CADS CADS Ambulance Billing & Reimbursement 2 — Questions and Answers
Question 1: What does 'medical necessity' mean in the context of Medicare ambulance documentation?
- The patient's condition required ambulance transport and could not safely use other means (Correct answer)
- The patient requested an ambulance and had Medicare coverage
- The transport occurred within Medicare's geographic service area
- A physician ordered the transport in advance
Correct answer: The patient's condition required ambulance transport and could not safely use other means
Medical necessity for Medicare ambulance billing means the patient's condition was such that transport by any other means would endanger the patient's health, as supported by PCR documentation.
Question 2: Which Medicare audit program specifically targets ambulance service billing compliance?
- Recovery Audit Contractor (RAC) (Correct answer)
- Meaningful Use Auditor
- Hospital Compare Program
- OSHA Inspection Program
Correct answer: Recovery Audit Contractor (RAC)
Recovery Audit Contractors (RACs) review Medicare claims, including ambulance services, for improper payments and documentation deficiencies, and can demand repayment of overpayments.
Question 3: Under HIPAA, how long must ambulance services retain patient billing records?
- 6 years from creation or last effective date (Correct answer)
- 3 years from the date of service
- 10 years from the patient's last visit
- Until the patient turns 21 if a minor
Correct answer: 6 years from creation or last effective date
HIPAA requires covered entities, including EMS agencies, to retain documentation related to protected health information for 6 years from the date of creation or last effective date.
Question 4: When an ambulance transports a patient to the closest appropriate facility, which documentation element supports this decision?
- Documentation of why the closest facility was appropriate for the patient's condition (Correct answer)
- The patient's insurance card showing in-network providers
- A verbal order from medical direction
- The facility's EMTALA certificate
Correct answer: Documentation of why the closest facility was appropriate for the patient's condition
PCR documentation must explain why the receiving facility was the closest appropriate facility capable of treating the patient's condition, supporting both medical necessity and billing claims.
Question 5: Which condition must be documented to bill Medicare for an ALS Level 2 (ALS2) transport?
- Three or more ALS interventions or administration of at least 3 medications (Correct answer)
- An ALS assessment indicating the need for BLS transport
- Specialty care transport with advanced monitoring
- Air medical transport with physician on board
Correct answer: Three or more ALS interventions or administration of at least 3 medications
ALS Level 2 requires documentation of three or more separate ALS interventions or administration of at least three medications during transport to qualify for the higher reimbursement rate.
Question 6: What is the purpose of the 'Origin/Destination' modifiers on ambulance HCPCS claims?
- To identify where the transport began and ended for proper reimbursement (Correct answer)
- To indicate the patient's diagnosis at the time of transport
- To document the crew certification level
- To specify the vehicle type used for transport
Correct answer: To identify where the transport began and ended for proper reimbursement
Origin and destination modifiers on ambulance HCPCS codes tell Medicare where the transport started and ended, which determines the applicable fee schedule rate and coverage rules.
CADS CADS Ambulance Billing & Reimbursement 2
What does 'medical necessity' mean in the context of Medicare ambulance documentation?