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Ambulance Fee
Schedule 2006
By Steve
Johnson, Director of Sweet Billing Services
The
first phase of what once seemed like an eternal process is quickly coming to
an end. I am speaking of the initial phase-in period of the Ambulance Fee
Schedule (AFS). This brings with it tremendous simplification in some
areas, and challenging decisions to be made in others. There are three
primary issues that we will discuss in this article, and hopefully provide
both some clarity and some “food for thought”. The three issues are: (1)
The “Blending Formula” for your allowed amounts (2) Method 4 vs. Method 2
Billing and (3) The “Q-Codes”.
First
of all, the “Blending Formula”: I’m not sure what all of us in the
EMS Industry will do come January when we don’t have to revise
all those elaborate spreadsheets to determine whether our Carrier is paying
us correctly, based on a blend of our “Reasonable Charge” and the Fee
Schedule. I do, however, hope that it will be something much more
enjoyable! As we should all be aware, as of
January 1, 2006, all
Ambulance reimbursement will be based 100% on the AFS, instead of a blend of
the old payment methodology and the
AFS. Of course the
AFS is still a blend of the
National Fee Schedule and one of nine Regional Fee Schedule until
December 31, 2009. What this means for Sweet-Billing users is
that it will no longer be necessary to update entries in your “Charge Code”,
“Payor Overrides”, “Allowable” fields for Medicare. Medicare Allowed
Amounts will be calculated solely on the entries in “Utilities”, “Database
System Setup”, “Fee Schedule 2 – 4” tabs. These are the tabs where you
enter the amounts for the National Fee Schedule, and your Regional Fee
Schedule.
Secondly, Method 4 vs. Method 2 Billing: (If you are already billing all
Payors ‘Method 2’, as many are, you can skip this paragraph) Method 4
Billing is no longer allowed for Medicare as of January 1, 2006. In other
words, we can no longer bill supplies and ancillary charges separately. We
must bill Medicare a Base Rate, and Mileage charge only. The most common
question that comes up next in this discussion is “Can I bill Medicare
‘Method 2’ and bill Commercial Insurance ‘Method 4’?”. The technically
accurate answer to that question is “Yes, you can do that.” However,
(here’s where we enter the “food for thought” arena) you should carefully
consider the possible repercussions of doing that. I believe there are
several good reasons to convert all Payors to “Method 2”. Very briefly
stated, my reasoning is this: We have seen over and over a trend on the
part of Commercial Insurers to mirror what Medicare does, especially if it
is financially beneficial to them. It seems reasonable to me that they will
soon (if they have not already) be advised by their consultants that it
would be in their best interest to declare A0427 (and all the other Base
Rate HCPCS) an “all inclusive code” per Medicare’s guidelines. If
they do that, you would simply not be paid for any of your ancillary charges
to them either. The worst thing is that if this happened, you would have no
time to react, as you would have several weeks of claims in the pipeline
when the problem first surfaced. Secondly, we currently run into Commercial
insurers that deny secondary claims if the charges on the CMS 1500 Form do
not exactly match the EOMB from Medicare. So, in these cases, we will have
to print a ‘Method 2’ 1500 form already. Thirdly, Method 2 Billing saves a
lot of time in Data Entry, as well as in required documentation from the
field. It also eliminates the possibility of decreased revenue due to
‘missed charges’ for supplies. So, from an efficiency and accuracy
standpoint, it is clearly the way to go. By taking the time now to
accurately determine what your charges need to be in order to meet your
revenue requirements, and moving yourself to an ‘All Method 2’ system, you
take control of your own destiny and make the changes on your terms,
eliminating the potential for undesirable results should outside forces
beyond your control force the change at some unknown point in the future.
Finally, the “Q-Codes”: These HCPCS, Q3019 and Q3020, have been used during
the AFS phase-in period to indicate those transports where
BLS level care to a
BLS patient was provided by
an ALS crew and vehicle. This was most often the case in jurisdictions that
are “ALS Mandated”, but was also appropriate under some other circumstances.
This is another provision of the
AFS that goes away
January 1, 2006. On and after that date, when you receive a dispatch
for a condition for which a
BLS response is indicated,
and you provide BLS level care, you must bill Medicare a BLS Base Rate,
regardless of the certification level of the crew / vehicle providing the
care / transport.
Could
any of this change? As we all know, with the Government involved, a law is
only written in stone until the law that changes it comes along. We have
seen the Fee Schedule change in the past, and certainly, it could change in
the future. At the time of this writing, there are some moves afoot to make
changes to some aspects of the AFS mentioned above, so it is clearly a good
idea to keep your “ear to the ground”. Know that if there are changes, we
will be here to assist you in working your way through them! In the absence
of new legislation however, these are the changes that you should make
preparation for in 2006.
All of
us at Ortivus North America wish you the best in 2006!
Global Justice XML
Data Model
by Alexandre Sagala, Product
Manager
What is GJXDM?
The Global Justice XML Data Model (GJXDM) is a data sharing standard and
vocabulary designed to allow agencies across the country to share
information effectively. It allows data to be shared and understood by
different systems without the need to modify or replace existing systems.
What is the purpose of GJXDM?
Global Justice XML Data Model was designed to
increase the ability of justice and public safety communities to share
information at all levels, laying the foundation for local, state and
national justice interoperability. The goal of the GJXDM is to make sharing
information between law enforcement agencies and justice very easy, hence,
increasing the amount of information available to everyone. As GJXDM is
adopted by more agencies across the nation, effective and efficient
information sharing is becoming a reality.
How does the GJXDM work?
The GJXDM version 3.0 consists of a data
dictionary, a data model and a reusable component repository - or database. The
data dictionary is the data model's underpinning structure. It is, in
effect, a spreadsheet containing identification of data elements and the
meanings or definitions of those data elements, all of which are unique. The
data model builds relationships between the data elements, and the result,
in simple terms, is that disparate systems connect via the unique
identifiers.
Who is using the GJXDM?
The DOJ's Office of Justice Programs (OJP) has
tallied at least 50 fully implemented extensible markup language (XML)
applications in the government justice and public safety realm thus far,
including Amber Alert. The DHS and DOJ also tied use of the GJXDM to federal
grants for information exchange projects in fiscal 2005, so more projects
are bound to start. Federal agencies are also adopting GJXDM, coincidently
encouraging the adoption by state and local agencies.
Is Ortivus North America (NA) incorporating
GJXDM into their applications?
Ortivus NA is currently incorporating GJXDM into its next release of CAD and
RMS products. Using GJXDM, these two products will be able to integrate
seamlessly into existing or future information systems. Another benefit
includes the possibility to easily access information stored in these
products for exporting to state and national levels, or even third-party
applications.
Ortivus North America
Prepares for CPIC Changes
by Alexandre Sagala, Product Manager
Ortivus North America (NA) has
already begun preparations for the upcoming Canadian Police Information
Centre (CPIC) changes, anticipated to begin in approximately one year.
The CPIC was created in 1966 to provide tools to assist the police community
in combating crime. It was approved by Treasury Board in 1967 as a
computerized information system to provide all Canadian law enforcement
agencies with information on crimes and criminals. CPIC is operated by the
Royal Canadian Mounted Police (RCMP) under the stewardship of National
Police Services, on behalf of the Canadian law enforcement community.
At this time, the CPIC is undergoing changes and is currently getting ready
for the implementation of the Third Phase of its reengineering plan. Here is
a brief description of what Phase Three is and what it will mean in terms of
changes:
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Phase Three will change Input
(queries) and Output (results from queries) formats of the CPIC system.
-
Potentially the Phase Three
implementation plan could be modified and split in two stages. The first
stage includes changing the Output formats; the second stage includes
modifying the Inputs. At this time, both formats are scheduled to change
concurrently.
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Once the Inputs and Outputs
are changed, the old formats will no longer be supported.
-
Although the RCMP is planning
for these changes to take place concurrently, it is evaluating the
possibility of postponing some of the tasks. The Outputs are currently
scheduled to change at the end of 2006 and new Input sometime in Spring
2007.
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No fallback system will be
available; therefore, agencies and vendors need to be prepared.
Ortivus NA is currently working with CPIC to
ensure the switch to the new system is seamless and ‘painless’ for our
customers.
NEMSIS - The Next
Agent of Change
by Dan Voss, Product Manager
Fee-Schedule, Y2K, HIPAA...These terms all relate to issues that have
required significant changes to the Sweet Billing and Field Data
applications in recent years. While the Y2K problem was purely a technical
issue, Fee Schedule and HIPAA are EMS industry issues that required
operational changes.
There’s a new industry issue ushering in the next round of change. That
issue is the National EMS Information System – NEMSIS.
Industry groups and Federal agencies have recognized that there is no
authoritative source of statistical information on EMS. There are national
crime statistics, and national fire statistics – but no national EMS
statistics.
The inability of the EMS industry to produce comparable statistics on a
national level decreases the effectiveness of efforts to lobby for needed
legislation and funding.
NEMSIS has been born from this need and is being driven by the National
Association of State EMS Directors.
The NEMSIS Dataset
The NEMSIS project has defined a list of 400+ data elements to be used to
describe EMS agencies and EMS events (incidents/calls/responses). The goal
of this list is to be a comprehensive list of data that could be collected
at the local level. States will establish state databases and will
require/request a portion of these data elements be electronically uploaded
from EMS agencies to their database. Participating states will then send a
smaller portion of this data – about 68 elements to the national database.
The NEMSIS Effect
Many of the data elements that are specified in the NEMSIS dataset are not
data elements that you collect today. Or, you may be collecting similar data
– just not in the form that the NEMSIS dataset requires.
We will be implementing changes in our software applications to make the
collection of this data as easy as we can, however, it can be stated with
some certainty that there will be new fields of information to be gathered
on calls, patients, and codefiles.
The number of these new data elements that will apply to your individual
agency will be determined largely by decisions made at your state EMS agency
level.
State Implementation of NEMSIS
48 of 50 states have signed a memorandum of understanding stating support
for NEMSIS. A number of states are moving quickly to either implement new
data collection programs based on NEMSIS, or to migrate their existing data
collection systems to the NEMSIS standard.
Some states have a relatively small number of data elements required, while
others are preparing to request the vast majority of these data elements be
submitted on every call. The more data elements the state requests – the
more work that your agency will need to do to satisfy the state.
NEMSIS – The Future
NEMSIS has the potential to be very beneficial to the EMS industry. For the
potential of NEMSIS to be realized, it requires adoption at the local level,
and there must be consistency of data entry nationwide.
As the NEMSIS national database is created, it is important that the
industry have common definitions for terms so the same events are being
reported with consistency. To date, NEMSIS has not defined exactly what an
‘EMS event’ is. Does it include 911 calls, fire stand-bys, pre-scheduled ALS
or BLS transfers, or wheel-chair transports? As another example, the
National dataset has elements for reporting things like reason for dispatch
delay, but does not define what constitutes a delay that should require
entry of a dispatch delay reason.
Without this type of guidance, it is possible that NEMSIS will result in 50
different state data systems that have great information about EMS in each
state, but that still cannot be accurately compared on a national level.
The individuals, organizations, and agencies that have tackled this project
are to be applauded. EMS agencies have a vested interest in this project
being successful, so should take an active role in making sure that NEMSIS
is a success. That can best be accomplished by communicating with your state
EMS agency about your expectations for NEMSIS.
For more detailed information on NEMSIS, visit our
FAQ section or
www.nemsis.org.
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