CMS Brings Early Christmas Gift in Addition of PHBT to ALS2 Level Transports
By Chuck Humphrey, B.A., EMT-B, CADS*
Final Rule Published
The Centers for Medicare and Medicaid Services (CMS) released the Final Rule for the Medicare Physician Fee Schedule on November 1, 2024, bringing an early Christmas gift to the ambulance industry.
The Final Rule, which will be published in the Federal Register on December 9, 2024, becomes effective for transports with dates of service on and after January 1, 2025. It adds an eighth skill to what has previously been referred to as the “Super Seven” skills, adding Prehospital Blood Transfusions (PHBTs) as a procedure that invokes reimbursement at the Advanced Life Support Level 2 (ALS2) base rate.
ALS2 Defined
Historically, ALS2 reimbursement has been invoked for Medicare transports when a critically ill or injured patient is administered at least three medications by intravenous push/bolus or by continuous infusion. The medications can be three distinct medications or three full dosage administrations of the same medication, excluding crystalloids, hypotonic, isotonic and hypertonics.
Additionally, heretofore, any one of the following seven advanced skill procedures also immediately invoked ALS2 Level reimbursement from Medicare, regardless of medication infusions. These skill sets include:
- Intraosseous line
- Endotracheal intubation
- Manual defibrillation or cardioversion
- Central venous line insertion
- Cardiac pacing
- Chest decompression
- Surgical airway insertion
The ALS2 definition also allowed for the monitoring of such infusions or and/or advanced skill sets should then initiation happen prior to the beginning of the patient transport.
Beyond O+!
Initially, CMS indicated that only O+ blood transfusions would be added to the ALS2 definition set. However, thanks to input from throughout the ambulance community, CMS elected to add all forms of PHBT including:
- Low titer O+ and O- whole blood (WBT)
- Packed red blood cells (PRBCs)
- Plasma; or
- A combination of PRBCs and plasma
CMS was consistent with the monitoring aspect of ALS2 as described with the historical advanced skill sets, clarifying in the Final Rule to note that ALS personnel monitoring a patient whose PHBT was initiated by another healthcare provider, prior to the transport, would qualify for ALS2 Level reimbursement under the new ALS2 definition rule.
Justification
In its written explanation, CMS justified that the PHBTs are already part of the ALS2 landscape, so to speak, as they noted that by March of 2024, more than 147 of the approximately 11,450 ground EMS agencies in the United States use blood products in some form. CMS also states that they believe that most patients who require such PHBTs already qualify for ALS2 reimbursement due to other advance skill interventions being in place for those transports.
CMS explained in the preamble to the Final Rule, that they do not believe they have the authority to increase the ALS2 Level reimbursement funding, while recognizing that PHBT interventions definitely add to the cost of the transport for those EMS agencies providing the service. Their notation was based on the belief that current ALS2 transports for patients requiring PHBT intervention already qualify for ALS2 Level payment given the employing of other qualifying skill-set procedures.
SCT?
CMS did provide a response to a comment seeking clarification regarding the administration of WBTs, which may also meet the requirements for Specialty Care Transport (SCT) Level reimbursement if all other requirements are met. In response, CMS stated that PHBTs alone do NOT meet the requirements of an SCT transport.
CMS noted that the SCT transport, by definition, is the interfacility transports of a critically injured or ill patient by a ground ambulance vehicle by advanced EMS providers with additional training as defined by individual state training definitions. As such SCT criteria are not met if the only service provided to the patient during transport is the administration of low titer O+ WBTs. Such O+ WBTs requires a trained EMT-Intermediate of EMT-Paramedic and while it may be possible that during a transport that meets the definition of an SCT, that the WBT may occur, the payment for the service would already be covered under the SCT definition but not as a stand-alone criteria.
*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 EMT credentials in Pennsylvania, he is also a Certified Ambulance Documentation Specialist via the National Academy of Ambulance Compliance. Humphrey is a periodic guest contributor to the QMC blog and podcast space.
