and
5. The transport meets Medicare’s reasonableness and medical necessity standards

Transports which meet all of the above criteria may be appropriately billed to Medicare as an ALS1-Emergency even though no ALS interventions were provided.

However, as outlined in the regulations, if the transport is dispatched as a non-emergency and/or the dispatch center does not have approved protocols in place which, at a minimum, designate which calls require ALS vs. BLS, then the on-scene condition of the patient and treatment provided are the only determinants which can be used to assign the level of service provided.

Dispatch Sets the Tone for an ALS Assessment

The Centers for Medicare and Medicaid Services (CMS) has made it quite clear that dispatch protocols are one of the key requirements necessary in order to properly bill for an ALS Assessment.

First, ALS Assessment billing can only be considered for emergency responses.

Furthermore, the EMS service must take the steps necessary to respond immediately to that dispatch request.

Next, the 9-1-1 or other Dispatch Center, which receives the call for medical assistance, must utilize a recognized dispatch protocol in order to consider billing for an ALS assessment.

The dispatch protocol, at a minimum, must have parameters which allow the call taker to obtain information based on the patient’s reported condition and determine if an ALS response is required. All of this must occur at the time of dispatch!

If the patient’s reported condition, at the time of dispatch, does not require an ALS level response, in accordance with the dispatch protocol, then an ALS assessment cannot be used as the ONLY basis for billing ALS 1-Emergency to a Medicare payer.

Arrival on Scene and Assessment

Let’s assume that a call was dispatched by the 9-1-1 Center and requires an ALS response, in accordance with its dispatch protocols, and an ALS provider arrives at the scene and performs an assessment of the patient.

Let’s also assume that after the assessment, the ALS provider (with or without a consult with medical command) determines that no ALS interventions are required. The patient is eventually packaged and transported with BLS care to a local hospital for further evaluation and treatment.

A well-documented PCR should then be drafted by the crew which specifies, at a minimum, the name of the dispatch center, the response priority, code or protocol which designated the call as ALS and all other required and appropriate information about the specific details related to the response, assessment, treatment, transport and transfer of the patient.

Assuming that this transport meets Medicare’s reasonableness and medical necessity standards, it can be appropriately billed to Medicare as an ALS1-E, even though no ALS interventions were provided.

Another version of the above scenario occurs in certain types of two-tiered EMS systems. Let’s assume that an ALS provider responds in a separate unit, arrives on the scene and performs a patient assessment. After determining that no ALS intervention is warranted, the ALS provider returns into service and does not accompany the transporting unit to the hospital.

The ALS provider and the BLS transporting crew should both draft well-documented PCR’s. The PCR’s, at a minimum, the name of the dispatch center, the response priority, code or protocol which designated the call as ALS and all other required and appropriate information about the specific details related to the response, assessment, treatment, transport and transfer of the patient.

Assuming that the transport meets Medicare’s reasonableness and medical necessity standards, the transport can be appropriately billed to Medicare as an ALS1-E, even though no ALS interventions were provided and the ALS provider did not accompany the transporting unit.

Obviously, if no ALS responder arrives at the scene (or en route) to perform an ALS assessment and/or an ALS intervention, then ALS Assessment cannot be used as the basis for billing the transport as an ALS1-E.

BOTTOM LINE

No Dispatch Protocol, No ALS Assessment Billing
We know of EMS systems where there are no dispatch protocols separating ALS from BLS level responses. In these areas, the EMS system is alerted by a common request for ambulance response and it’s quite possible that a fully-staffed ALS ambulance may respond to every call for help.

But remember, CMS long ago, has made it clear that they will no longer pay all billed claims at an ALS level in areas which has “ALS Mandates” In that era, all emergency transports claims were automatically accepted and paid by Medicare at the ALS level regardless of the patient’s condition or level of treatment provided.

Those days are long gone.

So let’s make this clear…

Where no dispatch protocol is in place, ALS assessment cannot be used to bill Medicare when the assessment is the only reason to upgrade a call to an ALS1-E. Period!
Keep in mind that if any of the following issues or statements are true, then “ALS assessment” CANNOT BE USED as the only means to justify ALS1-E level billing

1. The initial dispatch did NOT require an emergency response; or
2. The dispatch center does not utilize any type of dispatch protocols; or
3. The dispatch center uses a protocol which is not in compliance with the definition outlined in the above cited CMS regulations; or
4. The dispatch center does not designate which calls require an ALS level response based upon protocols and the patient’s reported condition at the time of dispatch

Document Clearly

Anyone who reads this space on a regular basis knows that we constantly are reminding providers to document their runs clearly and concisely using an appropriate amount of detail in the written narrative.

ALS assessment-only scenarios should contain all the detail possible to explain, not just for billing reasons, why the ALS provider found it possible for him/her to release care to a lesser-trained care provider.

ALWAYS document the nature of dispatch in your written narrative.

“Station 40 dispatched via Anywhere County 9-1-1 for an ALS Emergency, male patient experiencing chest pains with a past history of MI. Medic 45 responded at time noted on this report.”

Please notice, in the example above, our documentation includes the agency dispatched, captures that a 9-1-1 center alerted for the emergency and defined the initial report of the patient’s condition as provided by the 9-1-1 center. Our sample documentation also includes written verification that the responding agencies were notified that the 9-1-1 center followed protocol in alerting specifically for an ALS level response.

Naturally, this documentation would tie together with written 9-1-1 protocol on file at the PSAP and hopefully with copies of said dispatch protocol maintained at the local ambulance station for verification in the event of an audit or post-payment review.

Proper Education, Communication and Preparation

It’s important that your billing office educate all providers regarding these important parts of the process.

Accurate communication is the key to an effective ambulance billing program. Patient care providers at all levels along with ambulance company administrators, supervisory staff and most importantly the billing office itself must be prepared and well-versed in sorting out these sometimes confusing scenarios.

For these reasons, every Enhanced Management Services staff member is a Certified Ambulance Coder using the National Academy of Ambulance Coding curriculum. Our staff is well-trained and includes veterans of the ambulance billing industry who combine for decades of experience.

Our clients can rest easily that they are protected by our informed knowledge at all levels.

If that’s not the case in your world, then maybe it’s time to give us a call.