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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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