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TRANSCRIPT
Emergency Coding Clinic
Day Two
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2015-2016 Program Materials
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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
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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”)
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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)
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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
Run 102 E – Emergency Response
• 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
Run 102 E – Medical Necessity
• Pt. received multiple medications (Morphine Sulfate and Ondansetron)• Severe sudden/acute abdominal pain
(10/10)
Run 102 E – Reasonableness
• Severe abdominal pain requires evaluation and services not available at origin
Run 102 E – Origin/Destination
• 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”)
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Run 102 E – Mileage
• 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”
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Run 102 E – Lessons Learned
• Patient signature after DOS• Internet mapping to support mileage• ALS 1E vs. ALS2
Run 103 E
Bashful Dwarf
Run 103 E – Emergency Response
• Call received, dispatch, and enroute times within 2 minutes – shows immediate response• Initial dispatch for emergency
condition – “AMS”• Call “downgraded” after crew arrived
Run 103 E – Medical Necessity
• EKG monitoring, IV (saline lock)• Hemiparesis from previous stroke• Decreased GCS (11)• Though “baseline” conditions,
transport by other means is contraindicated
Run 103 E – Reasonableness
• 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
Run 103 E – Reasonableness
• “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
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Run 103 E – Reasonableness
• 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)
Run 103 E – Reasonableness
• 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
Run 103 E – Origin/Destination
• Origin = Magic SNF (“N”)• Destination = Community Hospital
(“H”)
Run 103 E – Mileage
• 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
Run 103 E – Documentation
• 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
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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
Run 103 E – Lessons Learned
• 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
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Run 104 E – Medical Necessity
• EKG monitoring• Slightly decreased GCS (14)• Headache (pain rated 4/10), with CVA
and cardiac history• Acute event• Hypertensive (210/98)
Run 104 E – Reasonableness
• Patient requires further assessment and evaluation not available at origin
Run 104 E – Origin/Destination
• Origin = Residence (“R”)• Destination = Medical Center (“H”)
Run 104 E – Mileage
• 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)
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Run 104 E – Documentation
• 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”
Run 104 E – Lessons Learned
• 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
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Run 105 E – Emergency Response
• 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)
Run 105 E – Medical Necessity
• Not applicable in this case• Medicare allows payment when
responding and patient is not yet legally declared dead
N/A
Run 105 E – Reasonableness
• Also, not applicable in this case
N/A
Run 105 E – Origin/Destination
• 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
Run 105 E – Mileage
• 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)
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Run 105 E – Documentation
• 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
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Run 105 E – ICD-10
• Possible Code:• I46.9 – “Cardiac Arrest, cause
unspecified” In abc QuikGuide and Novitas LCA, as
Group 1 Code
Run 105 E – Lessons Learned
• 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
Run 106 E – Emergency Response
• 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”
Run 106 E – Medical Necessity
• Multiple traumas (although minor)• EKG (for precaution)• Bandages applied
Run 106 E – Reasonableness
• Transport to hospital for evaluation due to injuries and to verify there are no latent injuries (fractures, head injury, etc.)
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Run 106 E – Origin/Destination
• Origin = Scene (“S”)• Destination = General Hospital (“H”)
Run 106 E – Mileage
• 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”
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Run 106 E – Documentation
• 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”
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Run 106 E – Lessons Learned
• 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
Run 107 E – Medical Necessity
• Pain (allegedly severe - 10/10) But, pt actions contradict this
• No interventions provided by crew• Conclusory statements by crew
Run 107 E – Reasonableness
• Constipation, sudden onset of pain• Possible GI issues/bowel obstruction• Pt requested transport to more distant
facility
Run 107 E – Origin/Destination
• Origin = Residence (“R”)• Destination = Good Samaritan Hospital
(“H”)
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Run 107 E – Mileage
• 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
Run 107 E – Documentation
• 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
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Run 107 E – Lessons Learned
• Excess mileage, with preference transport• Reasonableness vs. Medical Necessity• “Emergency Response” criteria
Run 108 E
Archimedes Q. Porter
Run 108 E – Emergency Response
• 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
Run 108 E – Emergency Response
• WARNING!• Emergency transports from a hospital
will be rare• This example is an anomaly, and will not
be a very common occurrence
Run 108 E – Medical Necessity
• Albuterol• O2 (15 lpm via NRB)• Unconscious upon arrival, regained
consciousness enroute to hospital
Run 108 E – Reasonableness
• 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
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Run 108 E – Origin/Destination
• Origin = Community Hospital (“H”)• Destination = “Medical Center (“H”)
Run 108 E – Mileage
• 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
Run 108 E – Documentation
• 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”
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Run 108 E – Lessons Learned
• 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
Run 109 E – Emergency Response
• 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
Run 109 E – Medical Necessity
• 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
Run 109 E – Reasonableness
• 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
Run 109 E – Origin/Destination
• 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
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Run 109 E – Mileage
• 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
Run 109 E – Documentation
• 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
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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
Run 109 E – Lessons Learned
• Lifetime Signature• ALS vs. BLS ALS assessment not applicable with a BLS
dispatch (contrast with Run 106 E)
Run 110 E
Tiger Lilly
Run 110 E – Emergency Response
• 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
Run 110 E – Medical Necessity
• 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
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Run 110 E – Reasonableness
• Patient requires blockage to be dislodged from feeding tube• Unable to be corrected at origin• Reasonable to move patient to correct
problem
Run 110 E – Origin/Destination
• Origin = Residence (“R”)• Destination = General Hospital (“H”)
Run 110 E – Mileage
• 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
Run 110 E – Documentation
• PCR explains facts and circumstances well, including commentary about bed confinement status, and hospice election
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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
Run 110 E – Lessons Learned
• Bed confinement in emergency transports• GW modifier use and hospice election
and terminal conditions• Representative signature for claim
submission purposes