“On July 08, 2015, the Centers for Medicare & Medicaid Services (CMS) issued a Proposed Rule that updates payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after Jan. 1, 2016. This year, CMS is proposing a number of new policies, including several that are a result of recently enacted legislation.”1

A Fact Sheet, provided by CMS, discusses the changes to payment policies and payment rates for services furnished under the PFS and other programs. The final rule is expected to be published in the Federal Register by Nov. 1, 2015.

“Under the ambulance fee schedule, the Medicare program pays for ambulance transportation services for Medicare beneficiaries when other means of transportation are contraindicated by the beneficiary’s medical condition and all other coverage requirements are met. Only ambulance services to local facilities are covered unless necessary services are not available locally, in which case, transportation to the nearest facility furnishing those services is covered. The report also indicates that transportation may also be provided from one hospital to another, to the beneficiary’s home, or to an extended care facility. Ambulance extender provisions have add-ons under section 1843(I)(13)(A) of the Act have been extended several times. Most recently, section 203(a) of the Medicare Access and CHIP Reauthorization Act of 2015 have extended these payment add-ons through December 31, 2017. Proposal is to continue implementation of the new OMB [Office of Management and Budget] delineations as described in the February 28, 2013 and subsequent calendar years to more accurately identify urban and rural areas for ambulance fee schedule payment purposes.”2

Table 16 on page 41791 in the proposed rule (PDF, 1.3 MB) contains the ZIP code analysis based on OMB’s revised delineations and updated RUCA codes.

Proposed changes to the staffing requirements

Section 410.41(b)(1) of the Act “requires that a vehicle furnishing ambulance services at the Basic Life Support (BLS) level must be staffed by two people, one of whom must meet the following requirements: (1) be certified as an emergency medical technician by the state or local authority where the services are furnished, and (2) be legally authorized to operate all life saving and life-sustaining equipment on board the vehicle.”

“Section 410.41(b)(2) states that, for vehicles furnishing ambulance services at the Advanced Life Support (ALS) level, ambulance providers and suppliers must meet the staffing requirements for vehicles furnishing services at the BLS level. In addition, one of the two staff members must be certified as a paramedic or an emergency medical technician…These requirements are further explained in the Medicare Benefit Policy Manual (Pub. No. 100-02), Chapter 10, sections 10.1.2 and 30.1.1.”

The Office of the Inspector General (OIG) discussed its investigations of ambulance suppliers and its concern that current regulations and manual provisions do not set forth licensure or certification requirements for the second crew member. “The OIG recommended that Medicare revise its regulations and manual provisions related to ambulance staffing to parallel the standard used for vehicle requirements at 410.41(a), which requires that ambulances be equipped in ways to that comply with state and local laws. Specifically, the OIG recommended that our regulation and manual provisions addressing ambulance vehicle staffing should indicate that, for Medicare to cover ambulance services furnished to a Medicare beneficiary, the ambulance crew must meet the requirements currently set forth in 410.41(b) or the state and local requirements, whichever are more stringent.”3

In addition, CMS is proposing to revise the definition of Basic Life Support (BLS) in 414.605 to clarify that, for BLS vehicles, at least one of the staff members must be certified at a minimum as an emergency medical technician-basic (EMT-Basic). Lastly, a proposal is made to revise the definition of BLS in 414.605 to delete the last sentence, which sets forth examples of certain state law provisions (i.e., in some states an EMT-Basic are permitted to operate limited equipment onboard the vehicle, assist more qualified personnel in performing assessments and interventions, and establish a peripheral intravenous (IV) line – this has been included in the BLS definition since 2002). The proposal is asking to delete this from the definition.4

1Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule and other Revisions to Part B for CY 2016, 80 Fed. Reg. 135, 41686 (July 15, 2015) (to be codified at 42 CFR Parts 405, 410, 411, 414, et al.).
2 Ibid at 41787-41788.
3 Ibid at 41792
4 Ibid at 41792-41793.

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About the author

Robert Bunting, CPC, CPC-H, CHC, CEDC, CEMC, CAC is Compliance Director – Emergency Medicine, McKesson Business Performance Services.