Helpful Questions to Determine Legal CPT Base Rate Codes for Ambulance Billing

Updated on June 13, 2017
Diana Majors profile image

Diana has nine years of experience in ambulance billing and training other billers. She considers it a most rewarding calling!

Legal Ambulance Billing

Before getting started with the how-to of determining the correct base rate CPT code for an ambulance claim, let me first establish that every ambulance claim should first be examined to ensure all legally required elements have been met. For example, the ambulance patient care report (PCR) should have a patient's name, date of service, and all required signatures from the time of service. In addition, the transport should have actually occurred. Fraudulent billing is considered illegal by all government agencies, especially the Centers for Medicare and Medicaid Services (CMS), and is punishable by law with prison, fines, or both. If these basic requirements on the PCR are not met, make sure the claim is not billed to CMS without these requirements present.

All examples here are examples only. The advice herein is my own advice as someone with many years of experience in ambulance billing. If any issues arise, CMS or the ambulance service's attorney should be contacted.

Star of Life on ambulance window
Star of Life on ambulance window | Source

Emergency versus Non-emergency?

One of the first questions to ask is whether the transport is an emergency transport or a non-emergency transport. What is the origin? What is the destination? Many times (but not always) these two questions will guide you in your quest to provide the appropriate code. If the patient was transported from their home to a nearby hospital emergency room, this is probably an emergency. If the patient was transported from a hospital back to that patient's skilled nursing facility, it is more than likely a non-emergency transport.

Was the patient taken to a lower level of care (residence) to a higher level of care (hospital ER)? This may help support an emergency determination.

Was the patient transported from a higher level of care (hospital inpatient) to a lower level of care (nursing home)? This will help support a non-emergent determination.

What about scheduled versus non-scheduled transports? This may sound repetitive after reading that last paragraph, but to those in the ambulance billing community, they will know it is a related issue, but still separate. Was the transport scheduled in advance? If it was, how long ago was it scheduled? According to CMS's definition, a transport must have been scheduled (someone contacting the ambulance service and arranging a time and date for pick up while giving patient-identifying information) at least 24 hours in advance of the transport. This means it can be scheduled for a week in advance, which is seen many times in the case of a hospice respite care transport.

If the ambulance service is contacted on Monday at 10:00 AM and they are notified of a transport on the following day at 11:00 AM, that is a scheduled transport since the transport is 25 hours away. However, if that same phone call schedules a transport for that same Monday afternoon at 3:00, that transport, according to CMS, is a non-scheduled transport since only five hours' notice was provided.

In the case of the scheduled transport, that is a non-emergent transport. If the transport does not meet the requirements for being a scheduled transport, then it is considered to be an emergency when determining the correct CPT base rate.

Source

BLS versus ALS

Basic Life Support (BLS) and Advanced Life Support (ALS) is different and they have different CPT codes and reimbursement amounts. This part of the evaluation is just as important in determining the correct CPT code. If the code is partly right and partly wrong, it's still the incorrect code for that transport and makes your entire claim to be in error.

When evaluating the PCR, it should be determined which interventions have been made that were required for the patient at the time of transport as well as which certified healthcare provider made those interventions. Different states have different guidelines that define the scope of practice for ambulance crew members, so be sure to familiarize yourself with the correct information for your area.

Each type of licensed healthcare provider on that call has a certain scope of practice they are legally allowed to operate within and the interventions are matched to the licensure of that provider.

For example, the patient's condition required the EMT to provide oxygen therapy and for the paramedic to perform IV therapy, that claim is legal to be filed as an ALS claim.

For example, EMTs are allowed to provide oxygen therapy, but are required to have extra training (such as becoming licensed as a Intermediate EMT) to perform interventions outside the EMT's scope of practice.

Paramedics are allowed to start IVs and perform cardiac monitoring within their scope of practice. But, as with EMTs, extra training is required for that provider before they can legally operate and/or monitor an IV pump or a CPAP machine.

I said all that to say this. To put much more simply, EMTs perform BLS interventions, Intermediates can perform BLS and certain ALS interventions and paramedics perform BLS and ALS interventions, as well as ALS II interventions (these require extra training).

Conclusion

These questions can be used for every ambulance claim to select the appropriate CPT base rate code for the claim. Was it a scheduled transport according to the Medicare definition of "scheduled"? Was it an emergency or non-emergency? Is the claim considered BLS or ALS based on the patient's condition at the time of transport and the healthcare provider who performed that intervention?

I know this is all confusing and can be overwhelming if you are just beginning your career as a biller, but with time it will get easier for you. Just keep using what you've already learned to continue to build your knowledge base. I hope this has helped you just a little to clarify all the seeming mumbo-jumbo on CMS's website!

What are your thoughts or comments? If I can clarify something for you, I'd love to do that. Did this article help you or just confuse you further? Please let me know what your thoughts are so I can be of more use to you in future articles because I really love ambulance billing! Thanks!

© 2017 Diana Majors

Comments

    0 of 8192 characters used
    Post Comment

    • Diana Majors profile imageAUTHOR

      Diana Majors 

      18 months ago from Arkansas

      Thanks for helping to spread the word! I'm sure he is a hard worker who is diligent in filing claims correctly!

    • profile image

      Georgia estes 

      18 months ago

      I am not a biller, but I live with one! Will make sure he sees this!

    working

    This website uses cookies

    As a user in the EEA, your approval is needed on a few things. To provide a better website experience, healdove.com uses cookies (and other similar technologies) and may collect, process, and share personal data. Please choose which areas of our service you consent to our doing so.

    For more information on managing or withdrawing consents and how we handle data, visit our Privacy Policy at: https://healdove.com/privacy-policy#gdpr

    Show Details
    Necessary
    HubPages Device IDThis is used to identify particular browsers or devices when the access the service, and is used for security reasons.
    LoginThis is necessary to sign in to the HubPages Service.
    Google RecaptchaThis is used to prevent bots and spam. (Privacy Policy)
    AkismetThis is used to detect comment spam. (Privacy Policy)
    HubPages Google AnalyticsThis is used to provide data on traffic to our website, all personally identifyable data is anonymized. (Privacy Policy)
    HubPages Traffic PixelThis is used to collect data on traffic to articles and other pages on our site. Unless you are signed in to a HubPages account, all personally identifiable information is anonymized.
    Amazon Web ServicesThis is a cloud services platform that we used to host our service. (Privacy Policy)
    CloudflareThis is a cloud CDN service that we use to efficiently deliver files required for our service to operate such as javascript, cascading style sheets, images, and videos. (Privacy Policy)
    Google Hosted LibrariesJavascript software libraries such as jQuery are loaded at endpoints on the googleapis.com or gstatic.com domains, for performance and efficiency reasons. (Privacy Policy)
    Features
    Google Custom SearchThis is feature allows you to search the site. (Privacy Policy)
    Google MapsSome articles have Google Maps embedded in them. (Privacy Policy)
    Google ChartsThis is used to display charts and graphs on articles and the author center. (Privacy Policy)
    Google AdSense Host APIThis service allows you to sign up for or associate a Google AdSense account with HubPages, so that you can earn money from ads on your articles. No data is shared unless you engage with this feature. (Privacy Policy)
    Google YouTubeSome articles have YouTube videos embedded in them. (Privacy Policy)
    VimeoSome articles have Vimeo videos embedded in them. (Privacy Policy)
    PaypalThis is used for a registered author who enrolls in the HubPages Earnings program and requests to be paid via PayPal. No data is shared with Paypal unless you engage with this feature. (Privacy Policy)
    Facebook LoginYou can use this to streamline signing up for, or signing in to your Hubpages account. No data is shared with Facebook unless you engage with this feature. (Privacy Policy)
    MavenThis supports the Maven widget and search functionality. (Privacy Policy)
    Marketing
    Google AdSenseThis is an ad network. (Privacy Policy)
    Google DoubleClickGoogle provides ad serving technology and runs an ad network. (Privacy Policy)
    Index ExchangeThis is an ad network. (Privacy Policy)
    SovrnThis is an ad network. (Privacy Policy)
    Facebook AdsThis is an ad network. (Privacy Policy)
    Amazon Unified Ad MarketplaceThis is an ad network. (Privacy Policy)
    AppNexusThis is an ad network. (Privacy Policy)
    OpenxThis is an ad network. (Privacy Policy)
    Rubicon ProjectThis is an ad network. (Privacy Policy)
    TripleLiftThis is an ad network. (Privacy Policy)
    Say MediaWe partner with Say Media to deliver ad campaigns on our sites. (Privacy Policy)
    Remarketing PixelsWe may use remarketing pixels from advertising networks such as Google AdWords, Bing Ads, and Facebook in order to advertise the HubPages Service to people that have visited our sites.
    Conversion Tracking PixelsWe may use conversion tracking pixels from advertising networks such as Google AdWords, Bing Ads, and Facebook in order to identify when an advertisement has successfully resulted in the desired action, such as signing up for the HubPages Service or publishing an article on the HubPages Service.
    Statistics
    Author Google AnalyticsThis is used to provide traffic data and reports to the authors of articles on the HubPages Service. (Privacy Policy)
    ComscoreComScore is a media measurement and analytics company providing marketing data and analytics to enterprises, media and advertising agencies, and publishers. Non-consent will result in ComScore only processing obfuscated personal data. (Privacy Policy)
    Amazon Tracking PixelSome articles display amazon products as part of the Amazon Affiliate program, this pixel provides traffic statistics for those products (Privacy Policy)