HANDOUTS Fall 2015 abc360 Emergency Coding Clinic · “PWW Media) Event (including but not limited...

Emergency Coding Clinic

Day Two

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EMERGENCY CODING CLINIC

Practical Skills Clinics Important Notes

• Any reference to actual persons or characters (real or fictional) is purely coincidental and/or for comic relief!• All claims analyzed in accordance with

Medicare guidelines – pre-submission• Reference the “Background Materials”• Use the checklist

Important Notes

• In these examples, a transport may not be billable to Medicare, pending receipt of more information• When requesting additional

information remember the following:

Important Notes• Any addenda, modification, or additional

information received must be reflective of the patient’s condition at the time of service• Information is requested so that a

proper billing decision can be made• Requests for addenda must not be

suggestive

Important Notes• Trips all occurred on or after 10/1/15 –

compliance date for ICD-10• ICD-10 Codes used in the questions

are for illustrative and educational purposes only• You are responsible for proper coding

of your claims

Important Notes

• ICD-10 Resources abc QuikGuide CMS Website

−Tabular list and GEM

Novitas Local Coverage Article −List of “suggested” codes

www.ICD10data.com−Crosswalk feature



Important Notes• Not required to bill a non-covered

service unless the patient requests and/or where a Medicare denial is required for coordination of benefits • Always use the appropriate non-

covered service modifier (e.g., GA, GY or GZ) when submitting a claim for a non-covered service

Run 101 E

Duke Weselton

Run 101 E – Emergency Response

• Call received, dispatched, and enroute times all within 2 minutes• Bravo (BLS Hot) dispatch for “fall”

Run 101 E – Medical Necessity

• Fall, with minor pain (3/10)• Possible head injury• Pt on Coumadin and beta blocker• Nose described as being “on fire”• C-collar, spinal immobilization• Found lying on sidewalk

Run 101 E – Reasonableness

• Requires services (evaluation for latent injuries) not available at origin

Run 101 E – Origin/Destination

• Origin = Hotel (“S”)• Destination = Community Hospital

(“H”)



Run 101 E – Mileage

• Miles at destination: 3.7• Miles enroute: 0.1• Total loaded miles: 3.6

Run 101 E – Forms

• AOB Signed by patient on DOS Valid

Run 101 E – Documentation• PCR is complete and paints a picture

of event and mechanism of injury• Provides detail about spouse and why

she needs to accompany the pt

Run 101 E – Other

• GM modifier used when two patientsare transported• Although wife accompanied, she was

not a patient, as she was not injured

Run 101 E – ICD-10

• W10.1XXA – “Fall on/from sidewalk/curb, initial encounter” Speaks to mechanism of injury than a

condition requiring ambulance Secondary external cause of injury code

• R52 – “Pain, unspecified”While accurate, pt. reports chronic back

pain

Run 101 E – ICD-10

• S09.90XA – “Unspecified injury of head, initial encounter” Best primary code (from these options) and

is on Novitas “suggested” list (from the LCA) and the abc QuikGuide

• Z74.3 – “Need for continuous supervision” Best Secondary Diagnosis Code (for

Novitas)



Run 101 E – Lessons Learned

• Most detailed ICD-10 Code may not always be the most appropriate, especially when it speaks to the mechanism of injury and not patient condition• GM modifier only appropriate with

multiple patients (wife was not a patient)

Run 102 E

George Sanderson


• Call received, dispatch, and enroute times all noted as 1023 – immediate response• Delta dispatch, to ALS condition of

“pain with other symptoms,” and PCR indicates call came through 911


• Pt. received multiple medications (Morphine Sulfate and Ondansetron)• Severe sudden/acute abdominal pain

(10/10)


• Severe abdominal pain requires evaluation and services not available at origin


• Origin = Scene (“S”) Although a “residence” this was not the

patient’s residence (his address is noted below as a different location)

• Destination = Good Samaritan Hospital (“H”)




• No mileage recorded on PCR• But, mileage printout appears Shows 9.8 total miles Acceptable method Novitas issued FAQ specifically

permitting internet mapping

Run 102 E – Forms

• AOB Signed by patient on 10/8/15

−After DOS−This is OK, claim not billed until after

signature was captured−Valid

Run 102 E – Documentation

• PCR is complete, and outlines background information leading up to the event• Outlines “OPQRST” assessment of the

abdominal pain – provides specificity

Run 102 E – Other

• ALS 1E vs. ALS2 None of the 7 “super skills” performed Only two IV administrations (morphine x2) Ondansetron was administered orally after

IV was unsuccessful (oral administration does not qualify for ALS2) ALS2 criteria not met

Run 102 E – ICD-10

• Variety of generic abdominal pain ICD-10 Codes could be used as primary: R10.84 – “Generalized abdominal pain” R10.9 – “Unspecified abdominal pain” R11.2 – “Nausea with vomiting” These appear on the Novitas Group 1

Codes list and the abc QuikGuide

Run 102 E – ICD-10

• Secondary Diagnosis Code (Novitas): Z99.89 – “Dependence on other enabling

machines and devices” Explanation from Novitas LCD indicates

this code is used to denote the “need for continuous IV fluids”




• Patient signature after DOS• Internet mapping to support mileage• ALS 1E vs. ALS2

Run 103 E

Bashful Dwarf


• Call received, dispatch, and enroute times within 2 minutes – shows immediate response• Initial dispatch for emergency

condition – “AMS”• Call “downgraded” after crew arrived


• EKG monitoring, IV (saline lock)• Hemiparesis from previous stroke• Decreased GCS (11)• Though “baseline” conditions,

transport by other means is contraindicated


• Not clear whether blood transfusion could be done at point of origin or whether patient is in a Part A stay• Need more information to determine

whether moving patient for blood transfusion is reasonable


• “When a Medicare beneficiary is in a Part A stay at a SNF, the Consolidated Billing requirement confers on the SNF the billing responsibility for the entire package of care that residents receive during a covered Part A stay” https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/index.html




• Certain services are specifically excluded from Consolidated Billing: Dialysis related services (including

ambulance transport)Other ambulance transports (initial

transport, discharge transport, trips for emergency services)


• Unless specifically excluded from CB, all other services would be included, including: Laboratory and diagnostic imaging

services Simple procedures (such as debridement) Blood transfusion services Rehab therapy services


• Origin = Magic SNF (“N”)• Destination = Community Hospital

(“H”)


• Miles at destination: 5.6• Miles enroute: 0.0• Total loaded miles: 5.6• Appears to have used trip odometer,

this is acceptable way to track mileage, using onboard equipment

Run 103 E – Forms• AOB Signed by Grumpy Dwarf on DOS No indication of pt. inability to sign, or

relationship of this person to the patient Clarified on PCR

−AOB was signed by Grumpy, who is brother and notes why pt was unable to sign


• Paints picture well, to describe change in circumstance (i.e. AMS to blood transfusion), but could be clearer• EKG monitoring is clinically warranted

based on pt condition and history, as documented on the PCR



103 E – Other

• ALS vs. BLS Dispatched as “Delta” Priority (ALS Hot) ALS assessment noted ALS interventions performed (IV, EKG)

Run 103 E – Other

• Emergency vs. Non-emergency level billing Dispatched Emergency, based on pt

reported condition – this dictates whether “emergency response” was met for billing Transport Priority (Charlie/Non-

emergency) irrelevant for emergency/non-emergency determination

Run 103 E – ICD-10

• Date of Service is 9/30/15 – prior to the ICD-10 effective date• ICD-10 codes would not be used• Viable ICD-9 (Condition) Code: 428.9 – “Cardiac/Hemodynamic

monitoring required enroute” Included in Novitas LCD L32252


• Emergency Response criteria determines emergency level billing• Trip Odometer for mileage• Use of PCR to explain AOB signatures• ICD-10 Code effective date• Reasonableness / facility liability

Run 104 E

Jafar Ameer

Run 104 E – Emergency Response• Call received, dispatch, and enroute times

within 4 minutes, shows immediate response• Dispatch for “CVA/Stroke,” with “Delta”

response priority, although condition on scene is Headache

• Documentation of 911 call




• EKG monitoring• Slightly decreased GCS (14)• Headache (pain rated 4/10), with CVA

and cardiac history• Acute event• Hypertensive (210/98)


• Patient requires further assessment and evaluation not available at origin


• Origin = Residence (“R”)• Destination = Medical Center (“H”)


• Miles at destination: 152800.4• Miles enroute: 152791.3• Total loaded miles: 9.1

Run 104 E – Forms

• AOB Signed by crewmember Tinker Bell Signed on 10/5/15, contemporaneous?

−Pt received a few minutes before midnight (2356) on 10/4/15– signature captured a few minutes later (0003) on 10/5/15

−Valid

Run 104 E – Forms

• Face Sheet Shows patient came to hospital by

ambulance and was admitted 10/5/15 Used in lieu of the missing “receiving

facility representative” on the AOB “Secondary form of documentation” to

satisfy 42 CFR 424.36(b)(6)




• Could be clarified to better explain why some of these interventions were done, instead of noting “per protocol,” but appear warranted due to pt. complaints and conditions (cardiac history, elevated BP, etc.)

Run 104 E – Other

• Patient inability to sign the AOB “Unable to hold stylus” not the strongest

reason, but other conditions as documented on PCR seem to support inability to sign

Run 104 E – ICD-10

• Primary Code:• G44.89 – “Other headache syndrome” In abc QuikGuide

• R51 – “Headache” Describes pt condition Is on Novitas Group 1 Code list from

LCA

Run 104 E – ICD-10

• Secondary Diagnosis Code (Novitas):• Z74.3 – “need for continuous

supervision”


• Face sheet as “secondary documentation”• Reason for inability to sign• Importance of good documentation Consider returning to crew for

clarification, but not necessary

Run 105 E

Stinky Pete




• Call received, dispatched, and enroute times all the same - shows immediate response• Dispatched as “man down,” pursuant to

911 call placed by son (as per PCR)


• Not applicable in this case• Medicare allows payment when

responding and patient is not yet legally declared dead

N/A


• Also, not applicable in this case

N/A


• Transported the deceased person’s body But note that a transport does not have

to occur to be eligible for payment for patient declared dead after dispatch

• Use QL modifier onlyN/A


• When pt is declared dead after dispatch, but prior to loading on the ambulance, the only reimbursable service is base rate, no mileage Medicare Benefit Policy Manual (100-2),

Chapter 10, Section 10.2.6

N/A

Run 105 E – Forms

• No additional forms• No pt. signature is required for claim

submission when pt. has died 42 CFR §424.36(a)




• Documentation complete to explain:Obvious death History of patient’s last few hours and

past poor healthWas pronounced Transport to decon room at hospital

Run 105 E – Other

• QL modifier is used to show pt was pronounced dead after dispatch• If pt is not pronounced, and transport

occurs, full reimbursement is available based on level of service provided• If patient is pronounced prior to

dispatch, QL cannot be used, and no reimbursement is available

Run 105 E – Other

• “Beneficiary Death” scenarios are described in Medicare Benefit Policy Manual (100-02), Chapter 10, Section 10.2.6

Run 105 E – Other • Although dispatched at ALS (and responded at

ALS), using the QL in this fashion only pays at the BLS base rate Medicare Claims Processing Manual, Chapter

10, Section 30.2 requires Hospital-based providers to bill A0428QL Other guidance is not specific about base rate

code to use Advisable to use A0428 unless you MAC

indicates otherwise

Run 105 E – ICD-10

• Novitas typically requires two ICD-10 codes – how do we pick a code to show medical necessity, when there was no transport of a live person?

Run 105 E – ICD-10• Novitas says: “Our system will not edit for the 4 codes listed in

the LCD when a QL modifier is submitted. So when billing the QL modifier only an ICD-10 code from the LCA or ICD-10 code from the manual is required.”

• No need to add one of the “extra” secondary codes from the LCD for the claim to go through if you are in Novitasjurisdiction



Run 105 E – ICD-10

• Possible Code:• I46.9 – “Cardiac Arrest, cause

unspecified” In abc QuikGuide and Novitas LCA, as

Group 1 Code


• Correct use of QL modifier• No patient signature needed when the

patient has died• Secondary ICD-10 Code exception

for Novitas

Run 106 E

J. Worthington Foulfellow


• Call received, dispatch, and enroute times are all the same, indicating an immediate response• 911 call, with “Delta” Response Priority

requested (ALS emergency) for “Mass/Multiple Trauma”


• Multiple traumas (although minor)• EKG (for precaution)• Bandages applied


• Transport to hospital for evaluation due to injuries and to verify there are no latent injuries (fractures, head injury, etc.)




• Origin = Scene (“S”)• Destination = General Hospital (“H”)


• Miles at destination: 1678.4• Miles enroute: 1672.4• Total loaded miles: 6.0• PCR reports 8.4 as “Total Mileage”

from “To scene” to “At Destination”• Make sure to bill loaded miles

Run 106 E – Forms

• AOB Signed by patient on DOS No indication patient was physically or

mentally incapable of signing Valid

Run 106 E – Forms

• Attestation Statement Signed by Sebastian Mon (lead

crewmember) after DOS – this is OK PCR was not signed Attestation from Flounder Ing should

also be obtained, before billing

Run 106 E – Forms

• Old CMS Transmittal 327, replaced by Transmittal 604 (July 24, 2015, effective 8/25/15) • Slightly modifies CMS Program

Integrity Manual (100-8), Chapter 3, Section 3.3.2.4 “Signature Requirements”

Run 106 E – Forms

• In post-payment reviews, Medicare Contractors (including MAC, RAC, ZPIC, SMRC and CERT) will verify that services “provided by/ordered be authenticated by the author”• Allows for signature logs or

“Attestation Statement”




• PCR paints picture of details surrounding the accident and events leading to the mechanism of injury• Clarifies the “mass/multiple trauma”

dispatch, in the dispatch notes, indicating it is one person with multiple trauma

Run106 E – Other • ALS dispatch and response• ALS assessment, despite no other ALS level

interventions• ALS level billing criteria met, pursuant to

ALS assessment rule (42 CFR § 414.605)• “ALS Assessment Rule” was recently

misstated by WPS

Run 106 E – ICD-10

• W37.0 – “Explosion of bicycle tire”• W10.1XXA – “Fall on/from sidewalk

curb, initial encounter” Both accurate, but speak more to

mechanism of injury than pt. condition Typically not “primary” diagnoses May be relevant for commercial payers

Run 106 E – ICD-10

• V16.9XXA – “Unspecified pedal cyclist injured in collision with other non-motor vehicle in traffic accident, initial encounter” Accurate, but speaks more to mechanism

of injury than pt condition Typically not a “primary diagnosis” Again, external cause of injury

Run 106 E – ICD-10

• S09.90XA – “Unspecified injury of head, initial encounter”• Trauma code Generic in nature Listed on Group 1 Novitas LCA and is in

the abc QuikGuide

Run 106 E – ICD-10

• Secondary Diagnosis Code (Novitas)• Z74.3 – “Need for continuous

supervision”




• Mileage (can end in a “0”)• Attestation Statement• ICD-10: beware of using codes that

relate to mechanism of injury and that do not relate to the condition that warrants transport by ambulance• ALS Assessment

Run 107 E

Mortimer Mouse

Run 107 E – Emergency Response• Delays between both call received and

dispatch times and dispatch and enroute times• No evidence of “Immediate Response”

or documentation of delay reason, despite BLS Emergency (Bravo) Response Priority and 911 call


• Pain (allegedly severe - 10/10) But, pt actions contradict this

• No interventions provided by crew• Conclusory statements by crew


• Constipation, sudden onset of pain• Possible GI issues/bowel obstruction• Pt requested transport to more distant

facility


• Origin = Residence (“R”)• Destination = Good Samaritan Hospital

(“H”)




• Miles at destination: 36.2• Miles enroute: 0.0• Total loaded miles: 36.2• Used trip odometer – this is permitted

– it’s “onboard equipment”

Run 107 E – Forms

• AOB Signed by patient on DOS Valid


• PCR paints a picture of the state of the home, patient’s complaint, and contradictory statements (severe pain, yet ambulating around the apartment in no distress and seeking personal items)

Run 107 E – Other

• ABN Not a “must use” situation Not necessary for emergency calls

emergencies or when patient is under duress But not a true emergency here

Run 107 E – Other

• Preference transport Three other hospitals bypassed to go to

preferred destination, 30+ miles away−Holy Spirit−General Hospital−Medical Center

Run 107 E – ICD-10

• Where medical necessity is not met, Novitas requires the use of a special ICD-10 Code: Z76.89 (along with the GY secondary

modifier) when billing to Medicare




• Excess mileage, with preference transport• Reasonableness vs. Medical Necessity• “Emergency Response” criteria

Run 108 E

Archimedes Q. Porter


• Call received, dispatch, and enroute times all within 1 minute• 911 call for “Respiratory Problem,” 911

call, even though pt was at a hospital• Could not care for patient at origin• Acute, emergency situation


• WARNING!• Emergency transports from a hospital

will be rare• This example is an anomaly, and will not

be a very common occurrence


• Albuterol• O2 (15 lpm via NRB)• Unconscious upon arrival, regained

consciousness enroute to hospital


• Respiratory services not available at origin• Pt required transfer for higher level of

care• Be careful if pt returns back to initial

hospital post treatment




• Origin = Community Hospital (“H”)• Destination = “Medical Center (“H”)


• Miles at destination: 65439.2• Miles enroute: 65423.8• Total loaded miles: 15.4• Miles not calculated on PCR – had to

do some math here!

Run 108 E – Forms

• AOB Signed by Sneezy Dwarf, MSW DP Representative of treating hospital

(Community Hospital) Signed on 10/3/15 Valid


• PCR explains facts and circumstances (especially details of why patient needs to leave a hospital with an acute event in the middle of the night)

Run 108 E – Other

• Note PCR date is 10/2/15 This is when call first came in (as per

response times) Pt. is not loaded onto ambulance until

early the next morning (0016) on 10/3/15 Midnight Rule applies – date of service

for the claim is when the loaded ambulance departs the scene

Run 108 E – ICD-10

• Primary Code• R06.02 – “Shortness of breath” Valid Primary Code from Novitas Group

1 LCA suggestion list and in abcQuikGuide

• Secondary Diagnosis Code (Novitas)• Z99.89 – “Dependence on other

enabling machines and devices”




• Midnight Rule• 42 CFR § 424.36 (b)(4) signature• Be careful of HH trips being billed as

emergencies – they will be rare!

Run 109 E

Shere Khan


• Call received, dispatched, and enroute times all within a few minutes of each other, shows immediate response• Dispatch for “Sick Person,” with Bravo

(BLS Hot) Response Priority


• Pt fled SNF, unclear of all details and circumstances• Pt A&O x2 (not place or event) and is

confused (with decreased GCS =14)• BGL = 60 – clinically hypoglycemic


• Evaluation at Hospital is warranted in light of circumstances• Intermediate stop at SNF was to get

information, not to return patient or to seek additional care for patient


• Origin = Power Plant (“S”)• Destination = Community Hospital

(“H”)• Intermediate stop at physician office Not applicable here, as stop was at SNF,

for information not for any type of care




• Miles at Destination: 4.0• Miles enroute: 0.0• Total loaded mileage: 4.0

Run 109 E – Forms

• AOB from DOS Not completed or signed at all

• AOB from 8/12/10 Signed by patient on 8/15/10 Valid lifetime signature


• PCR narrative is confusing, because of the chronological flow, but still paints picture of events• Explains assessments were performed

and communication with Medical Command and SNF

Run 109 E – Other

• ALS vs. BLS Dispatched BLS ALS crewmember (Donald Duck)

involved and performed ALS assessment ALS assessment rule to warrant ALS level

billing does not apply when there is BLS dispatch

Run 109 E – ICD-10

• F29 – “Unspecified psychosis not due to a substance or known physiological condition”On Novitas list, but not totally supported

by documentation

• R68.89 – “Other general symptoms & signs” Not on Novitas list, not specific enough

Run 109 E – ICD-10

• R41.89 – “Other symptoms and signs involving cognitive functions and awareness”While supported by documentation, and

on Novitas list, other codes provide greater specificity



Run 109 E – ICD-10

• R40.241 – “Glascow coma scale score 13-15”On Novitas suggested list from LCA

Group 1 codes, and abc QuikGuide Supported by documentation

Run 109 E – ICD-10

• Secondary Diagnosis Code (Novitas): Z78.1 – “Physical restraint status”

−Not appropriate, since no restraints were used

Z74.3 – “Need for continuous supervision”−Most appropriate as Secondary Diagnosis

Code


• Lifetime Signature• ALS vs. BLS ALS assessment not applicable with a BLS

dispatch (contrast with Run 106 E)

Run 110 E

Tiger Lilly


• Call received, dispatched, and enroute times all within a few minutes of one another – immediate response• 911 call for “sick person,” Bravo (BLS

hot) Response Priority


• Patient is bed confined due to cancer and related debility• Bed confined status customarily

associated with NE trips• “Presumed criteria” from Medicare

Benefit Policy Manual, 100-02, Ch. 10, Section 20




• Patient requires blockage to be dislodged from feeding tube• Unable to be corrected at origin• Reasonable to move patient to correct

problem


• Origin = Residence (“R”)• Destination = General Hospital (“H”)


• No mileage recorded on PCR• Internet mapping printout shows 6.9

total loaded miles from origin to destination

Run 110 E – Forms• AOB Signed by Bob Lilly, as POA/Guardian of

patient (also noted as spouse on PCR) Signed on DOS Pt unable to sign due to ALOC Valid

Run 110 E – Forms

• Mileage printout from Internet• Shown total miles from origin to

destination as 6.9• At least one MAC (Novitas) allowed

use of Internet mapping programs


• PCR explains facts and circumstances well, including commentary about bed confinement status, and hospice election



Run 110 E – Other

• GW modifier use Inappropriate hereOnly used where transport is unrelated

to hospice/terminal condition Appears that transport for G-tube

problem is related to stomach cancer diagnosis

Run 110 E – Other

• Because patient has elected hospice and is receiving hospice benefits, this transport is not separately billable to Medicare, as the reason for transport was related to terminal illness

Run 110 E – ICD-10

• ICD-10 Code typically not needed for billing facility, hospice, or pt.• Valid Primary Code: “Y82.8 – “Other

medical devices associated with adverse incidents” Appears in Novitas LCA “suggested” list

and on abc QuikGuide


• Bed confinement in emergency transports• GW modifier use and hospice election

and terminal conditions• Representative signature for claim

submission purposes

HANDOUTS Fall 2015 abc360 Emergency Coding Clinic · “PWW Media) Event (including but not limited...

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