EMT Ambulance...................In it for life!  

PPS Guidelines

1. PPS Applies to Skilled Nursing Facilities Only.
2. Applies to residents only during their 100 day  "Part A" stay.
3. Bill to SNF Only if Transport is part of Patients Normal Care Plan. (Rehab etc.)
4. Sending SNF is Billed if Resident is Transferred to another Facility for Upgrade in Care.
5. Wheelchair Services are Still "Private Pay" and to be Billed to Patient.

Effective April 1, 2000 - Dialysis Transports excluded from PPS -As a part of the Consolidated Appropriations Act signed by President Clinton, Skilled Nursing Facilities (SNF) will no longer be required to cover the expenses of ambulance transports under the PPS for patients with End Stage Renal Disease (ESRD). Any patients transported on or after April 1,2000, will fall under this new law.

Skilled Nursing Home Perspective Payment System

Skilled Nursing Homes with 100 day Part "A" Medicare Patients, are billed direct by the Ambulance Service for "Ambulance" Transports that are part of the Patients Care Plan. This includes Doctor Office Transports by ambulance..

Exceptions to this rule are:

1. Ambulance trips to the Skilled Nursing Facility for admission or from the Skilled Nursing Facility after discharge.
2. Ambulance trips to/from an outpatient hospital, relating to the following services:

    - emergency services;
    - dialysis treatment;
    - cardiac catheterization;
    - computerized axial tomography (CT) scan;
    - magnetic resonance imaging (MRI);
    - ambulatory surgery involving the use of an operating room;
    - radiation therapy; - angiographies codes; and
    - codes for lymphatic and venous procedures.

The facility is billed direct for Ambulance Service for Non-Emergencies Only. Any "Emergency Requests"  going to an emergency room for treatment of life threatening illness or injury, or illness or injury that may cause severe pain or threat to the patients overall health.

 Wheel Chair Transport Services are still billed direct to the patient and are not part of the PPS system.

Wheelchair Service is not part of Medicare PPS in any way. Medicare will never pay for Wheelchair Service under any circumstance. Medicaid will pay if patient is unable ambulate and is wheelchair bound all the time. You will experience few ambulance trips that will fall under PPS guidelines. Once patient is off part "A" 100 days, the facility will no longer be billed direct. The Ambulance Service can then bill the Medicare carrier direct for all Ambulance trips.

Certificates of Medical Necessity (CMN's)

A call is considered "scheduled" If the call for service is at least 24 hours before the transport.
The signature on the CMN can be from the attending physician or other trained health person but only if they are allowed to sign for the physician and their title is listed, e.g. John Doe, M.D. by Jane Smith, P.A.
No CMN is needed for transports that appear at the time of the response, in good faith, to be emergencies (e.g. 911, acute medical conditions etc.), even if they are subsequently downgraded to non-emergency.

Medically necessary non-emergencies transports must be "bed confined" or in need of special equipment, procedures, oxygen, or medical monitoring during transport to be covered by Medicare/Medicaid.

Certificates of Medical Necessity (CMN's)

A call is considered "scheduled" if the "call for service" is made at least 24 hours before the transport.
 

If the CMN is not attained within these timeframes, then the bill becomes the responsibility of the patient thus it is imparitive that they are attained promptly at time of transport or before.

* A transport is considered scheduled if the call was received 24 hours or more prior to the transport
** It is expected that the CMN will continue to be valid for the periods indicated if there is no change in the condition of the patient.

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Copyright © 2005 Emergency Medical Transport, Inc. Canton, Ohio
Last modified: February 21, 2006