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PPS Guidelines

Skilled Nursing Home Perspective Payment Plan

Certificate of Medical Necessity

PPS Guidelines

1. Skilled Nursing Facilities Only
2. Residents on Part "A" (100 Days) Only
3. Bill to SNF Only if Transport is part of Patients Normal Care Plan. (Rehab etc.)
4. Sending SNF is Billed if Resident is Transferred to another Facility for Upgrade in Care.
5. Wheelchair Service is Still Private Pay and is Billed to Patient.
6. See "Type of Trip" Sheet for more Details.

Effective April 1, 2000 - Dialysis Transports excluded from PPS
President Clinton signed into law the Consolidated Appropriations Act. As a part of this Act, Skilled Nursing Facilities (SNFs) will no longer be required to cover the expenses of ambulance transports under the PPS for patients with End Stage Renal Disease (ESRD). Any patients transported on or after April 1,2000, will fall under this new law.

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Skilled Nursing Home Perspective Payment System

Skilled Nursing Homes with 100 day Part "A" Medicare Patients, are billed direct by the Ambulance Service for "Ambulance" Transports that are part of the Patients Care Plan. This includes Doctor Office Trips. Exceptions to this:
1. Ambulance trips to SNF for admission or from the SNF following discharge.
2. Ambulance trips to/from an outpatient hospital, relating to the following services:
- emergency services;
- cardiac catheterization;
- computerized axial tomography (CT) scan;
- magnetic resonance imaging (MRI);
- ambulatory surgery involving the use of an operating room;
- radiation therapy;
- angiographies codes; and
- codes for lymphatic and venous procedures.

The facility is billed direct for Ambulance Service for Non-Emergencies Only. An " Emergency" is any transport  going to an emergency room for treatment of life threatening illness or injury, or illness or injury that may cause severe pain or threat to the patients overall health. Examples: Altered level of consciousness, severe pain, falls with injuries, fractures, lacerations etc., high fevers, uncontrolled vomiting, shortness of breath, unstable vitals, changes in heart rhythm, chest pain or discomfort, mental status requiring patient to be restrained, pneumonia, severe flu symptoms, or possible CVA's.
Ambulette or Wheel Chair Service is still billed direct to the patient. Note: Wheelchair Service is not part of Medicare PPS in any way. Medicare will never pay for Wheelchair Service under any circumstance. Medicaid will pay if patient is unable ambulate and is wheelchair bound all the time.
You will experience very few ambulance trips that will fall under PPS guidelines. Once patient is off part "A" 100 days, the facility will no longer be billed direct. The Ambulance Service can then bill the Medicare carrier direct for all Ambulance trips.

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Certificate of Medical Necessity

- Ambulance claims do not have to indicate the Certificate of Medical Necessity is on file. All that is required is that we have it on file, when required.
- Medically necessary non-emergencies in addition to bed confined are covered, e.g. IV maintenance, oxygen administration where special equipment such as a ventilator or balloon pump is needed, etc.
- The condition of the patient is based on the time of response.
- If the call is at least 24 hours before the transport.
- The signature on the CMN can be from the attending physician or other trained health person but only if they are allowed to sign for the physician and their title is listed, e.g. John Doe, M.D. by Jane Smith, P.A.
- No CMN is needed for transports that appear at the time of the response, in good faith, to be emergencies (e.g. 911, acute medical conditions etc.), even if they are subsequently downgraded to non-emergency.

A Chart, listing when the physician Certificate of Medical Necessity is needed, follows.

Physician Certification

* A transport is considered scheduled if the call was received 24 hours or more prior to the transport
** It is expected that the CMN will continue to be valid for the periods indicated if there is no change in the condition of the patient.

If you have any questions call Steve Mattern, Director of Marketing. 1-330-837-9748 or 1-800-870-9814. Or you can send your questions in e-mail to: SMattern@starksummit.com.

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