Documentation of Mileage to the Nearest Appropriate Facility

1. Documentation of Mileage to the Nearest Appropriate Facility Sunstar Mandatory CME August, 2001

2. Transport Destinations Ambulance destinations include the following patient care facilties: • Hospitals • Skilled Nursing Facilities • Diagnostic or therapeutic sites other than a hospital or physicians office (rehab, dialysis, wound care, MRI, CT scan, outpatient surgical center, radiation therapy, etc.) • Adult Living Facilities

3. Nearest Appropriate Facility • Medicare covers local transportation to the nearest appropriate facility which is equipped to provide the care needed for the illness or injury involved. For hospital services, it means that a medical specialist is available to provide the necessary treatment required to treat the patient’s condition. • See Categorization of Hospitals’ Reported Capabilities overhead

4. Nearest Appropriate Facility (continued) • Ambulance service to a more distant hospital solely to avail a patient of the service of a specific physician or specialist does not qualify under the definition of appropriate facilities. • The fact that a particular physician (e.g. the patient’s personal doctor) does not have staff privileges in a hospital is not a consideration in determining “appropriate facilities”.

5. Nearest Appropriate Facility (continued) • An institution is not considered an appropriate facility if there are no beds available. Medicare will presume that there are beds available at the local institutions unless the ambulance provider furnished evidence that the institution did not have a bed available at the time of the transport.

6. Institution to Institution within the Same Locality • Florida is divided into 4 localities. • Pinellas County is in locality 2. • If an institution does not have adequate facilities to provide subsequent care required by the patient, the patient must be transported and admitted to another institution that does have appropriate facilities. This is a covered transport provided the second institution is in the same locality, and all other medical necessity coverage conditions are met. • In this scenario, you would bubble “special needs” under Destination Selection.

7. Institution to Institution within the Same Locality (continued) • If the patient is transported past an appropriate facility or institution, the mileage beyond the closest appropriate facility must be documented. • Mileage beyond the closest appropriate facility is a non-covered ambulance service that will be billed directly to the patient.

8. Institution to Institution outside the Locality • Occasionally, the patient must be transported to an institution outside of the immediate locality (more than 50 miles one way) because the originating facility does not have appropriate facilities to treat the patient’s illness or injury. As with local transportation, payment for mileage charges may only be made to the closest appropriate facility available.

9. Institution to Institution outside the Locality • If the patient is transported for any non-medical reason (e.g. to be closer to family members or to receive services from his/her own personal physician) the PCR must be clearly documented as such, and all services will be denied by Medicare. Under this circumstance, the patient my be billed for all services provided.

10. Hospital Destination Policy • Florida Administrative Code states: “The Medical Director shall issue standing orders and protocols to the provider to ensure that the provider transports each of it’s patients to facilities that offer a type and level of care appropriate to the patient’s medical condition if available within the service region.”

11. Patient’s Hospital of Choice • Patient’s who present alert and oriented, regardless of the severity of their problem, have the legal right to go to the hospital of their choice. • However, it is our obligation to notify the patient or the family member who elect to participate in the healthcare decision making process anytime their decision is contrary to standard medical practice or EMS protocol.

12. Closest/Most Appropriate Facility • When you bubble “patient’s choice” and it is NOT the closest/most appropriate facility, the mileage from the origin to the closest/most appropriate facility must be indicated, as well as start and stop mileage. (if patient’s choice IS the closest appropriate facility, bubble in both the patient choice and closest/most appropriate boxes).

13. Transporting Stable Patients • The Most Appropriate Ambulance Transport Algorithm (MAATA) was created by the Medical Control Board and EMS Medical Director to assist EMS personnel in determining the most appropriate facility • See overheads of MAATA algorithm for ALS and BLS transports

14. Documenting Mileage • Beginning September 1, 2001 Sunstar Ambulance Personnel must document the mileage from the the scene of origin to the nearest appropriate facility in addition to start and stop mileage. • The mileage to the nearest appropriate facility will be written in the “Wait Time” box under “Hrs” (see example) • Utilizing the matrix provided, you must determine the mileage to the closest facility for each PCR where destination is marked “pt. choice” • Any other Destination Selection does not require additional mileage documentation, only start and stop mileage

15. Falsification of Mileage • Falsification of mileage is strictly prohibited. If you knowingly document incorrect mileage (or any other information) on a PCR, appropriate disciplinary actions will be taken.

16. Destination Selection • Be sure to mark the PCR correctly as to the patient’s destination (see pages 14 & 15 in Pinellas County EMS Patient Care Report Users Guide): • Closest/Most Appropriate • Patient’s choice • Trauma Center • Special needs/equipment • Selective Divert- equip. specialty • Bypass • Closed

17. Informing the Patient • It is the responsibility of Sunstar personnel to advise the patient or the patient’s representative of the additional mileage charges when the patient chooses not to go to the closest facility. • $8.60 per mile will be billed directly to the patient for each mile beyond an appropriate facility. • A suggested script would be:“I will be happy to take you to any hospital you wish, but I need to advise you that Medicare will only pay for mileage to the closest hospital. You will be responsible for the difference at $8.60 per mile.”

18. PCR Documentation • Care rendered • Medicare number • EKG strips • Signature Authorization • Landing Zones • Miscellaneous

19. Care Rendered • Care rendered section of PCR must indicate any treatments given. Treatments must also be documented in the flow chart area and/or your narrative portion of the PCR. • This includes all procedures done by FD prior to arrival or while SS is on scene.

20. Medicare Number • When documenting a patient’s Medicare number you must write out the entire number and alpha character. It is no longer acceptable to write a line with the letter after it. The County billing department uses an electronic scanner to record and archive the PCR’s, and it does not recognize anything other than numbers and letters.

21. EKG Strips • When attaching your EKG strip to the PCR do not use anything other than regular scotch tape. PBS is responsible for mounting EKG strips so that they can be scanned by the Authority. When medical tape or glue is used, it is very difficult to detach the EKG strips from the PCR without tearing them.

22. Signature Authorization • Ambulance personnel are responsible for obtaining the patient’s signature on the PCR. If the patient is physically or mentally unable to sign, the signature of a representative or legal guardian to the patient must be obtained. • If the patient is unable or unwilling to sign and there is no representative available, the crew must sign and give a VALID reason that there is no patient or representative signature. (“doctor with pt” or “pt unavailable” is not acceptable)

23. Landing Zone • Movement of a patient via stretcher to a landing zone is considered a transport even when there is no transportation in a vehicle. • A complete run report is required for all patient’s transported by Bayflight whether there is mileage or not. • Obtain all patient information (e.g. DOB, SS#, Insurance, Address, etc.) for all landing zone transports. • Documenting the 6 digit trauma number is critical if you are unable to obtain patient information.

24. Legibility • It is extremely important that your PCR is legible and grammatically correct. • Legibility of numerical information (addresses, DOB, SS#, mileage, etc.) is equally important. • If you have difficulty spelling, a pocket dictionary is recommended to lend credibility to your clinical skills

25. Scenarios • (1) Patient is injured in an MVA. MPH is the closest appropriate facility, however, they are closed. You take the patient to LMC. Which “destination selection” do you choose? • (2) Patient requires a neuro evaluation for suspected CVA. The closest hospital is POP. Where do you transport patient, and how do you document your destination selection?

26. Scenarios (continued) • (1) ANSWER: Bubble “Initial Facility Closed”, put “H18” in the initial facility box; then bubble “Closest/most appropriate facility” under Destination Selection. • (2) POP is not a neuro capable hospital, therefore, you would take the patient to SPGH, and bubble in “Closest/most appropriate facility” in the destination selection area.