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AMBULANCE REGULATIONS AFFECT TRANSFER DECISIONS UNDER EMTALA

Medicare regulations set levels of service for EMTALA transfer and other ambulance services and phase in a fixed fee payment system to replace "usual and customary charges" rule.

Published May 5, 2005



New Ambulance Regs
Affect EMTALA Choices

New regulations that affect ambulance service payments under Medicare and Medicaid went into effect January 1, 2001, and will have a significant effect on documentation and transfers made under EMTALA.

Previously, most hospitals were used to thinking of ambulance services in terms of basic life support, advanced life support, and helicopter services. The new rules structure services into multiple layers, and the properly designated level will determine payment rates. While this is viewed as primarily affecting scene response (EMS) cases, it also governs transfers of non-emergency cases and EMTALA transfers. Proper designation of levels of service, then, will become even more important in EMTALA transfer situations than before.

The new service levels and their definitions are:


a. Basic Life Support (BLS)

--When medically necessary, the provision of basic life support (BLS) services as defined in the National Emergency Medicine Services (EMS) Education and Practice Blueprint for the Emergency Medical Technician-Basic (EMT-Basic) including the establishment of a peripheral intravenous (IV) line. b. Advanced Life Support, Level 1 (ALS1)

--When medically necessary, this is the provision of an assessment by an advanced life support (ALS) ambulance provider or supplier and the furnishing of one or more ALS interventions. An ALS assessment is performed by an ALS crew and results in the determination that the patient's condition requires an ALS level of care, even if no other ALS intervention is performed. An ALS provider or supplier is defined as a provider trained to the level of the EMT-Intermediate or Paramedic as defined in the National EMS Education and Practice Blueprint. An ALS intervention is defined as a procedure beyond the scope of an EMT-Basic as defined in the National EMS Education and Practice Blueprint.

c. Advanced Life Support, Level 2 (ALS2)

--When medically necessary, the administration of at least three different medications or the provision of one or more of the following ALS procedures:

  • Manual defibrillation/cardioversion.
  • Endotracheal intubation.
  • Central venous line.
  • Cardiac pacing.
  • Chest decompression.
  • Surgical airway.
  • Intraosseous line.

d. Specialty Care Transport (SCT)

--When medically necessary, for a critically injured or ill beneficiary, a level of interhospital service furnished beyond the scope of the paramedic as defined in the National EMS Education and Practice Blueprint. This is necessary when a beneficiary's condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area (for example, nursing, emergency medicine, respiratory care, cardiovascular care, or a paramedic with additional training).

e. Paramedic ALS Intercept (PI)

--These services are defined in Sec. 410.40(c) ``Paramedic ALS Intercept Services''. These are ALS services furnished by an entity that does not provide the ambulance transport. Under limited circumstances, Medicare payment may be made for these services. (To obtain additional information about paramedic ALS intercept services, please refer to the March 15, 2000 final rule (65 FR 13911)).

f. Fixed Wing Air Ambulance (FW)

--Fixed wing air ambulance services are covered when the point from which the beneficiary is transported to the nearest hospital with appropriate facilities is inaccessible by land vehicle, or great distances or other obstacles (for example, heavy traffic) and the beneficiary's medical condition is not appropriate for transport by either BLS or ALS ground ambulance.

g. Rotary Wing Air Ambulance (RW)

--Rotary wing (helicopter) air ambulance services are covered when the point from which the beneficiary is transported to the nearest hospital with appropriate facilities is inaccessible by ground vehicle, or great distances or other obstacles (for example, heavy traffic) and the beneficiary's medical condition is not appropriate for transport by either BLS or ALS ground ambulance. Implications for EMTALA

 

Although the main push of this regulation is to determine what HCFA will pay for, and what they will not, in terms of levels of service, the EMTALA impact is that the regulation examples clearly indicate that they recognize transfers to a higher level of care under EMTALA and that they will honor the PHYSICIAN designation of level of care, so long as it would not be appropriate to transfer the patient other than by ambulance under EMTALA.

This probably does not insulate EMTALA transfers from fee challenges for other reasons, such as a closer "miminally adequate" facility, but does emphasize that in determining the level of care for transport under EMTALA and under Medicare, the responsibility rests on the transferring physician.

Proper levels of care

 

The regulations specify the following guidelines for non-emergency transports and EMTALA transports. The specification for transfers for "services not rendered here" would apply to services that are not certified as necessary for evaluation and stabilizing care under the EMTALA certification process.

 

Code #
Reason for Transport
General
Reason for Transport
Specific
Approved Service Level

91
EMTALA-certified interfacility
transfer to a higher level
of care
MD has made the determination
that this transfer is needed
--Carrier only needs to know
the level of care and mode
of transport
BLS, ALS, SCT, FW, RW

92
Services not available
at originating facility
and must meet one or more
emergency or non-emergency
conditions
Per above
BLS, ALS, SCT, FW, RW

93
Service Not Covered
Indicates to Carrier that
claim should be automatically
denied.
None authorized
[ABN indicated-- editor's comment]
For a complete listing of the levels of care for emergency and non-emergency services in the field EMS setting, you may view or download the entire regulations, along with the payment system structure at this link.



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