Incentives to not transport codes?

medicdan

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I'm a bit of a policy wonk, and doing research for a paper... so pouring through medicare payment documentation, and hundreds of pages of dense rules... fun, no?

Right now, i'm working through the Medicare Benefit Policy Manual (Chapter 10 for those interested).
Here we have talked about the myriad of benefits of not transporting working codes (dangers of driving while performing compressions [without an auto pulse-like device], relative uselessness of ACLS, etc.) and electing to phone a doc and declare on scene. I read that many progressive services and state protocols now call for deceleration of death (at the prerogative of the medic nand medical control doc) after so many minutes of ineffective rhythms on scene. I hear and see all of this.

Then I read medicare rules, which just encourage me to jump off a high building. Many of us work for private services that while sometimes progressive, are ultimately focused on unit efficiency and above all billing. See the below statement:
10.2.6 - Effect of Beneficiary Death on Medicare Payment for Ground Ambulance Transports
(Rev. 103; Issued: 02-20-09; Effective Date: 01-05-09; Implementation Date: 03-20-09)

Because the Medicare ambulance benefit is a transport benefit, if no transport of a Medicare beneficiary occurs, then there is no Medicare-covered service. In general, if the beneficiary dies before being transported, then no Medicare payment may be made. Thus, in a situation where the beneficiary dies, whether any payment under the Medicare ambulance benefit may be made depends on the time at which the beneficiary is pronounced dead by an individual authorized by the State to make such pronouncements.
The chart below shows the Medicare payment determination for various ground ambulance scenarios in which the beneficiary dies. In each case, the assumption is that the ambulance transport would have otherwise been medically necessary.
death_pronouncements.png


So... clever and knowledgeable friends, what are your experiences with this? Do you know of departments who's protocols allow for field pronouncements, but company policies prohibit? What does your billing department say about spending an hour on scene, giving a few rounds of meds, shocks, etc, declaring death, then leaving (and not billing)? Are things any different for third-services or fire departments?

Am I missing something here? Are you aware of services protesting this section, or movements for alternate policy? Do you agree with this policy? What incentives do services have not to transport a working code (albeit dangerously for crew), despite the known futility, just in order to bill?

Policy-makers out there, how do we discourage this practice (if you think it's wrong)?

Feel free to comment privately (via PM if you wish), especially if you're willing to share company policies or documents.

Thanks!
 

DrankTheKoolaid

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Code in house for 20min, ETCO2 less then 10mmHg after 20 minutes call it. Patient insurance if any is billed and we take what we get. The family will never see a bill from us.
 
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medicdan

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Code in house for 20min, ETCO2 less then 10mmHg after 20 minutes call it. Patient insurance if any is billed and we take what we get. The family will never see a bill from us.

Thanks. Is that company or regional policy? Many insurers simply follow the medicare reimbursement rules, so it seems your company may not receive any reimbursement for these calls.
 

DrankTheKoolaid

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More of a rural regional issue. Lemsa leaves it to the providers discretion with no further direction from the company (private non profit sole 911 provider for 1400 sq/mi)
 
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medicdan

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More of a rural regional issue. Lemsa leaves it to the providers discretion with no further direction from the company (private non profit sole 911 provider for 1400 sq/mi)

Is the provider decision a reflection of maintaining unit clearance for coverage, futility of resuscitation, or something else?
 

Handsome Robb

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We are allowed to call for termination orders after 3 rounds of ACLS with asystole or PEA presenting on the monitor.

I don't like transporting codes. Generally, most peds get transported unless there's obvious signs of death present, "high profile" patients such as EMS, Fire, PD or government officials, or other "extenuating" circumstances are present such as possible viability of a fetus.

Refractory VF/VT gets transported after 3-4 rounds on scene.

The docs here are pretty good about letting the medics make clinical decisions and generally will grant your request to terminate unless you really botched something in your care or your report to them on the phone.

No orders are necessary for obvious signs of death.

I can't comment on the billing, I stay far away from that can of worms. I figure it's not my job and it doesn't effect my decisions so there's no reason for me to know.
 
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medicdan

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We are allowed to call for termination orders after 3 rounds of ACLS with asystole or PEA presenting on the monitor.

I don't like transporting codes. Generally, most peds get transported unless there's obvious signs of death present, "high profile" patients such as EMS, Fire, PD or government officials, or other "extenuating" circumstances are present such as possible viability of a fetus.

Refractory VF/VT gets transported after 3-4 rounds on scene.

The docs here are pretty good about letting the medics make clinical decisions and generally will grant your request to terminate unless you really botched something in your care or your report to them on the phone.

Interesting, thanks. Does your employer have anything to say about it (encouraging you to transport or not, for example)?
 

Handsome Robb

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Interesting, thanks. Does your employer have anything to say about it (encouraging you to transport or not, for example)?

I've never heard anything about them encouraging transport from coworkers and have never been told to do so by a supervisor or other upper level managers.

Most all of the ER physicians actually start asking questions if we transport someone with CPR in progress unless we have a real obvious or good reason too. "Why'd you bring the dead guy here?" type of questions.

For what it's worth I work for a Not-for-profit Private operating under a Public Utility Model.
 

medicsb

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I'm curious if there is anyone lobbying to have the medicare rules changed. Considering that it costs X amount of dollar not only to treat and transport, it necessarily creates a bill from the ED physician practice and the hospital, which could quickly add up to thousands of dollars. Being able to pronounce without transport could result in huge saving, even if medicare/medicaid paid the EMS the same as they would had there been a transport. I imagine, though, that documentation would become more of a pain in the *** they'd would likely scrutinize transports for appropriateness when they do occur.
 

Christopher

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So... clever and knowledgeable friends, what are your experiences with this? Do you know of departments who's protocols allow for field pronouncements, but company policies prohibit? What does your billing department say about spending an hour on scene, giving a few rounds of meds, shocks, etc, declaring death, then leaving (and not billing)? Are things any different for third-services or fire departments?

Both the ALS hospital service and ALS fire department I work for do not bill for attempted resuscitation called in the field. We also only load patients into the ambulance if they have a pulse.

Cost of doing business.
 

TatuICU

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Workable rhythms (v-fib, v-tach) get transported after 2 rounds of drugs.

Asystole is a no go if CPR was not in progress upon your arrival after 3 epi's unless the provider feels a correctable cause has not been treated.

Asystole where CPR IS in progress upon EMS arrival gets transported still for now.
 

Christopher

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Workable rhythms (v-fib, v-tach) get transported after 2 rounds of drugs.

Asystole is a no go if CPR was not in progress upon your arrival after 3 epi's unless the provider feels a correctable cause has not been treated.

Asystole where CPR IS in progress upon EMS arrival gets transported still for now.

Ouch...work them where you find them until you call it or you get ROSC. Your ROSC and survival to discharge numbers will go up, up, up!
 

DrankTheKoolaid

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Futility is the sole reason we would cease resuscitation attempts, at least that is what i hope is going through our staffs minds when ceasing efforts.
 

TatuICU

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Ouch...work them where you find them until you call it or you get ROSC. Your ROSC and survival to discharge numbers will go up, up, up!

To my knowledge (insofar as this particular company is concerned) its less about that and more about protection from possible litigation. They've been sued countless times (deservedly so) and are a bit jumpy about the issue.
 

Christopher

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To my knowledge (insofar as this particular company is concerned) its less about that and more about protection from possible litigation. They've been sued countless times (deservedly so) and are a bit jumpy about the issue.

I guess I don't see how they would worry about it considering the standard of care is to remain on scene to work cardiac arrests (probably in the 2000 guidelines, certainly as of 2005, and reiterated again in 2010). I'd be more worried for lawsuits if they didn't!

If I were an enterprising lawyer and heard a patient expired in the ED after EMS transported during ongoing CPR...I would encourage the family sue for negligence :)

We've gone from 20% survival to discharge from VF/VT, into the high 60's and mid 70's after switching to staying and playing with pit crews and therapeutic hypothermia. 12.5% all rhythms survival to discharge.

You can't get those numbers transporting ongoing cardiac arrests to the hospital.

All in all, if it is a money issue, EMS and the hospital will make more money working cardiac arrests entirely on scene. This also means EMS needs to do a better job of not working cardiac arrests that are futile to begin with. The more ROSC, the more transports. The more transports, the more hospital admissions. The more admissions, the more procedures. The more procedures, the more ICU days. The more make it to the ICU, the more discharges. The more discharges, the more rehab! All of these are much bigger dollars than transporting everybody only to declare 90% of them DOA.
 

mycrofft

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Why am I reminded of the old Monty Python routine with the parrot?
dead-parrot.jpg


"Pining for the fjords? What kind of talk is that?"
 
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