Columns, Documentation & Patient Care Reporting

CMS Increases EMS Paperwork

A new rule issued by the Centers for Medicare and Medicaid Services that takes effect Jan. 1 substantially increases the burdens on ambulance providers to comply with the Medicare beneficiary signature requirement. The new rule treats emergency and nonemergency transports differently and also includes slightly different requirements for ambulance services reimbursed under Medicare Part A and those reimbursed under Part B.

Background
Historically, CMS regulations and manual provisions have required ambulance services to obtain the signature of the beneficiary whenever possible prior to the submission of a Medicare claim.

In the event the beneficiary was mentally or physically unable to sign, CMS regulations permitted a service to obtain the signature of one of four specified types of permitted representatives: the beneficiary s legal guardian, a relative or other person who receives social security or other governmental benefits on the beneficiary s behalf, a relative or other person who arranges for the beneficiary s treatment or exercises other responsibility for their affairs, or a representative of an agency or institution that did not furnish the ambulance services but which furnished other care or services to the beneficiary.

The ambulance industry has long interpreted the signature rule as permitting a crew member to sign after documenting the unavailability of any other qualifying signature if the beneficiary was unable to sign and none of the permitted representatives were available or willing to sign at the time of transport.
Because it s frequently difficult to obtain a beneficiary or representative s signature at the time of transport, this exception to the signature requirement has been widely used. Now, the new rule essentially modifies this exception and limits its use to two situations, described below.

Exception for Emergency Transports
First, under the new rule, ambulance services (both those reimbursed under Part A and Part B) may submit a claim for emergency transports without a signature from a patient or permitted representative if the provider obtains (and maintains for four years) the following:

Documentation signed by a crew member at the time of transport that the patient was unable to
sign and that none of the permitted representatives were available or willing to sign on the patient s
behalf;
Documentation of the date and time of transport, and the name and location of the facility that
received the beneficiary; and
Documentation from a representative of the receiving facility that includes the name of the
patient and the date and time the patient was received.

Although most ambulances already obtain the first two pieces of documentation, the third item will impose substantial new burdens on some services. The rule provides two options for meeting this new requirement. The first is for the ambulance crew to obtain a signed statement from a representative of the facility at the time of transport setting forth the required information. The second is for the crew to obtain secondary verification after the transport setting forth the required information. This can be in one of the following forms:

A copy of the patient care report signed by the receiving facility;
The hospital registration/admission sheet;
The patient s medical record;
The hospital log; or
Other internal hospital records.

To make matters worse, there is a discrepancy between the rule itself and the preamble CMS wrote to the rule: In the preamble, CMS indicates that the secondary verification must include a signature of a facility representative. However, no such requirement appears in the rule itself. Because such hospital documentation as an admission sheet or log would not normally include a facility representative s signature, CMS will hopefully clarify that no signature is required on the secondary verification except when a copy of the PCR is used for verification.

Exception for Part A Providers
The new rule provides a second exception to the requirement for a patient or representative signature for Part A organizations. If the patient is unable to sign, a Part A provider may submit a claim to Medicare related to either an emergency or a nonemergency transport if the ambulance provider creates and signs documentation indicating it has made reasonable efforts to locate and obtain the signature of the patient or a permitted representative.

The unavailability of a patient or representative signature at the time of transport will not, in most cases, be sufficient. Part A organizations will be required to seek a patient or representative signature after transport for some reasonable period of time prior to submitting a claim. The rule does not specify how long this period must be. For emergency transports, services paid under Part A will be able to use either this exception or the new emergency exception described above.

No Part B Exception for Nonemergency Transports
The most onerous aspect of the new rule is that it essentially takes away the exception Part B services have historically relied on for submitting claims for nonemergency transports when the patient is unable to sign and no permitted representative is available to do so at the time of transport. In the preamble to the new rule, CMS states that Part B suppliers may no longer utilize this option.

Therefore, services reimbursed for nonemergency transports by Medicare Part B now must obtain a signature either from the patient or one of the other permitted representatives prior to submitting a nonemergency claim unless the patient has died. CMS clarifies that although the signature need not be obtained at the time of transport, it must be obtained prior to the submission of a claim. CMS further indicates that if a Part B suppler is unable to obtain such a signature, it may not submit a nonemergency claim to Medicare, but should bill the patient.

Compliance Recommendations
The new rule will require ambulance services to modify their policies, procedures and forms to achieve compliance.

Notably, one of the four types of representatives permitted to sign on behalf of a patient for either emergency or nonemergency transport (for services paid under either Part A or Part B) is a representative of an organization that did not furnish the ambulance services but furnished other care, services or assistance to the beneficiary. This would include a representative of the sending facility (as long as that facility didn t also own or operate the ambulance service) or the sending physician. It could, under some circumstances, also include the representative of the receiving facility (e.g., if that facility has previously rendered care to the beneficiary).

Therefore, one possible strategy is to begin routinely obtaining a signature from these facilities as backup in case a signature can t be obtained from the patient or one of the other permitted sources. A signature from the sending facility or physician for nonemergency transports could be routinely obtained by adding appropriate signature language to the physician certification statement.

To comply with the new emergency exception, language should be added to the PCR and/or other documentation to be signed by receiving facilities. This new language should document receipt by the facility of the patient and specify or reference the date and time the patient was received. Providers may also want to add additional verbiage to the documentation signed by the receiving facility that would (when appropriate) constitute a representative signature in circumstances when that facility has previously provided care to a patient.

The Bottom Line
Providers should remember that as of now Medicare claims that don t comply with the new rule may be subject to recovery as overpayments and potentially expose ambulance services to liability under the False Claims Act and other health-care fraud statutes. Given the enormous importance of compliance with the new rule, ambulance services should aggressively in-service their crews to ensure that the required signatures and documentation are obtained and train billing personnel not to submit claims that don t comply with the requirements. Services should also undertake aggressive efforts to monitor compliance through internal audits and reviews. Finally, because many facilities may resist signing new or different documentation, it will be necessary to educate them as well.

The sections of the new rule related to ambulance signature requirements can be found on p. 66321 66324 of the Nov. 27, 2007 Federal Register (Vol. 72, No. 227) at www.setonresourcecenter.com/register/2007/Nov/27/66222A.pdf.