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Provided by Coventry Health Care®
©2010 Coventry Health Care. All rights reserved.Proprietary – Do not copy, distribute or disclose without permission of
Coventry Health Care.
California Medical Bill Reviewer Re-Certification
Unit 6: Other Fee Schedules
Module 1: Ambulance & DMEPOS Guidelines
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
Overview Hi! In this module, you will learn about
two different fee schedules—
Ambulance and DMEPOS.
You will learn about ambulances
services, the crew requirements,
ambulance modifiers, and how these services are
reimbursed.
Then, you will learn about the DMEPOS
fee schedule and the guidelines for
reimbursement.
Part I: Ambulance Guidelines Ambulance Fee Schedule Crew Requirements Ambulance Services Supplies & Materials Modifiers Ambulance Reimbursement
Let’s start by discussing some
general ambulance guidelines...
Part I: Ambulance Guidelines Ambulance Fee Schedule
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
Ambulance Fee Schedule
Just like medical legal services, ambulance services are covered in a separate fee schedule.
Ambulance guidelines include
reimbursement for: Transportation Services Supplies & Materials
Let’s take a look…
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
Vehicle & Crew Requirements
The ambulance must be designed and equipped for transporting the sick, or injured, and include patient care equipment.
The ambulance crew must have two members, one of which has medical training equivalent to the standard and advanced Red Cross training.
Patient care equipment includes:
Stretchers Clean linens First aid supplies Oxygen equipment Lifesaving equipment
required by state and local authorities.
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
Ambulance Services
The ambulance fee schedule covers transportation services only if other means of transportation are contraindicated, or inadvisable, due to the patient’s medical condition.
Transportation services must be provided only to local facilities, unless necessary services are not available locally.
Transportation may also be provided:
From one hospital to another.
To the patient’s home. To an extended care
facility.
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
Air Ambulance Services
In addition to ground ambulance services, air ambulance services are included in the ambulance fee schedule.
Air ambulance services are covered when:
The point of pick-up is inaccessible by land vehicle.
The distances and/or other obstacles impede getting the patient to the nearest hospital with appropriate facilities.
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
Supplies and Materials
Some types of supplies are considered part of general ambulance services, and are included in the charge for the trip.
Reusable devices, not separately reimbursed
include devices such as: Back boards Neck boards Inflatable leg and arm
splints
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
Supplies and Materials
In contrast, a separate reasonable charge may be recognized for non-reusable items and disposable supplies.
Separate charges may be allowed for supplies,
such as: Oxygen Gauze IV Tubing
...that are required for patient care during the
trip.
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
Modifiers
For ambulance services, one-digit modifiers are combined to form a two-digit modifier.
Please refer to the state reference guide for a list of modifiers.
The first digit of the modifier identifies the ambulance’s place of origin.
The second digit identifies the ambulance’s destination.
Just like other types of
service, special modifiers are associated with
ambulance services.
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
Ambulance Reimbursement Now that you
understand the basics of ambulance services, let’s look at how these services are reimbursed...
Part I: Ambulance Guidelines Ambulance Fee Schedule Crew Requirements Ambulance Services Supplies & Materials Modifiers Ambulance Reimbursement Ambulance Reimbursement
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
Ambulance Reimbursement
Reimbursement is consistent across all providers of ambulance services.
The maximum reasonable fee for ambulance services shall not exceed 120% of the applicable fee as set forth in the CMS' Ambulance Fee Schedule.
Providers of ambulance services
include: Hospitals Private companies Fire departments
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
Ambulance Reimbursement
For services provided in the year 2007, Medicare announced ambulance fees must be increased by an Ambulance Inflation Factor (AIF) of 1.025.
To apply the new AIF, multiply the ambulance service fees in the CY 2007 Ambulance Fee Schedule by 1.025. As you can see, it is
important to check the website often for
updates!
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
Ambulance Reimbursement
The ambulance fee schedule amount is determined by the zip code of the point of pick-up, not the provider’s address.
Zip codes are divided into nine
Medicare localities:
03 05 06 07 09
17 18 26 99
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
Zip Code Localities
Within each of the nine localities, certain zip codes may be a rural area, which will have a different mileage rate than urban zip code areas in that same locality.
A zip code table lists the locality of the zip code and indicates whether it is a rural or urban area.
Different Mileage Rates
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
State Zip Code Carrier Locality
Urban (Blank)/Rural (R)/
Super Rural (B)CA 95568 31140 99 BCA 95569 31140 99 RCA 95570 31140 99 RCA 95571 31140 99 RCA 95573 31140 99 RCA 95585 31140 99 BCA 95587 31140 99 BCA 95589 31140 99 RCA 95595 31140 99 BCA 95601 31140 99 RCA 95602 31140 99CA 95603 31140 99CA 95604 31140 99CA 95605 31140 99CA 95606 31140 99
Zip Code Localities
The zip code table is located at the following link:
National Breakout of the Geographic Area Definitions by Zip Code
Remember, for a specific zip code, the table
indicates the: Locality Rural Indicator, if
applicable
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
Zip Code Localities
Each locality has several different associated values that you need to be familiar with.
These different values include:
Geographic Practice Cost Index (GPCI)
Conversion Factor (CF) Mileage Ground Rate (MGR) Relative Value Unit (RVU) for each
HCPCS code
Let’s take a look…
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
Ambulance Reimbursement
You should be familiar with conversion factors and relative value units from your earlier studies of reimbursement calculations.
However, you may not be familiar with the GPCI and MGR.Geographic Practice Cost Index (GPCI):
Mileage Ground Rate (MGR):
A factor used to adjust for geographic
differences in the cost of maintaining a medical
practice.
The reimbursement rate per mile for ground ambulance services.
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
Ambulance Reimbursement
There are different reimbursement calculations for mileage and other types of service.
Mileage Reimbursement: (MGR x Mileage)(AIF) = Total Reimbursement
All Other Reimbursements: (RVU x CF x GPCI)(AIF) = Total Reimbursement
Suppose an ambulance picks up an injured worker in the 95605 zip code area and travels nine miles to the nearest facility. How should the services be reimbursed?
Let’s take a look…
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
State Zip Code Carrier Locality
Urban (Blank)/Rural (R)/
Super Rural (B)CA 95568 31140 99 BCA 95569 31140 99 RCA 95570 31140 99 RCA 95571 31140 99 RCA 95573 31140 99 RCA 95585 31140 99 BCA 95587 31140 99 BCA 95589 31140 99 RCA 95595 31140 99 BCA 95601 31140 99 RCA 95602 31140 99CA 95603 31140 99CA 95604 31140 99CA 95605 31140 99CA 95606 31140 99
Ambulance Reimbursement
1. The first step is to identify the zip code locality from the zip code table.
2. For zip code 95605, the locality is 99. After identifying the zip code locality, reimbursement values can be calculated.
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
Ambulance Reimbursement
Ambulance reimbursement information is available at the following website:
http://www.dir.ca.gov/dwc/FeeSchedules/AMBULANCE_FeeSchedule/OMFS_Ambulance.pdf
There, you will find tables listed by state that provide information specific to different localities.
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
Ambulance Reimbursement
From the table you can get information for the following: Carrier #
Locality HCPCS Code Conversion Factor
Relative Value Unit GPCI Urban Mileage Rates Rural Mileage Rates
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
Ambulance Reimbursement
For the example we are working with, suppose the bill
shows HCPCS codes: A0425: Ground mileage, per
statute mile. A0426: Ambulance service,
advanced life support, non-emergency transport, level 1.
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
Ambulance Reimbursement
From the zip code table we found that 95605 corresponds to Locality 99 and an urban area, because the rural indicator is blank.
Zip Code Carrier LocalityRural
Indicator
95605 31140 99
HCPCS RVU CF GPCI MGR
A0425 1.0 1.0 1.265 6.87
A0426 1.20 209.65 1.265 333.58
Then, by locating the correct locality on the table in the fee schedule, we found the information in the table below.
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
Ambulance Reimbursement
Using the information in the table:
HCPCS RVU CF GPCI MGR
A0425 1.0 1.0 1.265 6.87
A0426 1.20 209.65 1.265 333.58
Mileage Reimbursement: (MGR x Mileage)(AIF) = Total Reimbursement
($6.87 X 9 miles) = $63.37(1.025)
Now let’s take a look at the reimbursement calculation for the other expenses...
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
Ambulance Reimbursement
Now, let’s calculate the reimbursement for the services related to A0426.
HCPCS RVU CF GPCI MGR
A0425 1.0 1.0 1.265 6.87
A0426 209.65 1.20 1.265 333.58
All Other Reimbursements: (RVU x CF x GPCI)(AIF) = Total Reimbursement
($209.65 X 1.20 = $326.19 (1.025)X 1.265)
Now that you have learned about ambulance services and how they are reimbursed, we will discuss DMEPOS guidelines.
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
DMEPOS Here, you will learn about DMEPOS
services, how they are differentiated, and how they are
reimbursed.
Let’s start by taking a look at some
general guidelines...
Part II: DMEPOS Guidelines DMEPOS Guidelines Asterisked Items Modifiers DMEPOS Reimbursement
Part II: DMEPOS Guidelines DMEPOS Guidelines
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
DMEPOS Guidelines
The DMEPOS Fee Schedule provides reimbursement guidelines for durable medical equipment, prosthetics, orthotics, and supplies. Prosthetics and orthotics
are appliances or supplies that: Restore function
Immobilize joints Protect joints Provide pain relief Correct & prevent deformity Replace body parts
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
DMEPOS Guidelines
Reimbursement for orthotic and prosthetic services accounts for more than the device itself.
Prosthetic and orthotic codes have a “L” or “X” prefix attached to a four digit numeric code.
Reimbursement accounts for: Evaluation & consultation
Construction Delivery Training on the proper use
of the device
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
Asterisked Items
Prosthetic and orthotic supplies can be designated by a single asterisk or a pair of asterisks in the fee schedule.
One Asterisk Two Asterisks
Items denoted by a single asterisk in the Maximum Reimbursement list may be billed by a provider only if the item falls within the provider’s scope of their practice.
Items denoted by a two asterisks may be
reimbursed if the item falls within the provider’s
scope of their practice, and if the pharmacy or
pharmacist is certified by the NARD Health
Support & Appliances Program.
NARD stands for National
Association of Retail
Druggists.
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
Modifiers Just like other types of services, DMEPOS
services can have associated modifiers. Let’s take a look...
Part II: DMEPOS Guidelines DMEPOS Guidelines Asterisked Items Modifiers DMEPOS Reimbursement
Modifiers
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
Modifiers
The DMEPOS reimbursement guidelines include three two-digit modifier supply codes.
51:This modifier
indicates a medical supply company with
certified orthotic personnel accredited by an organization recognized by the
National Organization for Competency
Assurance.
52:This modifier
indicates a medical supply company with certified prosthetic personnel accredited by an organization recognized by the
National Organization for Competency
Assurance.
53:This modifier
indicates a medical supply company with
certified orthotic and prosthetic
personnel accredited by an organization recognized by the
National Organization for Competency
Assurance.
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
Modifiers
In addition to the modifier supply codes, there are two digit alphabetical modifiers.
Most commonly these modifiers include:
NU: Purchase, New RR: Rented UE: Purchased, Used KM: Replacement
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
DMEPOSReimbursement Lastly, let’s take a
quick look at DMEPOS
reimbursement guidelines...
Part II: DMEPOS Guidelines DMEPOS Guidelines Asterisked Items Modifiers DMEPOS Reimbursement DMEPOS Reimbursement
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
DMEPOS Reimbursement
The maximum reasonable fees for durable medical equipment, prosthetics, orthotics, and supplies should not exceed 120% of the applicable California fees set forth in the Medicare calendar year 2007. It is important to realize that the
DMEPOS fee schedule is
updated quarterly.
Therefore, it is important to
check for updates!
To check for updates, you can find the DMEPOS fee schedule
at:http://cms.hhs.gov/DMEPOSFeeSched/LSDMEPOSFEE/list.asp
The most current version is: D07 JAN C.zip
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March 2010CA Regulations RefresherTraining – AMB & DMEPOS
Summary
Ambulance Guidelines
Ambulance Crew Requirements, Services, Supplies & Materials
Ambulance Modifiers & Reimbursement Guidelines
DMEPOS Guidelines
DMEPOS Modifiers & Reimbursement Guidelines
Asterisked Items in the DMEPOS Guidelines