Transported for HIGHER Level of Care
By Katie Harrison and Chuck Humphrey, QMC Compliance Team
If we had a dollar…
Here in our QMC billing office, if we had a dollar for every time we have opened a patient care report (PCR) to read the documentation of an ambulance transport from one facility to another that contains the phrase “transported for higher level of care” none of us would still be working! We’d be retired because we’d be rich!
The Scenario
From an actual PCR we recently encountered the following…
“72 year old male with a history of CHF being transported to a higher level of care.”
That was it!
A few vitals, patient demographics, origin and destination information wrapped up the remainder of the supporting documentation.
While the statement may seem like a straightforward piece of information to incorporate into a PCR, on the revenue cycle management side of things, that sentence can cause a lot of confusion. Complicating matters even further, if the patient is transported for a long distance, it’s even worse.
Why?
Well, there simply isn’t enough detail.
Reasonableness
We talk a lot about reasonableness and medical necessity as medical transportation billers.
The word defined has two elements: sound judgment and a sense of fairness and being appropriate. In the eyes of the Center for Medicare and Medicaid Services (CMS) the definition narrows to vetting if a service provided to a patient for which the Medicare or Medicaid programs are going to pay out dollars to support has been furnished appropriately to meet the medical needs and conditions of the patient and for which there is no appropriate alternative treatment to maintain the life and health of the patient.
The only way that CMS, aka Medicare, Medicaid and, by extension typically, healthcare insurance payers have of determining reasonableness is to review the circumstances that led to and required that an ambulance be used for transport between two locations.
As such, CMS continually asks the question by auditing and reviewing claims “Was this trip reasonable in the eyes of Medicare?” The answer then is derived by reviewing the details of the ambulance transport and for that purpose they use the only written record of the trip, the PCR.
As written…
And so, back to our example, as the statement is currently written, a claims reviewer doesn’t have the details available to determine reasonableness. There are questions that remain unanswered such as…
- What higher level of care was needed? Or, put another way, what treatment was not available at the origin facility?
- Why did the patient need the treatment?
- Why did the patient require ambulance transport to move from one location to the other?
Stating the patient needed a “higher level of care” technically could mean that the patient had to be moved from the first floor to the third floor of a medical facility. Think about it, making that statement speaks nothing to the need for ambulance, movement from one address location to another and certainly doesn’t even begin to resemble an actual medical record level of detail.
It all comes down to money…
Medicare will only cover (pay for) ambulance transportation between facilities IF the services the patient needs are not available at the sending facility. A transport to a more distant facility is only covered for payment if the services are not available at the point of origin, the facility or location where the patient is currently being treated.
Of course, in this day and age, thanks to the wonder of the Internet, it isn’t difficult to determine if certain specialties (cardiac, for example) are available at a hospital or not. However, it isn’t as easy to find out if specific interventions are available at one facility or another. This uncertainty regarding available treatments can lead to billing delays due to the extended amount of time it can take to request and receive sending and receiving medical records. Additionally, when documentation is lacking, it can cause a claim to suspend or even deny for payment after being submitted to an insurance carrier for medical review.
Even though not all payers are as stringent as Medicare, it is best practice for the provider/supplier of the ambulance transport to be as specific as possible in the PCR, regardless of the payer source. In order to receive the appropriate reimbursement for any ambulance trip and to avoid unnecessary patient out-of-pocket responsibility, ambulance providers and suppliers must be sure to take the time to provide as much detail as possible when documenting details about inter-facility transports in the PCR.
A little bit more time and detail when documenting the transport within the PCR will equate to reimbursement claims being processed in a timelier manner and with less follow-up work on the back end of the revenue cycle.
We suggest…
How could the documenter have been more precise in our example? Consider these relatively easy revisions…
“72 year old male with history of CHF being transported for LVAD placement not available at sending facility.”
“72 year old male with history of CHF being transported for evaluation of patient’s previous heart transplant.”
