Got a billing question? Ask Away!

[BillingSpecialist]

Can you explain how BLS vs ALS Level 1 vs ALS Level 2 is decided for billing?

BLS v/s ALS 1 is basically if there's a medic on board providing any ALS Services. If there's a medic it's ALS, if there's not then it's a BLS.

ALS 1 v/s ALS 2 to determine if it's an ALS 2 there have to be at least 3 separate administrations of one or more medication via IV or by continuous infusion (excluding crystalloid fluids) or 2 of the following ALS2 procedures: manual defib/cardioversion, endotracheal intubation, central venous line, cardiac pacing, chest decompression, surgical airway or intraosseous line. The monitoring & maintence of an endotracheal tube that was previous inserted prior to transport also qualifies as an ALS 2 procedure.

Hope that's helpful. If you need more or different detail please let me know.

Thank You!

 

[BillingSpecialist]

Thanks for offering your expertise on this forum. For nearly all of us paramedics, how billing works is a mystery. Hope you stick around for a while!

Can you give examples of poor documentation that would result in Medicare or Medicaid not reimbursing a transport or treatments?

You're welcome! And I've been around for awhile. and this thread always seem to do very good. It generates lots of questions and lots of interest. It's my pleasure to help! And I'm not afraid to say I'm not sure on something I'm really not sure on. I don't mind talking all about the things I do know about but I don't want to blow smoke about something I really don't know! LOL!!

Comprehensive documentation of the patient encounter is vitally important to accurately paint a picture of patient conditions and treatment
•If there’s pain, include a pain scale, where that pain is coming from and what caused that pain
•If there’s a wound, include where that wound is, how much bleeding, and what cause the wound
•If there’s a fall, include where the patient fell, what they hit when they fell, and what caused the fall

If the picture can not be painted when someone reads the run, then it could give you issues. What crews have to understand is that the insurance representative that's processing the claim and reading the runsheet may know nothing about ambulance transports, they have to be able to read that runsheet and a picture start generating in their mind as they read.

Examples of Poor Documentation:
1-Pt has possible fracture to the right tib/fib
2-Pt found in bed. Transferred pt from bed to stretcher. Moved pt via stretcher to ambulance and transport to hospital uneventful
3-Pt was transported in position of comfort.
4-Pt complains of chest pain and says the pain comes and goes
5-Pt was found in bed and transferred from bed to stretcher
6-Pt complains of abdominal pain since 8 am this morning.
7-Pt has a decubitus ulcer on left side of buttocks.

Examples of Good Documentation that should be in place of the bad ones above (in the same order, ex: Line 1 under poor, Line 1 under good is they way it should be written)
1-Pt has possible fx of R tibia after falling down approximately 6 steps at home. Pt has a 3” hematoma mid right anterior lower leg, approx. 2” above the ankle. No angulation or deformity. Distal pulses intact. Good skin color, sensation and capillary refill above and below injury site. Pain upon movement rated 8 out of 10 described as sharp
2-Pt found in hospital bed in living room supine with oxygen running at 2 lpm via nasal cannula. Pt unable to sit up without passing out. Pt moved to stretcher via 3 person sheet pull with pt unable to assist due to severe weakness. Transported pt supine to hospital with no change in pt condition.
3-Pt was transported in a semi-seated position and denied any pain or discomfort during transport
4-Pt complains of chest pain. Pain started 3 hours ago while mowing grass. Describes pain as “dull” centered under sternum. States pain comes and goes at intervals of 10-15 min and does not radiate to arms or neck. Severity 8 on a 1-10 scale. No complaints of SOB, nausea or vomiting
5-Pt was found in hospital bed in hospital room in supine position unresponsive to voice with arms and legs flaccid. Pt was log rolled onto side and then back onto a sheet. Moved to stretcher via a sheet pull and secured in a supine position on the stretcher with four cot straps
6-Pt complains of abdominal pain since 8 am this morning. Pt states pain is in the RLQ and is sharp in nature. Describes pain as very severe at 10 on a 1-10 scale. Pt denies nausea, vomiting or fever
7-Pt has a decubitus ulcer on left side of buttocks that is bandaged. SNF staff state the wound is Stage 3 approximately 4 inches across. Staff state that severity of wound and pain upon movement make it impossible for patient to sit up in a chair or wheelchair

Hope this is helpful to you. I didn't realize when I was typing that I was typing such a book! LOL!! Have a great weekend!!

 

[BillingSpecialist]

How much gets charged? Do you have an agreement with the Govt that you must only charge a specified amount so you are given a level of public funding in return for not increasing fees? What percentage of funding is public vs user fees? Is this set at the state level presumably?

For example; the ambulance part charge down in my part of the world is fixed at $98 and cannot be raised beyond, for example, 1% or something because this has been agreed to in return for increased bulk funding from the Ministry of Health. The bulk funding is approximately $70 million which is about half of costs but a large increase has been negotiated with the Ministry of Health between now and about 2022.

What happens if the patient doesn't pay or cannot pay? In my case, the local aforementioned part charge is written off.

In my neck of the world, the rates charged are not determined by the government. The ambulance companies can choose what they charge, but payers have the ability to only allow them to bill a certain amount for them to consider.

For example, Medicare allows $300.00 for a BLS Emergency. If I have a company who wants to charge $600.00 for a BLS Emergency, then they bill Medicare. Medicare says we can only bill $300.00, so therefore $300.00 will have to be written off and can not be billed to the patient. Then Medicare woould pay 80% of the $300.00 and the 20% left over could be billed to the patient or the secondary payer. Each payer has a fee schedule of their own, but they can initially charge what ever they want the write off amounts will just be large.

Is that along the lines as to what you are asking? If not please let me know.

Thank You! Have a good weekend!

 

[wanderingmedic]

Thanks so much for taking the time to answer all these questions! It is really enlightening.

How does billing work when two patients are transported in one ambulance? (Example, one patient on the stretcher, one patient on the bench seat, both patients are monitored and receive interventions from the paramedic from the same incident transported to the same hospital)

 

[DesertMedic66]

My company recently started making us get and record the name of the attending physician (not even the physician who is seeing our patient) on our paperwork. Company states that they are now required by Medicare to have this information or else they are not able to bill for services rendered. Is this true?

 

[Jim37F]

My company recently started making us get and record the name of the attending physician (not even the physician who is seeing our patient) on our paperwork. Company states that they are now required by Medicare to have this information or else they are not able to bill for services rendered. Is this true?

My company was doing that too. It was a required, critical, "can't upload without it" field (Dr None Assigned Yet apparently worked at a few of my hospitals haha...) they also claimed it was a new Medicare requirement to fight fraudulent billing from ambulance companies..

Anytime a Paramedic so much as talked to our patient on scene (which amounted to roughly 95-99% of our 911 calls, as ALS FD went to every call), even if it was the engine medic on an Assessment Engine who then cancelled the incoming Paramedic Squad and all they did was talk to the patient (no hooking up of monitors or anything more invasive than blood pressure) and then the patient was sent BLS with no medics on board the ambulance, we were still supposed to mark "ALS Assessment" on the ePCR...because "a Paramedic still did the assessment regardless" that still wouldn't be billed as an ALS1 call would it?

 

[GMCmedic]

we were still supposed to mark "ALS Assessment" on the ePCR...because "a Paramedic still did the assessment regardless" that still wouldn't be billed as an ALS1 call would it?

My old company did this. Anytime a call was dispatched with an ALS assessment code, it was automatically billed ALS.

And since EMD dispatch is designed around leading questions, we billed a lot of ALS.

Sent from my SAMSUNG-SM-G920A using Tapatalk

 

[BillingSpecialist]

Thanks so much for taking the time to answer all these questions! It is really enlightening.

How does billing work when two patients are transported in one ambulance? (Example, one patient on the stretcher, one patient on the bench seat, both patients are monitored and receive interventions from the paramedic from the same incident transported to the same hospital)

When you transport 2 patients in the same truck, you bill both of them a loading fee and u split the mileage. So, for example, you pick 2 patients and the hospital is 50 miles away. You would be each patient a loading & each 25 miles.

 

[BillingSpecialist]

My company recently started making us get and record the name of the attending physician (not even the physician who is seeing our patient) on our paperwork. Company states that they are now required by Medicare to have this information or else they are not able to bill for services rendered. Is this true?

We have not had to do that in WV or VA. There are carriers that make you do funny stuff. For example if your area's Medicare carrier is Novitas, then it's possible. We do have our crews obtain the physicians name if it's a repetitive transport patient, because in our area we have to get prior auths and we have to request documentation from them.

 

[BillingSpecialist]

My company was doing that too. It was a required, critical, "can't upload without it" field (Dr None Assigned Yet apparently worked at a few of my hospitals haha...) they also claimed it was a new Medicare requirement to fight fraudulent billing from ambulance companies..

Anytime a Paramedic so much as talked to our patient on scene (which amounted to roughly 95-99% of our 911 calls, as ALS FD went to every call), even if it was the engine medic on an Assessment Engine who then cancelled the incoming Paramedic Squad and all they did was talk to the patient (no hooking up of monitors or anything more invasive than blood pressure) and then the patient was sent BLS with no medics on board the ambulance, we were still supposed to mark "ALS Assessment" on the ePCR...because "a Paramedic still did the assessment regardless" that still wouldn't be billed as an ALS1 call would it?

Yes it would still be an ALS call. If it's dispatched that way and an assessment is done by the medic, then it's billed as an ALS transport.

So the other part of your post, please review my answer to DesertMedic66's post.

 

[chriscemt]

Thanks for the thread!

I recently transferred a patient and had the patient's child remind me to obtain the Certificate of Medical Necessity. It turns out that a crew during the past year did not properly attach the PCS to their PCR, and that created a personal bill to the family.

Is there any way to retro-actively perform this (?) - the patient requires ambulance transport at all times, no question, and I hoped to offer the family the chance to get reimbursed.

 

[DesertMedic66]

Thanks for the thread!

I recently transferred a patient and had the patient's child remind me to obtain the Certificate of Medical Necessity. It turns out that a crew during the past year did not properly attach the PCS to their PCR, and that created a personal bill to the family.

Is there any way to retro-actively perform this (?) - the patient requires ambulance transport at all times, no question, and I hoped to offer the family the chance to get reimbursed.

Our Dispatch Center requires a faxed PCS before they will even set up the transfer.

 

[NysEms2117]

@BillingSpecialist how would something like phillys police transport work for billing? Where ambulances have a waiting list and urgent things like gsw's and stab wounds just get tossed in a cruiser and taken to the hospital that way? I'd imagine they'd still be billed for the gauss and blood that was in the cruiser, things would still need to be restocked and cleaned. Hopefully this isn't too out there.
My guess anyway?

 

[DesertMedic66]

@BillingSpecialist how would something like phillys police transport work for billing? Where ambulances have a waiting list and urgent things like gsw's and stab wounds just get tossed in a cruiser and taken to the hospital that way? I'd imagine they'd still be billed for the gauss and blood that was in the cruiser, things would still need to be restocked and cleaned. Hopefully this isn't too out there.
My guess anyway?

If there is no medical personnel with the patient then I doubt it would be billed.

 

[BillingSpecialist]

Thanks for the thread!

I recently transferred a patient and had the patient's child remind me to obtain the Certificate of Medical Necessity. It turns out that a crew during the past year did not properly attach the PCS to their PCR, and that created a personal bill to the family.

Is there any way to retro-actively perform this (?) - the patient requires ambulance transport at all times, no question, and I hoped to offer the family the chance to get reimbursed.

No there is no way to retro-actively get the medical necessity now. Depending on the type of insurance they have they may be able to file an appeal with their insurance company, but it will take a lot of work from them to appeal it. They will need copies of their medical records, showing medical need for the transport.

Maybe some sort of policy should be out into place to make sure these are obtained prior to the transport. I seen where someone commented that dispatch takes care of it, and that method does not work for any clients that I have. Around my clients they has dispatchers that handle 2 or 3 counties and they could care less. But if you have a good relationship with dispatch and can accomplish this....that would be great. Some kind of plan should definitely be put in place so patient's aren't getting large bills for transports that should've been covered if the right paperwork would've been obtained.

 

[BillingSpecialist]

@BillingSpecialist how would something like phillys police transport work for billing? Where ambulances have a waiting list and urgent things like gsw's and stab wounds just get tossed in a cruiser and taken to the hospital that way? I'd imagine they'd still be billed for the gauss and blood that was in the cruiser, things would still need to be restocked and cleaned. Hopefully this isn't too out there.
My guess anyway?

Without medical personnel, it could not be billed to the insurance company. You may check with your county ordinance and see if the police department could bill the patient for something like that. But it would be something only the patient can be billed for.

 

[Ying]

Simple question: if there is only one blood pressure check and one finger glucose check plus transportation, can this be billed for ALS1 in Los Angeles?

 

[luke_31]

Simple question: if there is only one blood pressure check and one finger glucose check plus transportation, can this be billed for ALS1 in Los Angeles?

Look back on this thread and you will find your answer by someone who actually does billing. The user hasn't been on in a while but they have previously answered a similar question.

 

[BillingSpecialist]

Sorry for my absence on this thread!

Anyone got any questions that I could help with?

 

[Trvlr]

Random question, if you end up transporting an employee of said Company/Agency do they still get billed? or do you waive it as professional courtesy?

I didn't see anywhere if you worked for government or private.