CMS Releases First GADCS Reports- Part II, Medicare FFS Claims Analysis
By Chuck Humphrey, B.A., EMT-B, CADS*
Ground Ambulance Industry Trends
In this Part II blog post, we’ll look at the second of two reports recently released by the Centers for Medicare and Medicaid Services (CMS) using the newly acquired data from the Ground Ambulance Data Collection System (GADCS) project.
In Part I previously released, we blogged concerning the subtitled report An Analysis of Ground Ambulance Organization Entrance and Exit for the period 2017 through 2022. This blog focuses on the Analysis of Medicare Fee-for-Service Claims report.
Traditional Medicare Reminder
It’s important to remember that the analysis strictly focuses on Traditional Medicare. The reports allowed for weighting the analysis, accounting for the expected and noticeable dip in the number of transports billed to Traditional Medicare when comparing the pre-PHE years of 2017 through 2019 to the anomaly of 2020.  And, thus, a contrast to a rebound in 2021 and thereafter.
COVID-19 Equals Sharp Decline
Data from the GADCS showed a sharp decline in billings to Traditional Medicare in 2020. When CMS reviewed billing totals prior to the Public Health Emergency (PHE) declaration in early 2020, they found that as far back to the year 2015 and forward through 2019, billing numbers to Traditional Medicare were fairly constant. As late as January 2020, a total of 1,170,355 transports were billed to Traditional Medicare. By April of that same pandemic year, the number had decreased to 857,838 following the declaration of a PHE.
The transport volume rebounded somewhat by the end of 2020, but then there was a sudden decrease in January 2021 which did not recover right away in the months that followed.
The analysis shows that the average monthly number of transports per National Provider Identifier (NPI) in 2017 stood at 1,377 transports. By 2022, the numbers showed a 25 percent decline, down to 1,032 transport per NPI monthly. The median transport volume per NPI in each year also declined by 16 percent between 2017 and 2022 for the over 12,000 NPIs sampled in the first leg of the GADCS project.
Move to Managed Care?
The report accounts for an overall increase in the number of Medicare beneficiaries (patients) who moved from Traditional Medicare coverage to the Medicare Advantage (MA) model. However, even after accounting for changes in the county-level Traditional Medicare enrollment, the reports authors still reported decreases in average volume over time from an adjusted average of 4,665 transports in 2017 to 4289 transports in 2022 which is an 8.1 percent decrease- but noticeably smaller than the unadjusted enrollment which showed a 26.0 percent decrease.
The report included a comparative analysis of MA penetration rates to support their MA adjustment factor with a rise in the number of counties with a very high MA penetration rate (50 percent or higher) increasing from 8.7% in 2017 to a noticeable 27.8% in 2022.
ESRD Transport Changes
The analysis included a brief look at trends in frequent ICD-10-CM diagnosis codes reported for ground ambulance transports. The data shows that the top ten ICD-10-CM diagnosis codes in 2017 and 2022 for non-emergency ground ambulance transports (defined as transports with HCPCS codes A0426 ALS non-emergency and A0428 BLS non-emergency) included the most frequently used was end stage renal disease (ESRD, N18.6).
We all know that CMS has focused on this particular line of transport to combat what they deemed not-medically-necessary overuse of billings to Medicare. They combatted this in a few ways, by placing a credentialing moratorium in some geographic areas and, in the most ambitious project, expanding the prior authorization model nationwide.
Their efforts seemed to be successful as borne by the GADCS data. In 2022, the analysis shows that non-emergency ESRD transports accounted for 4.3 percent of all transports and 12.8 percent of non-emergency transports. By contrast, this was lower than in 2017, when non-emergency ESRD transports made up 6.4 percent of all ground ambulance transports and 16.2 percent of non-emergency ground ambulance transports.
The ESRD decline also is borne out when viewing the number of transports to and from ESRD facilities over time, down from 15.9% of all transports in 2017 to just 9.5% of all transports in 2022.
Totals Compared
The report publishes a very interesting ICD-10-CM diagnosis code analysis.
Findings show an all-transports total billed to Traditional Medicare of 14,652, 995 with non-emergencies comprising 5,805,197 of those transports in 2017. By comparison, 2022 numbers show a total of 10,787,064 transports billed nationwide with non-emergencies amounting to 3,615,848 of that total. Just shy of 4 million few transports billed to Traditional Medicare with 50% of that drop accounted for by a drop in non-emergency transports.
While ESRD remains the dominant ICD-10-CM diagnosis code used to bill non-emergencies, on the emergency side, Shortness of breath (R06.02) is the most used diagnosis code utilized when billing for emergencies with little change from 2017 compared to 2022. It is interesting to note that the use of Chest pain (R07.9) has dropped from the number two code used by percentage in emergencies comprising 6.0% of all transports billed in 2017 down to 4.5% in 2022 falling behind Altered mental status, unspecified (R41.82) and Weakness (R53.1) at 5.6% and 5.0%, respectively.
That the use of weakness has grown, I must say, baffles me as we all know this is a very dicey code to use in supporting medical necessity when billing to any Medicare product, FFS or MA.
The top ten emergency diagnosis codes used by percentage in 2022 in order included;Â
- Shortness of breath (R06.02)
- Altered mental status (R41.82)
- Weakness (R53.1)
- Chest pain, unspecified (R07.9)
- Syncope and collapse (R55)
- Unspecified injury of head, initial encounter (S09.90XA)
- Pain, unspecified (R52)
- Dizziness and giddiness (R42)
- Unspecified abdominal pain (R10.9)
- Transient alteration of awareness (R40.4)
*Chuck Humphrey is an independent contractor who spent 25 years in the EMS revenue cycle management industry, prior to his retirement from Quick Med Claims. In addition to holding active EMT credentials in Pennsylvania, he is also a Certified Ambulance Coder, Certified Ambulance Compliance Officer and Certified Ambulance Documentation Specialist via the National Academy of Ambulance Compliance. Humphrey is a periodic guest contributor to the QMC blog and podcast space.
