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Below are questions, and corresponding answers, that were posed during the Janaury 7, 2005 Audio Conference on Condition Codes.
Other Payers
Coverage
Air Ambulance
Other Codes
ALS Dispatch to BLS Condition
BLS Responding to ALS Condition
SCT Transport
Dispatch
ICD-9 Codes
Q Codes
Modifiers
Electronic Claims
Other Payers
Question
Are insurance companies going to accept these new codes or do we have to provide the current code as well as these new condition codes when filing claims?
Answer
Other primary payers are under no obligation to accept the condition codes. Therefore, you will have to continue to use the current ICD-9 codes until the specific payer on a claim switches to the condition codes.
Question
If I used condition codes and my Medicare Carrier or Intermediary paid the claim, must the supplementary Carrier accept the condition codes?
Answer
Yes, if Medicare pays, the supplementary must pay, as long as the patient has eligibility with that supplementary Carrier, regardless of which condition vs. ICD-9 code was used.
Coverage
Question
Our operation is the only acute care center in area and we are related to an independent inpatient rehab facility. Often patients from the surrounding areas are brought to these facilities by air (both fixed wing and helicopter). They arrive at the regional airport. Except for the ambulance, there are no transportation facilities for the patients who are not capable of using other means of transportations (taxi or private car) and are picked up by the EMS provider owned by the hospital. Most of the time such claims are rejected by Medicare for not meeting the LMRP promulgated criteria. What code will be appropriate for such a trip and what information should be entered on the medical documents such as service or trip report. How can we get paid for such trip?
Answer
If the patient can be transported, safely, by other means, whether those other means are available or not, ambulance is not covered by Medicare. Thus, an ambulance is not covered if the patient could be transported by car, taxi, wheelchair van, based on their condition, even if no car, taxi or wheelchair van is available. In such cases, if you use an ambulance and bill Medicare, you should bill with the GY modifier, for a denial. Use the closest condition code and put an explanation in the narrative as to the condition of the patient.
Air Ambulance
Question
Will there be definitive directions coming out from the Carriers or CMS on where to place these modifiers-we are an air service-rotor wing?
Do I understand we will use two modifiers the D’s & C’s?
Plus-we do frequent H-H—where there is definitive DX of “Acute Inferior wall MI”, Septic Shock, Ruptured AAA etc etc—we code the DX—none of these are on the condition code cross walk—will that be a problem if we use an ICD-9 with no cross walk to a Condition Code?
Answer
With respect to the modifiers, only one condition code modifier is needed. The “D” modifiers listed in the latest (but not yet finalized) version of the condition codes, are for air transports. You do not use the “C” modifiers as those are for ground ambulance transports. The “D” modifier will be placed after the origin/destination modifiers. CMS still has to issue instructions on these issues.
With respect to the second question, if you find situations where no condition code fits the condition of the patient, you may choose to use ICD-9 codes rather than condition codes. However, you will have to work out with your Carrier or Intermediary a system so that they will know if you are using condition codes or ICD-9 codes. Either can be used, but you and your Carrier/Intermediary need to have a common understanding of which system of codes is being used.
Other Codes
Question
Will the utilization of the condition codes eliminate the need to use external cause codes to report the mechanics of injury?
Answer
If you are using the condition codes, you would not use the “E” or “V” codes.
ALS Dispatch to BLS Condition
Question
In a situation where an EMS provider is an All ALS provider, how does example number 4 (ALS dispatch and BLS on scene condition) of the list of examples provided by the AAA affect the claim to Medicare? Can the All ALS provider bill as an ALS Emergency? If so, would you still put the C3 modifier?
Answer
Regardless of whether you are all ALS or not, it was an ALS dispatch to a BLS on-scene condition. Therefore, the C-3 modifier is needed with two condition codes -- the first would be the condition code for the BLS on-scene condition and the second condition code would be for the ALS condition recorded by dispatch.
BLS Responding to ALS Condition
Question
In response to example 3 on the list of examples provided by the AAA, was your intent to give us an example of how a BLS service responding to an ALS condition code on scene, and how they should bill this call? If this was your intent we understand the answer you gave, it was just not clear to us what type of service was responding. A suggestion might be to list a BLS responding service billing procedure and an ALS crews billing procedure for this and any other similar scenario. If it was not your intent and the on-scene condition code should have been BLS, Abdominal pain w/o other signs or symptoms. – 789.00[2] – BLS-E, then you might want to look at this scenario again.
If our above assumption was correct, this then presented our second question; For those ambulance services that only have ALS Crews and who responded to a “Dispatched” BLS patient as listed above and find an On Scene Condition Code suggesting a potential ALS patient (as this condition code suggests – Service Level ALS) and they do an ALS assessment, what modifier should be used or no modifier is needed just bill A0427? The C3 modifier does not seem to be appropriate because of what is listed in the Modifier Description, “ALS response required based upon appropriate Dispatch Protocols” and our Dispatch Protocols say it is a BLS patient. So our thoughts were it should be billed straight out as an A0427 because we meet the immediate response condition and we found a potential ALS patient according to the on-scene condition code, which is how we currently bill without the condition codes (see “ALS crew transports or a BLS service transports with a mutual aid paramedic (contracted agreement)”, below).
BLS service responds and transports:
Billed as BLS Emergency claim to Medicare.
One condition code reported on claim along with a modifier that accompanies the BLS HCPCS [currently C5 on latest draft list of codes] that indicates that a BLS level ambulance and crew treated and transported an ALS level patient.
Condition on claim: 535.50[1] - Abdominal pain w/ symptoms
ALS crew transports or a BLS service transports with a mutual aid paramedic (contracted agreement):
Billed as ALS Emergency claim to Medicare.
One condition code reported on claim: 535.50[1] - Abdominal pain w/ symptoms
Answer
It is correct that the ambulance service being dispatch was a BLS service,…thus the need for the C5 modifier. As for an all ALS service responding to a BLS call, there would be no modifier and the only CC needed would be the On Scene condition which is also ALS. This confusion will easily be corrected with their suggestion that we ID the type of service responding on our examples.
SCT Transport
Question
When the examples of condition codes were reviewed on the audio conference of January 7, one example, number 42 on the list of examples provided by the AAA, was confusing to us. The speaker said to bill as follows:
“Bill this transport as a SCT HCPCS code along with a modifier indicating that this is an interfacility transport for a higher level of care.”
We have gotten mixed answers on this issue. We have been told that we could not bill an SCT, even though we had a nurse on board, was transporting interfacility to higher level of care, because the nurse was employed by the hospital, not the ambulance provider. The example you have used states the exact opposite.
Answer
The RN does not have to be employed by you. If the RN is needed to provide a service that is above the level of the paramedic, the hospital to hospital transport qualifies as SCT. Whoever told you differently is wrong. Perhaps what they meant to include in their evaluation of this situation is that you are supposed to have an agreement with the hospital employing the RN that indicates who is billing for the service. As an aside, the RN can be an employee or an independent contractor.
Dispatch
Question
The question that I have relates to dispatch centers that fall outside of supplier controls. There are dispatch environments where Fire/City dispatch the ambulances making the Dispatch data more difficult to capture. How will this be handled from a documentation standard and coding standard with respect to condition codes? What if any recommendations do you have for this issue?
Answer
Since it is the recommendation that the condition code that corresponds to the dispatch information be sent with all claims where you are requesting ALS level reimbursement when you appropriately respond an ALS level ambulance but encounter, treat and transport a BLS level patient, you must have that information from your dispatch center in order to request that level of reimbursement. If you are not currently obtaining adequate documentation and information about the response, then you will not be able to request the ALS level reimbursement for these situations. Although the condition code would now be submitted on the claim, that would be the only change in this process from what should be occurring today
Question
Given the statement that claims would be considered based on both primary and secondary conditions (i.e. on-scene versus dispatch), do you anticipate that the carriers will be required to incorporate claim edit checks to look at the secondary position code?
Answer
I do not know if they will be required or if it will be voluntary on their part. Either way, it would be prudent for them to have such edits.
ICD-9 Codes
Question
Would it make more sense to have the carriers to expand their approved diagnosis lists to include those ICD-9 codes that correlate to a condition code? The carriers appear to not be required to recognize the ICD-9 codes as listed on the conditions list into their LMRP’s or approved diagnosis lists. This disconnect will continue to create denials and allow for individual carrier latitude. For example, the condition code 69 and 69 tie to a diagnosis code that is not on the approved list for Trailblazer. Can you comment on this?
Answer
As currently designed, Carriers will have to accept the condition codes if the supplier wants to use condition codes. In these cases, the Carrier will have to accept the condition codes and will have to revise their LMRP (Local Medical Review Policy) accordingly. Thus, if there are conditions on the condition code list not currently used by a Carrier, the Carrier will have to revise its current list to include these conditions.
Q Codes
Question
How do the condition codes affect the use of Q codes? If my service is an all ALS service and ALS responds to a condition that could be dispatched BLS Emergency under the Condition Codes, but in fact the on scene condition turns out to be ALS E how would you bill the claim?
Answer
First of all, this issue goes away for dates of service after 12/31/05, since the Q-codes will no longer be used for dates of service after 12/31/05. For 2005 dates of service, as well as thereafter, you will use the ALS on-scene condition code with a secondary code for the BLS dispatch condition.
Modifier
Question
What modifier should be used for #16?
Answer
QL
Electronic Claims
Question
Will the condition codes, when implemented, apply for electronic as well as paper claims to Medicare?
Answer
Yes.
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