Condition Code Project Update Deb Gault, Chair AAA Federal Reimbursement Committee

1. Condition Code Project UpdateDeb Gault, ChairAAA Federal Reimbursement Committee

2. Topics of Discussion • Project History “Refresher” • Condition Codes during the NRM process • Condition Codes Post NRM • Current Status of Project • Implementation • Condition Code Examples

3. Project History • AAA worked on development of condition codes for over a decade • HCFA published a short list of “condition-like” codes in 1997 Proposed Rule • AAA met with HCFA to talk about the inadequacies of this list - offered to develop a more inclusive list of condition codes • The list was developed and was used to begin discussions during the NRM process

4. During NRM • HCFA originally stated that discussion of any type of condition code system was “off the table” • AAA met with HCFA to persuade them to take advantage of the NRM process to develop condition codes to accompany the new ambulance fee schedule • Other parties in the NRM process agreed and pushed HCFA to include condition code development in the NRM process

5. During NRM • NRM Workgroup formed to discuss condition codes and level of service definitions and bring recommendations back to the NRM committee • Dr. Robert Bass representing NAEMSP and ACEP in the NRM process led the workgroup • At least one representative from all NRM parties was involved in workgroup • 8 clinical specialists, 2 billing/coding specialists, 2 Carrier Medical Directors, 1 HCFA policy representative • The AAA condition code list was used as the base to begin discussions in the workgroup • Lengthy debate occurred within the workgroup during the medical condition list development

6. During NRM • Medical Issues Workgroup Outcome • Condition Code List and Level of Service definitions were developed and brought back to the full NRM Committee for approval • Condition Codes linked the appropriate level of service to the patient’s condition based upon what was encountered on-scene and during the patient transport • NRM Committee voted unanimously on the need to include the condition codes with the ambulance fee schedule

7. During NRM • On the day the NRM agreement was signed, HCFA stated that the condition codes would NOT be included as a part of the fee schedule agreement • HCFA committed to move forward with them outside the scope of the NRM process • This was almost a “deal killer” for many of the NRM participants

8. During NRM • Advantages • We could continue commenting and working on them after the process ended • We involve Members on the Hill if necessary to ensure that the condition codes proceeded toward implementation

9. Post NRM • Initial Condition Code List appeared in the NPRM for the ambulance fee schedule • Many comments were received – only ONE stated concern with condition codes (AHA) • CMS used that ONE negative comment as the initial reason not to proceed with the condition codes

10. Post NRM • CMS asked AAA to meet with the AHA to resolve their issues with the condition codes • CMS committed to move forward with the codes IF we could alleviate the AHA’s concerns • AHA issue - did not want to learn new coding system – wanted to use same codes used to submit hospital claims (ICD9-CM) to submit ambulance claims

11. Post NRM • Solution was to attempt to crosswalk the condition list to ICD9-CM codes • Limited success with an “exact match” approach • Only 26 of the conditions translated EXACTLY to an existing ICD9-CM code • The project stalled and condition code implementation looked like it was not going to happen

12. Post NRM • AAA included the condition code issue in its legislative strategy to ensure that appropriate pressure was maintained on CMS from Capitol Hill • Condition Code language included in all ambulance Medicare Relief legislation • Condition Code language included in 2002 Senate Labor/HHS bill in the form of report language

13. Post NRM • Several Members have assisted us • Senator Mark Dayton (MN) • Senator Tom Harkin (IA) • Senator Nighthorse-Campbell (CO) • Congresswoman Nancy Johnson (CT) • Congressman Amo Houghton (NY)

14. Post NRM • AAA met with AHA again to seek compromise: • An agreement to allow the use of condition codes OR allow providers/suppliers to continue using ICD9-CM codes for claims submission was reached • Compromise was communicated to CMS and project began moving forward again

15. Post NRM • Next Hurdle – HIPAA • Coding System mandated within HIPAA for use by all providers/suppliers is ICD9-CM • Result: We either had to find a way to crosswalk the condition list to ICD9 codes OR petition to become exempt from the HIPAA coding mandate

16. Post NRM • No other provider/supplier group has petitioned thus far for an exemption under HIPAA for an issue of this magnitude • Disadvantage that we would be the first group to try to find our way through the exemption petition process • Likely to take a VERY long time • Reconsideration of use of ICD9 crosswalks seemed the better option • Couldn’t do that if CMS would not agree to a “best fit” crosswalk approach

17. Post NRM • Met with CMS again to discuss plan to move forward in September, 2002 • CMS agreed to consider an ICD9 crosswalk that used a “best fit” approach • CMS committed to move forward with condition codes IF AAA developed: • An ICD9 crosswalk • A draft list of codes and instructions that would discuss how the codes would be implemented • Obtain input and sign-off from all other groups in the industry on the documents produced

18. Post NRM • AAA and Dr. Bass worked together • Drafted a “User’s Guide” and Medical Condition List • Submitted the documents in July, 2003 to NRM participants for review, comment and approval

19. Post NRM • Other groups involved with document development and approval process: • National Association of EMS Physicians • American College of Emergency Physicians • International Association of Fire Chiefs • International Association of Firefighters • National Association of State EMS Directors • National Volunteer Fire Council • American Hospital Association • Dr. Charlotte Yeh

20. Post NRM • Next Hurdle: AHA decided they did not like the use “best fit” ICD9 crosswalk approach and wanted to include many ICD9 codes for every condition on the list to use for submission • All other groups involved felt the use of more than one ICD9 code to designate a condition would jeopardize the integrity and objective which is to simplify and standardize the way ambulance claims are submitted • AAA had to try to reach another compromise with the AHA to move the project forward

21. Post NRM • AHA agreed to a structure that would include a primary code (in most cases ONE ICD9 code) with the optional allowance of additional secondary/tertiary codes to be included IF there was additional information available about the patient’s condition

22. Post NRM • Documents were finalized and submitted to CMS with 100% sign-off by NRM participants in September, 2003 • CMS and AHA agreed upon the plan to use a primary condition code with the option of including secondary codes if appropriate • Only primary code will be mandatory

23. Post NRM • Next Hurdle: CMS believed that the condition codes needed to go through the formal comment process AGAIN before they could move forward • AAA convinced CMS that this was not a legal requirement and totally unnecessary • Codes had already appeared for comment once before with almost unanimous support • No other coding system for any other provider group has EVER gone through formal comment process • Compromise: Town Hall Meeting to allow for input scheduled for February 4, 2004

24. Post NRM • Federal Register Notice announcing Town Hall Meeting appeared in November, 2003 • Condition List was posted on the CMS website on January 6, 2004 • New Hurdles became apparent • User’s Guide developed by industry previously with CMS as a part of the project was not included • CMS stated that condition codes would be “voluntary”

25. Post NRM • AAA and Dr. Bass met with CMS prior to Town Hall Meeting to attempt to understand CMS’ position on the “voluntary” status of the codes and the lack of inclusion of the industry-developed user’s guide

26. Post NRM • CMS position: HIPAA legislation states that they cannot mandate the use of ICD9 • Not true – only mention of ambulance claims not requiring ICD9 codes comes from a June 6, 2003 CMS Program Memorandum • We explained that while suppliers have taken the position that ICD9 codes do not work for us in the past, we have no objection to communicating that condition through an ICD9 code IF they are cross walked to a patient condition on the list • CMS understood and committed to work internally with HIPAA folks to move forward • AAA provided CMS legal document outlining argument to assist them with internal discussions

27. Post NRM • CMS stated that they cannot give “coding advice” and will NOT endorse the industry’s “User’s Guide” • Opposed to giving coding guidance to anyone – (CMS P.I.G.) • CMS is not opposed to the AAA and other trade associations promoting and distributing the guide • Currently exploring advantages/disadvantages • CMS agreed to include critical pieces of the “guide” with instructions that go out with the final list of codes • AAA and Dr. Bass asked to work on critical instructions to submit to other groups for input and ultimately to CMS for inclusion with final code list

28. Post NRM • Town Hall Meeting Outcome • Over 100 attendees • Clear and unanimous support from providers and suppliers for condition code implementation • Clear message that the codes should be mandatory – NOT voluntary • Clear message that specific instructions should accompany condition code implementation to preserve integrity of implementation • Clear message that the process needs to continue to move toward an imminent implementation • AAA asked to take the lead on developing the minimum instructions needed for implementation

29. Post NRM • Minimum instruction document developed and distributed to other NRM groups for review and input • Comments received – some requiring clarification – process of incorporating input was moving forward • HUGE surprise occurred just as the process was nearing completion….

30. Post NRM • CMS P.I.G. made significant changes to the condition code list • AAA received the changes and sent them to other NRM participants for their input • ALL groups felt that the changes made by CMS P.I.G. compromised the objective and integrity of the project

31. Post NRM • Contact made with CMS to inform them that we could not agree to the changes and a meeting was scheduled for June 3, 2004 • Clinical debate must occur at this meeting between CMS clinical representatives and ambulance clinical representatives

32. Post NRM • June 3, 2004 meeting occurred • Attending for ambulance industry: • Dr. Robert Bass (University of Maryland) • Dr. Sandy Bogucki (Yale Medical Center) • Dr. Ted Delbridge (University of Pittsburgh Medical Center) • Deb Gault (American Ambulance Association)

33. Post NRM • Meeting Outcome • Each change made by CMS P.I.G. was discussed and debated • A document was prepared and submitted to CMS outlining our position on each of the changes made to the condition code list • CMS agreed to meet internally and consider the issues we discussed at the meeting and outlined in the document we submitted to them

34. Post NRM • Parallel track: • Met with Congresswoman Nancy Johnson (R-CT) who has helped us previously with the condition code issue to inform her of the recent snag in the project • Met with Secretary Tommy Thompson to provide an update on the project and ask that he assist with moving the project forward

35. Current Status • CMS sent draft list back to AAA which incorporated the changes we discussed in the June 3 meeting – made sure that it was understood the list was still in DRAFT form • CMS representative stated just last week that there were still “problems” with the project internally but discussions were “progressing”

36. Current Status • CMS still states that they are committed to getting the codes into the Medicare Manual by the end of the year • AAA currently pressing for firmer idea of timeline • We must keep engaged Members informed and they will weigh in for us when timing is right • Will also ensure Secretary Thompson stays informed of progress (or lack thereof)

37. Current Status • Finalizing Minimum Instructions document with CMS • MUST ensure that clear instructions accompany the implementation of the codes – need to stay engaged in the project on a regular basis to make sure this happens

38. Current Status • Several codes from original condition code list have been changed to ground ambulance “modifiers” • These codes describe the type of transport; not the condition of the patient • Thought it would be more consistent to include them as modifiers rather than actual patient conditions • Decreased the need to request new ICD9 codes for the crosswalk

39. New Ground Modifiers 1. Inter-facility Transport. EMTALA-certified inter-facility transfer to a higher level of care. Physician has made the determination that this transfer is needed – carrier needs to know level of care and mode of transport. All levels of service – indicated by HCPC billed. Excludes patient-requested EMTALA transfer.

40. New Ground Modifiers 2. Inter-facility Transport. Service not available at originating facility and must meet one or more emergency or non-emergency condition on list. Must specify what service is not available on the submitted claim in the narrative/comment field.

41. New Ground Modifiers 3. Inter-facility Transport – Specialty Care Monitoring Required. A level of service provided to a critically injured or ill patient beyond the scope of the national paramedic curriculum. SCT level of service.

42. New Ground Modifiers 4. ALS-level response to a BLS-level patient. ALS response required based upon appropriate dispatch protocols – BLS-level patient transport. Indicates that an ALS-level ambulance responded appropriately based upon the information received at the time the call was received in dispatch and after a clinically appropriate ALS-assessment was performed on scene, it was determined that the condition of the patient was at a BLS level. These claims, properly document, should be reimbursed at an ALS-1 level based upon coverage guidelines established under the AFS. Must specify BOTH medical conditions on the claim. Initial condition is BLS-level on-scene/transport condition and second condition indicates ALS-level condition received at the time of dispatch.

43. New Ground Modifiers 5. BLS Transport of ALS-level Patient. ALS-level condition treated and transport by a BLS-level ambulance. Used for ALL situations where a BLS-level ambulance treats and transports a patient that presents and ALS-level condition. No ALS-level assessment or intervention occurs at all during the patient encounter.

44. New Ground Modifiers 6. Emergency Trauma Dispatch Condition Code – Major incident or mechanism of injury. Indicates situations where standard dispatch protocol warrants “Calvary” response – will send highest clinical level response available to these situations – regardless of what is found on scene. Examples would include: Trapped in machinery, close proximity to explosion, building fire with persons reported inside, major incident involving aircraft, bus, subway, metro, train and watercraft. Victim entrapped in vehicle.

45. New Ground Modifiers 7. Medically Necessary Transport NOT to Nearest Appropriate Facility. This would indicate situations where the transport meets medical necessity criteria but it was necessary to take the patient to a facility that is NOT the nearest appropriate facility. Would need to indicate in comment/narrative field the reason the patient could not have gone to nearest appropriate facility. Examples: hospital diversions, no available bed, traffic congestion patterns warrant more distant transport based upon condition of patient.

46. Current Status • AHA has agreed to assist with obtaining new ICD9 codes for those conditions on the list that do not have a current ICD9 crosswalk available as soon as the condition list is finalized • ICD9 committee has agreed to do this informally and will not require a formal petition process to add required codes for purposes of condition code crosswalk

47. Implementation • How will condition codes be used? • Only condition code required on a submitted claim will reflect the “on-scene/transport” condition of the patient UNLESS the level of service of the on scene condition does not match the level of service responding to the call based upon the information obtained in dispatch In that case…….

48. Implementation • If an ALS ambulance is appropriately dispatched based upon information in dispatch to an ALS condition, an ALS Assessment is performed and a BLS condition is found, treated and transported, two condition codes will be submitted on the claim • The corresponding modifier describing this transport situation must be included on the claim • The first condition code on the claim will be the “on-scene” BLS condition • The second condition code will be the ALS condition reported at the time of dispatch • Carriers/Intermediaries will be instructed to process the claim using all information reported, but if payment is warranted, the ALS level of service should be received

49. Implementation • A few other special circumstances will warrant two condition codes on claims: • Where an ALS condition is encountered, treated and transported by a BLS-level ambulance, there will be a modifier that must accompany your claim that indicates that the claim should be paid only at the BLS level since an ALS level response/transport did NOT occur at any time during the patient encounter – this would be included with the BLS level HCPC on your claim • Where there is a mass casualty/trauma incident when it is ALWAYS appropriate to send the highest level of resource available based upon information received at the time of the call, a modifier will be included on the claim and two condition codes if the condition of the patients transported are at a BLS-level

50. Implementation • Although the medical condition list includes “primary” and “secondary” ICD9 codes for each condition, the “primary” ICD9 code is mandatory and other codes are optional for processing the claim • Secondary ICD9 codes were included on the posted medical conditions list at the request of the AHA for those circumstances when there is more information available at the time of submission and the provider wishes to provide it and are optional