The “Continuous Monitoring” Factor for Inter-facility, Non-emergency Ambulance Transports

From the Open Door Forum

One of the staples of being an ambulance biller is religiously following any information provided by the Center for Medicare and Medicaid Services (CMS).

Ambulance billers can easily follow CMS by participating in the Ambulance Open Door Forum audio-conferences. The Open Door Forum is conducted by the CMS ambulance gurus at various times throughout the year. Only Medicare ambulance issues are discussed during these calls and participants’ questions are fielded live by the experts.

The “Continuous Monitoring” Factor for Inter-facility, Non-emergency Ambulance Transports

The “Continuous Monitoring” Question

In the course of the last Forum, a caller representing an ambulance service that provides inter-facility type transports, called to question the CMS experts regarding the agency’s ongoing dilemma following a recent Medicare claims audit. The results of the audit were not favorable and this particular EMS agency was apparently forced to re-pay Medicare reimbursement dollars for a significant number of transports.

The caller explained that the Medicare Administrative Contractor (MAC) for their particular geographic area had provided documentation following the audit to support their request for repayment. The caller lamented that the MAC noted there was insufficient documentation provided by the agency to demonstrate that “Continuous Monitoring” was provided to patients to support medically necessary and reasonableness thus warranting payment of the claims to the caller’s agency.

When the CMS expert fielding the call attempted to explain that detailed documentation regarding all services and specific monitoring of the patient must be documented in the Patient Care Report, the caller turned slightly argumentative and presented a flimsy argument. The caller argued “by definition” any person who requires ambulance transport from one facility to another facility is continuously monitored simply because a trained EMT or Paramedic accompanies the patient in the back of the ambulance.

Nice try!

Of course, the argument was refuted by the CMS expert who went on to explain that if there are not specifics contained in the PCR to definitively note what monitoring skills were provided; then basically, in the eyes of CMS and by extension the MAC, the all-important and necessary “continuous monitoring” didn’t happen.

Visualizing the PCR…

Gazing out the billing office window, we can close our eyes and visualize this caller’s PCR documentation.

We’re guessing the PCR probably had a minimal amount of information. You know, let’s admit….the industry is guilty many times of allowing sub-par PCRs to transform into claims where there is basically nothing more than “Arrived on scene at ABC referring facility, placed patient on litter, took a set of vitals and transported to XYZ destination facility” is included in the written portion of the PCR.

With minimal effort and a bit of supervisory coaching…

Listening to this from our perch was painful when we sympathized over the tragedy that this person was forced into the position of having to submit claims to Medicare that most likely weren’t completely supported by detailed and specifically clear clinical documentation.

With minimal effort and a bit of supervisory coaching, this caller’s EMS agency providers could have provided sufficient information so the agency never was audited and the caller would not have needed to present her flimsy case in an attempt to get the claim paid for good.

How to overcome?

So how can you overcome this problem?

One word… Document!

We are huge advocates of using precise, specific and clear clinical documentation as the DNA that comprises each and every EMS PCR that is written.

No exceptions!

Medicare, Medicaid and Commercial Insurance payers WILL NOT read between the lines. “Continuous monitoring” – whatever that means in your scenario, is NOT implied.

If the PCR doesn’t specifically list all the steps that the EMS provider on the run takes to “continuously monitor,” treat and transport the patient, then the patient hasn’t been “continuously monitored.”

Key Points

The key points to include in your documentation should also answer these questions…

  • How did I find the patient upon arrival at the referring facility (lying down, seated, walking, talking…)?
  • How did I transfer the patient?
  • Once in the ambulance what did I do to “continuously monitor” the patient (vitals, observations, conversations, positioning, condition- same, better, worse, interventions initiated or maintained…plus a zillion more)?
  • How can I be descriptive?
  • Have I “painted a picture” in words about my transport scenario?
  • Have I employed clear clinical documentation when writing my subjective narrative?
  • Did I shy away from the use of “history of” or “complained of” phrases as the sole basis for my medical necessity explanation?
  • Did I document an independent patient assessment without mimicking the Physicians Certification Statement (PCS)?
  • Was I able to effectively explain upon arrival at the destination facility…
    • How the patient was moved?
    • How the patient was positioned?
    • What the patient’s status was upon completing my patient care/transport scenario?

Set A Goal

Finish reading this post and set a goal that your agency billing person will NEVER be the person calling into the Ambulance Open Door Forum to attempt to explain away information that you weren’t able to provide to him/her to help do his/her job.

It’s up to you!

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