August 26, 2020
Notification of Service Specific Post Payment Reviews for Ambulance: BLS Non-Emergency (A0428), BLS Emergency (A0429) and Mileage (A0425)
The goal of CGS's Medical Review (MR) program is to reduce errors through claims, reviews, and education on Medicare's coverage, coding, payment and billing policies. To achieve this goal, we conduct data analysis to identify the provider billing services of CPT/HCPCS codes that pose the greatest risk to the Medicare program.
The considerable high dollars involved (compared to other Part B services) create the potential for significant risks. To mitigate potential risks to the Medicare program, in August 2020, CGS will initiate service-specific post payment reviews to address potential insufficient documentation issues.
The reviews will involve Ambulance transport billing codes A0428, A0429 and A0425. Documentation will be reviewed for compliance with Medicare rules and regulations such as: medical necessity, required components and signatures, deliverance of the service; as well as correct coding and billing per medical necessity.
Additional Documentation Requests (ADR) letters will be sent. Please submit requested documentation within 45 days of receipt of the ADR letter date. Please include a copy of your ADR letter and cover sheet with each claim documentation submission. Failure to respond by the 45th day will result in denial for non -response and recoupment of dollars paid in error.
Documentation Necessary to Process the Claim
We expect the documentation submitted with each ADR letter to include a copy of the following legible and signed documentation from each patient's medical record:
- Beneficiary's name
- Date of service
- PCS signed with credentials and dated or Documentation of signed receipt for unsigned PCS request from the U.S. Postal Service or other similar services
- Transport note with documentation as to why patient needs to be transported by ambulance. (paint a picture such as patient unable to sit upright due to contractures)
- Mileage noted to support transport to the nearest facility or documentation to support why transport was not to the nearest facility.
- Documentation to show illness or injury that supports other means of transportation is contraindicated.
- Relevant history, condition and/or level of function
- Hospital to Hospital transports - Documentation to support services not available at originating hospital or higher level of services needed.
- Documentation supporting level of transport being billed.
- Transport note with signature and credentials of the crew member providing care of the beneficiary.
- Appropriate signatures
- Signature and credentials of person performing the service do not meet CMS signature requirementsÂ
- Amendments/corrections/delayed entries are properly identified
- Amendments/corrections/delayed entries are initialed and dated by Author within 30 days of the billed service.
- For more information regarding signature requirements, please visit our website at:
Guidelines regarding signature requirements are located in the CMS Medicare Program Integrity Manual (Pub. 100-08), chapter 3, section 3.3.2.4
, "Signature Requirements." Information is also available in CMS MLN Matters article MM6698, "Signature Requirements for Medical Review Purposes".
Notification of Results
Providers will be notified via results letter for denied claims with an estimated overpayment. You will receive a letter from Overpayment Recovery with the final overpayment amount. If you disagree with the decision, you may request a redetermination within 120 days of the date of your demand letter.
References:
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