Systems Design Northwest Inc.


	Medical Practice Management Software

	Ambulance Billing Services

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How long have we been in business?
Systems Design was established in 1989 as a software firm specializing in systems for medical providers. In 1991 we signed our first contract to provide billing services with the Bremerton Fire Department. We now provide billing services to over 60 ambulance providers.

What is your service area?
While we are currently providing services to clients in Washington, Oregon and Alaska, we would welcome the opportunity to expand into other areas. Because of the way we conduct our business, we can provide the same high level of service no matter where you are located. All our customer service is provided via nationwide toll free numbers.

Why should we out-source our billing?
There are actually many reasons why out-sourcing your billing may be right for you. If you have been doing your own billing in-house, you already know how complicated it can be. It can be very time consuming trying to keep up with all the changing regulations. Knowing how to accurately submit bills to ensure the highest possible payment is also very important. Being able to provide full time customer service can be difficult, especially for smaller ambulance providers with limited staff. Throw in sick days, vacations, etc and it becomes even more difficult.

Of course, often times the overriding issue has to do with the bottom line. Does it make sense financially to out-source? The answer for many ambulance providers, small and large alike, is very often yes. A billing agency can concentrate on the billing, including the very important follow-up. When the billing is done in-house, it is usually just one of the many responsibilities the staff must manage. Not being able to concentrate exclusively on the billing can, and usually does, result in a lower collection rate. The cost of using a billing agency can usually increase the bottom line, even after the cost of the service is considered.

Is it better to pay a billing agency based on a percent of collection or based on a flat fee per transport.
You may be surprised by the answer! We firmly believe that paying based on a flat fee per transport is better for all parties involved, the ambulance provider, the billing agency and the patient. Take a look at this document for a further explaination.
Open Microsoft Word document Open Adobe Acrobat Reader file

Where do we start?
Give us a call. It can be confusing getting started, let us help you through the process. We've even developed a check list you can use to help you know what needs to be done. That checklist is available on our Documents Page.

Why should we bill for our services?
Because by not billing for your transports, your tax payers are having to pay the entire cost of your ambulance service. If you bill for your services, the insurance companies and government agencies (Medicare, Medicaid, Labor & Industries, etc.) will pay a major portion of the total costs. If you don't bill, it's the insurance companies that are getting the break, not your tax payers.

Medicare covered services
Medicare will pay for ambulance transports only if the patient could not have traveled any other way. Below are Medicare's medical necessity guidelines.

Unconscious or in shock
Restraints needed
Requires oxygen
Requires emergency medical treatment
Needs emergency transport because of a situation, illness or injury
Has to remain immobile due to a possible fracture
Is hemorrhaging
Sustained an acute CVA or MI
Is bed confined and can only be moved by stretcher

Medicare non-covered services
The following are non-covered services:

Transports which do not meet the above medical necessity guidelines
Ambulance trip to a funeral home
911 response if no transport takes place
Transfer from one residence to another, including nursing homes
Transfer from one appropriately facilitated hospital to another for the patient's or physician's convenience
Transportation to a free-standing dialysis facility for routine maintenance dialysis, unless the patient's condition justifies the medical necessity of the transport
Routine trip to return the patient home, when the patient had previously been transported to the hospital, unless the patient's condition meets one of the above guidelines, such as bed confined.
The patient is transported to a physician's office, unless the patient's condition requires stabilization before transfer to the hospital.

Remember, payment is not guaranteed when a doctor, nursing home personnel or hospital orders the ambulance transport. This by itself does not substantiate medical necessity for the use of an ambulance.

Documentation Hints
To determine if the ambulance transport was reasonable and necessary, Medicare needs relevant, clear, and concise facts reflecting the patient's condition at the time of dispatch and transport.

The general rule for all Medicare documentation is "If it is not documented, it is not done". Use objective (descriptive) terms describing why the patient needed an ambulance. Use terms like "chest pain radiating into the jaw" rather than "cardiac emergency", which is a phrase that presumes a condition rather than describes a state of affairs. Similarly, phrases like "per doctors orders" or "ordered by nursing home personnel", do not justify transport. State objective findings, such as, "difficulty breathing, respiratory rate 32 with diaphoresis".

Give a specific reason for transfer from facility to facility, i.e., transfer is necessary because services are not available at the transferring hospital.

Provide reasons for any extenuating circumstances prohibiting transport to the closest, appropriate facility. Examples: hospital on divert, no fly zones, blizzard conditions, black ice, heavy fog, smoke, extensive road construction, specialist not available (orthopedic surgeon not available and no locum tenens available).

Do not use terms, such as, "non-ambulatory", "bed confined", "bed ridden", "bed rest" or "limited movement", etc., unless the patient is bed confined by Medicare standards. See Section XV "Transporting Bed Confined Beneficiaries" for definition. Sometimes these descriptors are incorrectly written on claims. A patient who was ambulatory prior to having back pain is not "bed confined". These terms are not meant to be the sole criterion in determining medical necessity. These terms are only one factor to be considered. A medical record must contain adequate information supporting the reason for bed confined, bed ridden, bed rest or non-ambulatory status.

Documentation Challenges and Solutions

Challenge: The chief complaint, exam and vitals are not documented or only a brief exam is documented.

Solution: If documentation is too brief, the extent of illness or injury of the beneficiary cannot be determined. SOAP (Subjective findings, Objective findings, Assessment and Plan) documentation is recommended so the condition of the beneficiary can be better understood. Documenting the patient's ambulatory status also gives Medicare staff a better picture of the beneficiary's condition. The stated condition of the beneficiary plays a major part in determining Medicare reimbursement.

Challenge: Boxes checked on the trip report i.e., bed confined, requires oxygen, restraints, requires stretcher or infectious disease.

Solution: Use a narrative description describing why the box is checked. If a checked box states "bed confined", explain why the patient is bed confined, such as contractures of all extremities, or patient is quadriplegic and unable to sit in a chair, or unable to move extremities because of severe back pain or injury.

Challenge: Pain scale of five on a scale of ten does not describe the symptoms of pain.

Solution: The pain scale should be supplemented with a description of the quality of the pain using the patient's own words to describe pain. For example stabbing, burning, shooting, severe, limits movements, etc. Also document if anything makes pain better or worse.

Challenge: Abbreviations used are not standard medical abbreviations and are known only to the supplier. Also when abbreviations are used for origin and destination information, it can be troublesome, i.e. MMC.

Solution: Use accepted standard medical abbreviations. Report the origin and destination without abbreviations, for example Mercy Medical Center, not MMC.

Challenge: Illegible documentation on trip reports may cause claim denials, due to incomplete information.

Solution: Print documentation or write legibly. The trip report is important for processing claims, determining the medical necessity of ambulance services and continuity of care.

Challenge: Medical necessity for billing extra mileage is not documented.

Solution: In order for extra mileage to be considered, the situation must be documented. Identify when a hospital is on "divert" and not accepting patients, a "no fly zone" must be avoided, weather problems exist, a construction site must be avoided to save time or the air ambulance is unable to land somewhere.

Challenge: Mileage billed is not accurate according to Medicare internal mileage guidelines and maps.

Solution: Good documentation includes odometer readings on the trip report, for both land and air, from point of pick up to destination.

Challenge: Reviewers are unable to determine what care was provided for the beneficiary during transport or what treatment was needed during the transport for a beneficiary that could have traveled by other means.

Solution: Include the treatments given to the patient in chronological order, findings at the scene, enroute details if significant, and the patient's condition at the destination.

Challenge: Trip report documentation is very brief on routine trips, for example dialysis patients.

Solution: Each trip report has to "stand on it's own". Medically necessary information needs to be submitted with each claim, as previous claims and documentation are not used for current claims. The reason for bed confinement needs to be included.

Challenge: The reason a beneficiary is transported between hospitals is not identified on the trip report or claim.

Solution: Document in the trip report the reason for the transfer from one hospital to another. Examples are: a cardiac test is not available at the first hospital, or the trauma unit is better able to handle a head injury. These transports are covered only if going for additional services not available at the first hospital and other means of transport would endanger the patient's health. If the beneficiary is not discharged from the first hospital, the ambulance trip is billed to the Medicare Part A through the hospital.

Challenge: Documentation does not support the reason for a beneficiary's transfer from a larger hospital to a smaller hospital.

Solution: Often the reason for this transfer is a beneficiary admission to a "swing bed." Trip report documentation should state this.

Challenge: Psychiatric transport claim does not contain the necessary information to pay the initial claim.

Solution: Documentation needs to state the reason for the transport, such as suicide watch, harmful to self, needs restraints, overdose requiring monitoring. Include documentation of signs and symptoms for "court ordered mental health hold" or "legal circumstances" with the claim. Dementia or Alzheimer's is not a payable condition by itself. Documentation needs to state why beneficiary could not be transferred by other means. If there is a psychiatric emergency, document signs and symptoms. Documentation stating "medical clearance" is not payable without documentation stating why the beneficiary could not travel another way.

Challenge: The only reason for a transport listed on the claim is the patient required oxygen.

Solution: Document the need for oxygen. The administration of oxygen itself does not satisfy the requirement that the patient needs oxygen. For example, patient needs oxygen because of hypoxia, syncope, pulmonary edema, shock, stroke, respiratory rate, labored breathing etc.

Ambulance transport is not medically necessary if the only reason for the ambulance service is to provide oxygen during the transport and the patient has a portable oxygen system available.

Challenge: Ambulance company name is not on the trip report.

Solution: Add the name to the trip report so Medicare can verify the documentation.

Challenge: Claims submitted without a zip code or with an invalid zip code.

Solution: A zip code is required and is the basis for determining correct mileage reimbursement levels. Use the correct zip code for the pick-up location.

Challenge: Often the claim form does not clearly identify or classify the destination. For example, reviewers are not aware whether a medical center is a hospital or clinic.

Solution: When documenting origin or destination information on the claim form, list whether it is a hospital, clinic, nursing home or other type of facility. Classifications of medical facilities are required.

Ferry Charges
When a ferry is used to transport patients, water ambulance is charged the same way as ground ambulance. There is no accommodation in the fee schedule for a ferry charge, so the payment is calculated the same as ground ambulance. This is like a bridge toll and is included in the base rate. However, the distance traveled on the ferry is reflected in the total number of miles billed.

ALS Assessment
If a paramedic releases a patient to be transported BLS can we still bill that transport at an ALS rate?

Yes as long as certain criteria have been met:

You must have taken immediate steps to respond to the call.
The patient's condition required an ALS response in accordance to your dispatch protocol.
The patient was transported to a medical facility
The paramedic must "lay hands" on the patient, that is he must perform a hands-on examination.

If all of these criteria are met do not hesitate to bill for the assessment. Be careful to include dispatch information in the MIR and also to note that a paramedic assessment was done and the patient was released to go BLS.

Responses by multiple providers
When a BLS entity provides the transport of the patient and an ALS entity provides a service meeting the fee schedule definition of an ALS intervention (i.e., ALS assessment), the BLS entity bills Medicare the ALS rate if a written agreement exists between the BLS and ALS entities. You may be required to provide a copy of the agreement upon request.

While there must be a written agreement between the BLS supplier furnishing the transport and the ALS entity furnishing the ALS service, Medicare does not regulate the compensation between the two parties. If no agreement exists between the BLS ambulance entity and the ALS entity furnishing the service, only the BLS level of payment is made.

Emergency Response Rule
Emergency response is a level of service that has been provided in immediate response to a 911 call or equivalent. For a response to be emergent the ambulance provider must begin as quickly as possible to take the steps necessary to respond to the call. For instance, you are called out to a group home for a routine transport for a resident who is in need of a chest x-ray. You get there, the patient is ashen, sweaty and c/o chest pain. The transport becomes ALS, however you cannot bill it emergent because you did not take immediate steps to get there. Emergency response has nothing to do with lights or sirens.

Multiple Patients in One Ambulance
If two patients are transported at the same time in one ambulance to the same destination, the adjusted payment allowance for each Medicare beneficiary would equal 75% of the single-patient allowed amount, plus 50% of the total mileage payment allowance for the entire trip.

If three or more patients are transported at the same time in one ambulance to the same destination, the adjusted payment for each Medicare beneficiary would equal 60% of the single-patient allowed amount, plus the total mileage allowed amount divided by the number of all the patients onboard.

The fact that the level of medically necessary service among the patients may be different is not relevant to this payment policy. The percentage is applied to the allowed amount applicable to the level of service that is medically necessary for each beneficiary.

Transports to Air Ambulance
When a patient is transported by ground ambulance and transferred to an air ambulance, the ground ambulance bills Medicare for the level of service provided and mileage from the point-of-pick-up to the point-of-transfer to the air ambulance. Remember, when billing mileage, you can bill for all miles or portions thereof. So if you transport the patient 7.1 miles, you should bill it as 8 miles. You are not required to round up or down to the nearest mile.

Transporting Bed Confined Beneficiaries
Ambulance transport is indicated for non-emergency situations when bed confinement is necessary before and after the ambulance trip and a one way or round trip is medically necessary.

For Medicare purposes all the following criteria need to be met for a patient to be considered bed confined:

Unable to get up from bed without assistance,
Unable to ambulate, and
Unable to sit in a chair or a wheelchair.

The "bed confined" definition does not apply to a patient restricted to bed rest on physician's instructions due to a short-term illness. Bed confined is not synonymous with "bed rest" or "non ambulatory". In this context, Medicare defines 'bed confined' as a chronic condition and not simply the result of an acute injury or illness.

Bed confinement is not meant to be the sole criteria to determine medical necessity. It is one factor to be considered when making medical necessity determinations. Whenever bed confinement is one element justifying ambulance transport, include adequate information in the medical record justifying this claim.

Physician Certification Statement (PCS)
A PCS is required for the following ambulance services:

Non-emergency, scheduled, repetitive ambulance services
Unscheduled, non-emergency ambulance services or non-emergency ambulance services scheduled on a non-repetitive basis for a resident of a facility who is under the care of a physician.

Note: For non-emergency, scheduled, repetitive ambulance services, the physician's order must be dated no earlier than 60 days before the service is furnished.

A PCS is not required for any emergency services

A PCS is not required for Non-emergency, unscheduled ambulance services for a beneficiary who at the time of the transport, was residing either at home or in a facility and was not under the direct care of a physician.

If unable to obtain the physician's signature, it is acceptable to obtain a signed certification statement from the physician assistant, nurse practitioner or clinical nurse specialist (where all applicable state license or certification requirements are met), or discharge planner, who has a personal knowledge of the beneficiary's condition at the time the ambulance transport is ordered or the service is furnished. The beneficiary’s attending physician or the hospital or facility where the beneficiary is being treated and from which the beneficiary is transported must employ this individual.

For non-emergency ambulance services that are either unscheduled or that are scheduled on a non-repetitive basis, suppliers may submit a claim after 48 hours if a PCS or certification from an acceptable alternative person has been obtained, or after 21 days if acceptable documentation of attempts to obtain the certification has been obtained. This policy also applies when a supplier responds to a non-emergency call and, upon arrival at the point-of-pick-up, the condition of the beneficiary requires emergency care.

Note: Although the condition of the patient in this scenario would require the supplier to concentrate on the emergent treatment of the patient upon arrival at the scene, the claim for this service would not qualify as an "emergency transport" because the original dispatch was non-emergent. (See definition of Emergency Response Rule above.)

When a PCS cannot be obtained, a supplier may send a letter via USPS Certified Mail or other similar commercial service with a return receipt for proof of mailing as evidence of the attempt to obtain the PCS.

Pronouncement of Death
You may bill for a patient who is pronounced dead at the scene. The payment level is as follows.

Before dispatch	No payment
After dispatch, before patient loading	BLS base rate only, no mileage
After pickup, prior to or upon arrival at receiving facility	Level of service and mileage