Scheduled Repetitive Ambulance Transports for Dialysis Treatment
Railroad Retirement Board Specialty Medicare Administrative Contractor (RRB SMAC) Provider Outreach and Education
May 25, 2016
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May 2016
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3
Disclaimer
This presentation was current at the time it was presented, published or uploaded
onto the Palmetto GBA website. Medicare policy changes frequently so links to
the source documents have been provided within the document for your
reference.
This presentation was prepared as a tool to assist providers and is not intended
to grant rights or impose obligations. Although every reasonable effort has been
made to assure the accuracy of the information within these pages, the ultimate
responsibility for the correct submission of claims and response to any
remittance advice lies with the provider of services
The Centers for Medicare & Medicaid Services (CMS) and the Railroad Retirement
Board (RRB) employees, agents, and staff make no representation, warranty, or
guarantee that this compilation of Medicare information is error-free and will
bear no responsibility or liability for the results or consequences of the use of
this guide
This publication is a general summary that explains certain aspects of the
Medicare Program, but is not a legal document. The official Medicare Program
provisions are contained in the relevant laws, regulations, and rulings.
CPT only copyright 2015 American Medical Association.
All rights reserved.
The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology
(CDT), Copyright © 2015 American Dental Association (ADA). All rights reserved.
May 2016
4
What is Railroad Medicare?

Railroad Retirement Acts of the 1930s

First retirement system for nongovernmental workers

Provisions created in 1965 to provide the benefits of the Medicare
program to railroad employees and their dependents

The Railroad Retirement Board (RRB) works with CMS to ensure
Railroad beneficiaries receive the same benefits as their SSA Medicare
counterparts

Part B claims for Railroad Medicare beneficiaries are processed
nationally by Palmetto GBA in Augusta, Georgia as the Railroad
Retirement Board Medicare Specialty Administrative Contractor (RRB
SMAC)

Part A and DMEPOS claims for Railroad Medicare beneficiaries are
processed by jurisdictional Medicare Administrative Contractors (MACs)
May 2016
5
Objectives
At the end of this presentation you will be
familiar with:
 Medicare Part B coverage guidelines for
ambulance transportation for dialysis
treatment
 Medicare’s documentation requirements
for repetitive scheduled ambulance
transports
 Medical review of ambulance transports
May 2016
6
Agenda

Medicare Coverage for Ambulance Transports for Dialysis Treatment

Documentation Requirements

Medical Review of Ambulance Services 
Resources

Questions and Answers
May 2016
7
COVERAGE FOR AMBULANCE TRANSPORTS RELATED TO DIALYSIS TREATMENT
May 2016
8
End-Stage Renal Disease (ESRD) 
End-Stage Renal Disease (ESRD) is a medical
condition in which an individual's kidneys cease
functioning on a permanent basis leading to the
need for a regular course of long-term dialysis or a
kidney transplant to maintain life.

Patients with ESRD often need to travel to a free standing or hospital based facility for dialysis. 
When a patient qualifies for Medicare, regardless
of the reason for qualification, they are entitled to
Medicare benefits for all covered services including
ambulance services.
May 2016
9
Transportation for Dialysis
Treatment

Medicare does not have a benefit for ambulance
services that is specific to ESRD beneficiaries
for dialysis transports.

In some cases, Medicare may cover non­
emergency ambulance transportation to or from
a dialysis facility when a beneficiary:



has ESRD,
needs dialysis, and
meets the criteria for Medicare covered ambulance transports. May 2016
10
Coverage Requirements The following coverage requirements apply to ground
ambulance transports:

The transport is medically reasonable and necessary; 
A Medicare beneficiary is transported;

The purpose of the transport is to obtain a
Medicare-covered service or to return from obtaining
such service;

The destination is local; and

The facility is appropriate.
May 2016
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Medical Necessity

Medical necessity for an ambulance service
is established when the patient's condition is
such that use of any other method of
transportation is contraindicated.

In any case in which some means of
transportation other than an ambulance
could be used without endangering the
individual's health, whether or not such other
transportation is actually available, no
payment may be made for the services.
May 2016
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Medical Necessity
Questions to help establish medical
necessity:

Does the patient require medical treatment during transport?

Could this patient travel safely by stretcher
van? By wheelchair van?

Can this patient travel by personal vehicle?

How does this patient travel to the doctor’s
office or non-medical destinations?
May 2016
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Examples of Non-Covered
Situations
Examples of repetitive scheduled transports which do not meet coverage guidelines:

Family requests ambulance transportation for
dialysis treatment but not medically
necessary

Patient could have been transported in family
member or caregiver’s personal vehicle.

Stretcher/wheelchair van service could have
transported the patient safely
May 2016
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Non-emergency Transports for Dialysis Treatment



HCPCS A0428 –
Ambulance Service, Basic
Life Support (BLS), non­
emergency transport
HCPCS A0426 –
Ambulance Service,
Advanced Life Support
(ALS), non-emergency
transport
A0425 – Ground mileage,
per statute mile
HCPCS Origin and Destination
Modifiers

G = Hospital based ESRD
facility

J = Freestanding ESRD
facility

E = Residential, domiciliary,
custodial facility

N = Skilled nursing facility
(SNF)

R = Residence
May 2016
15
Scheduled Repetitive Transports

Transports are
considered
scheduled if the
ambulance
transports were
previously
established/ordered
(e.g., scheduled for
the beneficiary)

Transports are
considered
repetitive once the
patient requires
transport:

3 times in a 10
day period or

Once a week for
3 weeks, etc.
May 2016
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DOCUMENTATION REQUIREMENTS
May 2016
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Documentation Requirements
Documentation elements to include:
 Beneficiary Signature
 Crew Signatures and Credentials
 Physician Certification Statement
 Trip Report
May 2016
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Beneficiary Signature

Medicare requires the signature of the beneficiary, or that of his or her representative, for both the purpose of
accepting assignment and submitting a
claim to Medicare.

If you were unable to obtain the signature of
the beneficiary, or that of his or her
representative, at the time of transport, you
may obtain this signature any time prior to
submitting the claim to Medicare for payment
within the claims filing period.
May 2016
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Beneficiary Unable to Sign Due to
Mental or Physical Condition
If the patient is unable to sign because of a mental or physical condition at the time of transport,
 Must document the reason the patient cannot
sign
 Must obtain signature of a representative such
as




Patient’s legal guardian
A relative or other person who arranges for the
beneficiary’s treatment
A representative of the receiving facility
Or other acceptable representative listed in 42
CFR 424.36(b) (1– 4)
May 2016
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Refusal to Sign for Medicare
Claim Submission

If the beneficiary or representative refuses to authorize
the submission of a claim, including a refusal to furnish
an authorizing signature, the claim cannot be submitted
to Medicare.

You may bill the full charge directly to the beneficiary or
their estate.

If, after seeing the bill, the beneficiary or his/her
representative decides to have the claims submitted to
Medicare:

A beneficiary/representative signature is required

You must afford the beneficiary/representative this
option within the claims filing period
May 2016
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Beneficiary Signature Resources 
CMS Guidance on Beneficiary Signature Requirements for Ambulance Claims Calendar Year (CY) 2009 Update
https://www.cms.gov/Medicare/Medicare-Fee-for-Service­
Payment/AmbulanceFeeSchedule/Downloads/Guidance_
on_Beneficiary_Signature_Requirements_for_Ambulance
_Claims.pdf

Beneficiary Signature Requirements
http://www.palmettogba.com/palmetto/providers.nsf/Docs
Cat/Providers~Railroad%20Medicare~Articles~Ambulanc
e~8EEMJ24204?open
May 2016
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Crew Signatures

Crew member signatures and credentials
should be clearly documented and
legible

Signatures serve as documented
evidence that the crew members attest
to providing services and were qualified
to do so

A signature log or attestation should also be included if crew signature is illegible
May 2016
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Crew Credentials

Crew credentials must be
documented



Crew credentials can be simply
stated (i.e. paramedic, B-EMT)
or
Crew member license number
Documented credentials
confirm crew is licensed to
provide level of service billed
May 2016
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PCS and Repetitive Transports

A Physician Certification Statement
(PCS) is a written order certifying
the medical necessity of non­
emergency ambulance transports

A PCS is required for non­
emergency repetitive scheduled and unscheduled transports for patients under the direct care of a physician
May 2016
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PCS Special Rule - 42 CFR 410.40

Establishes the necessity of the attending physician’s order
for nonemergency, scheduled, repetitive transports

In these transports, the only person allowed to sign the PCS
is the patient’s attending physician (M.D. or D.O.)

The PCS must be obtained before the transport

The PCS must be dated no more than 60 days before the
date of the transport
(d)(2) Special rule for nonemergency, scheduled, repetitive ambulance services
(i) Medicare covers medically necessary nonemergency, scheduled, repetitive
ambulance services if the ambulance provider or supplier, before furnishing the
service to the beneficiary, obtains a written order from the beneficiary’s
attending physician certifying that the medical necessity requirements of
paragraph (d)(1) of this section are met. The physician’s order must be dated
no earlier than 60 days before the date the service is furnished.
May 2016
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PCS Documentation
General
Information
• Patient’s Name and information
• Transport date(s) being authorized
• Origin/Destination of transport
Medical
Necessity
•
•
•
•
Medical Condition
Bed Confinement
Mobility
Complicating Conditions
Physician
Signature
• Legible name and credentials (MD or DO)
of the provider
• Date signed must be no more than 60 days
before transport
May 2016
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PCS to Support the Transport

PCS should be individualized for each patient and
reflect the patient's condition at time of the provider’s
evaluation. The conditions should support medical
need for repetitive transports.

The patient’s condition at the time of transport must
meet medical necessity to qualify for coverage.
It is important to note that the presence (or absence) of a physician’s
order for a transport by ambulance does not necessarily prove (or
disprove) whether the transport was medically necessary. The
ambulance service must meet all program coverage criteria in order
for payment to be made.
~ IOM Pub. 100-02, Chapter 10, Section 10.2.1
May 2016
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Trip Reports
The trip report or run sheet is the documentation the crew records on each patient encounter. Each report should include the following:
•
Beneficiary name
•
Date of transport
•
Origin and Destination
•
Loaded Mileage
•
Reason for transport
•
Explanation of why patient cannot be safely transported by other means
•
Any relevant history
•
Description of the patient’s condition and functional status at the time
of transfer
•
Assessment and clinical evaluation
May 2016
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Assessment and Clinical Evaluation
Include elements
such as:
• Vital signs
• Respiratory/cardiac
status
• Mental status
• Mobility issues
• Skin integrity
Properly document
procedures such as:
• Oxygen
• IV therapy
• Medication
administration
• EKGs
• Suctioning
• Dressing changes
• Restraints
May 2016
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DOCUMENTING MEDICAL NECESSITY
May 2016
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Supporting Documentation

Documentation should support medical
necessity for transport

All elements should fit together to support
medical necessity

Trip Record/ Run Report

PCS

Medical records
May 2016
32
Supporting Documentation and
Bed Confinement


Bed confined requires all the following criteria to
be met:

The patient is unable to get up from bed without assistance 
The patient is unable to ambulate

The patient is unable to sit in a chair or wheelchair Bed Confinement alone does not support medical necessity. May 2016
33
Clear Documentation 
Documentation must clearly identify the patient’s medical
need for skilled crew and ambulance transport.
Example: 80 year old male going to dialysis. Medicated with
mild sedative prior to pick-up. Uncooperative, sliding off
gurney, pulling off oxygen leading to drops in O2 levels. He
requires frequent redirection and constant monitoring to
maintain oxygen level.

Document O2 levels several times to show the monitoring
is occurring.

Report any other measures such as restraints or response
to medications given prior to departure.
May 2016
34
Conflicting Documentation

Conflicting documentation makes it more difficult to reach a determination

Conflicting documentation may adversely affect
the review result

Examples:

PCS indicates patient is bedbound. Run
sheet documents patient ambulating to the
cot.

The trip report states the patient was unable
to sign due to confusion, but the Glasgow
Coma Scale was in normal ranges.
May 2016
35
MEDICAL REVIEW OF AMBULANCE SERVICES May 2016
36
Defining Medical Review

Medical review is the collection of information and
clinical review of medical records by Medicare
Contractors to ensure that payment is made only for
services that meet all Medicare coverage, coding, and
medical necessity requirements

Medical Review was implemented by the Centers for
Medicare & Medicaid Services (CMS) as an initiative
to prevent or identify and recover improper payments
before CMS processes a claim, and to identify and
recover improper payments after processing a claim
May 2016
37
Railroad Medicare Prepayment
Medical Review

Performed as a result of vulnerabilities determined by data analysis

Service specific

Widespread

Performed on claims prior to payment

Additional Documentation Requests (ADRs)
are sent to providers/suppliers to request
supporting documentation

Review results in an initial determination
May 2016
38
What is an ADR?

Request for documents
to support service

Respond to ADR
promptly within 45 days

Claims deny on the 46th
day if no response is
received

Responses reviewed by
Medical Review within
30 days of receipt
May 2016
39
How to Respond to ADR

Provide the documents
listed on the ADR and
any supportive
documents

Make sure crew
signatures are legible
or include a signature
log or attestation if
necessary

Include a copy of ADR letter with each claim
May 2016
40
Methods of Responding to an
ADR

Upload your documentation online
through eServices

Submit your documentation via the esMD
(Electronic Submission of Medical Documentation)
mechanism. See www.cms.gov/esmd for details

Fax your responses to 803-264-8832

Mail documents or an encrypted CD/DVDs to:
Palmetto GBA Railroad Medicare Medical Review PO Box 10066 Augusta, GA 30999
May 2016
41
Important ADR Reminders

Do not submit requested documentation by more
than one method (such as fax and mail, etc.)


Duplicate responses slow down the documentation review process Do not submit replacement/duplicate claims for
claims pending in medical review


Can result in claim denial or rejection
Can prolong the medical review process

Respond promptly within 45 days

ADR Calculator Tool available
May 2016
42
Prepayment Review Results
When a reviewed claim finalizes, it will receive a status of
either:
 Paid
 Denied
 Rejected
 Paid claims may be either:
 Allowed at the level billed,
 Down-coded based on level of service supported by
provided documentation, or
 Up-coded based on level of service supported by provided documentation  Outreach and Education may contact providers to
discuss review findings

May 2016
43
Granular Denial Letters 
Claim Review
Decision and
Education Letter

Sent when a claim is
denied by Medical
Review

Explains why a claim
was denied
May 2016
44
TOP DENIALS FOR AMBULANCE SERVICES May 2016
45
Non-Response to ADRs

Represents greatest
number of claim denials

No response received

Response received more
than 45 days after date
of request

Make sure your correct
mailing address is on file
with Railroad Medicare
May 2016
46
Service not Medically
Reasonable and Necessary

Not medically necessary
 Alternative services were available and should
have been utilized
 Patient’s documented condition at the time of
transport did not warrant ambulance transportation
 Medical necessity could not be determined based
on documentation submitted
o Submitted trip report does not clearly document
the patient's condition at time of transport
o Conflicting documentation
May 2016
47
Incomplete or Missing
Information

A response was received but documentation
may have been:

Missing crew or beneficiary/representative
signatures

Missing valid PCS signed by physician

PCS signed after date of transport

Deemed illegible

For wrong date of service

For the wrong beneficiary
May 2016
48
Appeal Rights
If you do not agree with the
outcome of the review:
 Submit a redetermination
request within 120 days
from the receipt of the
initial determination notice*
 Redetermination: First
Level Appeal Form
 eServices First Level
Appeal eForm
 Do not resubmit denied
claim
Appeals should include:

Beneficiary name

Medicare health insurance claim
(HIC) number

Name and address of
provider/physician/supplier of
item/service

Date of initial determination

Date(s) of service for which the
initial determination was issued.

Which item(s), if any, and/or
service(s) are at issue in the
appeal

Signature of the appellant
* Receipt of the notice of initial determination is presumed to be five days after the
date of the Remittance Advice.
May 2016
49
RESOURCES
May 2016
50
CMS Medicare Ambulance
Resources

CMS Ambulance Services Center
https://www.cms.gov/Center/Provider­
Type/Ambulances-Services-Center.html

CMS IOM Publication 100-02 Medicare Benefit
Policy Manual, Chapter 10, “Ambulance
Services”

CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 15, “Ambulance” 
Guidance on Beneficiary Signature
Requirements for Ambulance Transportation
May 2016
51
Medicare Learning
Network® Resources

Medicare Ambulance Transports Booklet
https://www.cms.gov/Outreach-and-Education/Medicare-Learning­
Network-MLN/MLNProducts/Downloads/MLNCatalog.pdf

Ambulance Fee Schedule Fact Sheet
https://www.cms.gov/Outreach-and-Education/Medicare-Learning­
Network-MLN/MLNProducts/downloads/AmbulanceFeeSched_508.pdf

MLN Matters® Number MM8269 - Ambulance Payment
Reduction for Non-Emergency Basic Life Support (BLS)
Transports to and from Renal Dialysis Facilities
https://www.cms.gov/Outreach-and-Education/Medicare-Learning­
Network-MLN/MLNMattersArticles/Downloads/MM8269.pdf
May 2016
52
MLN Connects® National
Provider Calls

Free educational conference calls held by CMS for
the Medicare providers and suppliers to educate
and inform about new policies and/or changes to
the Medicare program

Prior registration is required

Subscribe to weekly MLN Connects® Provider
eNews newsletter to receive the latest Medicare
program information including MLN National
Provider Calls announcements
https://www.cms.gov/Outreach-and­
Education/Outreach/NPC/index.html
May 2016
53
CMS Ambulance Open Door
Forums

CMS sponsors regularly scheduled “Ambulance
Open Door Forums“ providing opportunities for live
dialogue between CMS and the ambulance
stakeholder community at large

Subscribe to the Ambulance Open Door Forum
Mailing List to be notified when forums are
scheduled or when new information is posted to
the website

CMS Ambulance Open Door Forums page
https://www.cms.gov/Outreach-and­
Education/Outreach/OpenDoorForums/ODF_Ambulance.html
May 2016
54
RRB SMAC Resources
www.palmettogba.com/RR
May 2016
55
Ambulance Resources
May 2016
56
CERT Resources


RRB SMAC CERT Page

Articles

Checklists

Tips

FAQs
CERT Provider Website
https://www.certprovider.com/Home.aspx
May 2016
57
Visit www.PalmettoGBA.com/RR

MLN articles from the Centers for Medicare & Medicaid
Services (CMS)

Articles and FAQs by topic

Self-Services Tools

eServices Online Portal

Redetermination Status Tool

Quick Reference Guide

Modifier Lookup

MSP Lookup

Reason/Remark Code Lookup
May 2016
58
eServices
Claim Status
Eligibility
Remittances
Appeals
Submission of Requested Medical Records
Greenmail notification of Pending ADR Requests
Greenmail eDelivery Responses
www.palmettogba.com/eServices
May 2016
59
Respond to ADRs in
eServices

Respond to Medical Review ADR and postpayment
review notification letters through eServices using the
MR ADR Response secure eForm

Attach an unlimited number of PDF files to each form.
Each attachment can be up to 40 MB. The total size of
all attachments on each ADR eForm can be no more
than 150 MB.

Track submission of your ADRs

Must have an Electronic Data Interchange (EDI)
Enrollment Agreement on file with Palmetto GBA
Railroad Medicare

Enroll for eServices at www.palmettogba.com/eServices
May 2016
60
eServices Greenmail

Receive eDelivery of:


Medical Review ADRs for
prepayment reviews
Overpayment Demand
letters

Medicare Redetermination
Notices for your appeal
requests

Responses to General
Correspondence inquiries

Provider Administrators
may select the eDelivery
option to receive:

eLetters in eServices
inbox

email notification of
new eLetters
May 2016
61
eServices Resources
May 2016
62
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•
Join our listserv at www.PalmettoGBA.com/rr
•
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•
Choose ‘Sign up for our Listserv’ and select
the topics you want to receive updates on
•
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•
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•
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•
eChat
May 2016
63
Railroad Medicare Contacts
RAILROAD MEDICARE RESOURCES
Provider Contact Center
EDI / eServices
Telephone Reopenings
Provider Enrollment
Railroad
Medicare
Homepage
www.PalmettoGBA.com/RR
Palmetto
GBA
Listserv
www.PalmettoGBA.com/RR
Select ‘Listservs’ from top tool bar
888-355-9165
Contact Us
By Email
[email protected]
Interactive Voice
Response (IVR)
www.palmettogba.com/eServices
eServices
CMS
Listserv
877-288-7600
www.PalmettoGBA.com/RR
Under Forms/Tools
https://www.cms.gov/About-CMS/Agency­
Information/Aboutwebsite/EmailUpdates.html
Palmetto GBA
Railroad Medicare
PO Box 10066
Augusta, GA 30999
May 2016
64
Questions?
May 2016
65
Thank you!
Questions about this webcast?
Provider Contact Center
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[email protected]
May 2016
66