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Sweet-TALK: 1st Quarter 2005
Condition Codes |
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And the sad news is that the current state of the Condition Codes makes about as much sense as the lyrics of that old song by The First Edition did. Remember, # 61 in 1968? Oh well, never mind, hopefully we’ll soon forget about this too. First of all, I need to start out with a big disclaimer. There is probably as much about the Condition Codes that is not yet set in stone, as there is that is set in stone. The things that we know for sure are that they are in fact coming (or here), that there will be plenty of opportunity for confusion in the beginning, and that there is a great probability that when it is all said and done, they will be a very good thing! As you probably are already aware, Medicare issued Change Request # 3619 on December 15, 2004, introducing the Ambulance Condition Codes to the Carriers & Intermediaries. Here is the link to that Change Request. http://www.cms.hhs.gov/manuals/pm_trans/R395CP.pdf Included with this Change Request is the proposed list of Condition Codes & Modifiers. Some problems remain, including the fact that CMS published the list with “place-holders” as the new Modifiers, thereby causing an apparent duplication, in cases like “D” & “E”, of modifiers that already exist. Also, the first two on the list had the same “Condition Code”, even though one was identified as an “ALS Condition” and the other as a “BLS Condition”. These are just a couple of issues that CMS is aware of, and is working on getting clarifications for. Another open question, at this time, is where these new modifiers should go on the Claim Form, or in the Claim File. In addition to this, there was some confusion on the part of some of the Carriers, as to whether they needed to implement these in their systems. CMS stated that the use of Condition Codes was “optional”, intending that it was optional for the providers, whether they choose to begin using Condition Codes on their claims, or continue the way they are currently doing it. Unfortunately some of the Carriers took that to mean that it was optional for them, whether they wanted to recognize these new Condition Codes, or not. CMS has planned a conference call with all of the carriers in early February to straighten this out. In the mean time it is entirely possible that some carriers may understand what is going on with Ambulance Condition Codes, while others will not. All that said, here are some things that we do believe to be known at this time. For most claims, it is only necessary to send one Condition Code. When you do send more than one, the first Condition Code should always represent the condition of the patient at the time of transport. One situation that the Fee Schedule allows for, but that has at times been difficult to communicate adequately to the Carriers, is billing ALS1 Emergency in those cases where you have a medically necessary ALS assessment performed, based on the information given at the time of dispatch, but the patient was released to BLS providers because that assessment resulted in the determination that BLS transport was appropriate based upon patient condition at the time of transport. This is a situation where the Condition Codes should really help to get these claims properly adjudicated the first time. In this situation, your first Condition Code on the claim, as always, would indicate the patient’s condition at the time of transport. The Carrier should recognize that this Condition Code would indicate that BLS treatment & transport is appropriate for this patient. You should then also send a second Condition Code indicating the patient’s condition, as reported by Dispatch. This would be a Condition Code that would indicate that an ALS response was indicated, based on the information Dispatch gave you. You would also attach the Modifier with the “place-holder = C” in the Medicare Change Request. If all goes according to plan, the Carrier will then recognize that even though this was really a BLS transport in the end, it should be paid correctly at the ALS1 Emergency level according to the Ambulance Fee Schedule! Since the Condition Code is actually an ICD9 code, they will simply be entered into the Sweet Billing system in your Reason Codes. A tip for handling them is to create a Category for your Reason Codes called “Condition Codes” and put all of the appropriate Reason Codes into that Category, thereby making them easy to identify when entering a Medicare Claim! As stated before, there is more information needed, and some changes needed to what was originally published by CMS in order for it all to be “ready for prime time”, but the industry appears to be well on the way to what in the end should turn out to be a very good thing. We will all just need to stay tuned for the latest developments, and work with our Carriers to help assure a smooth implementation! For more information on the Condition Codes, see this month’s guest article by Doug Wolfberg, Esq.
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