Economist's View: Links for 7-15-14

Links for 7-15-14

    Posted by on Tuesday, July 15, 2014 at 12:06 AM in Economics, Links |


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    News 4/16/14 | HIStalk

    Top News


    FDA left unanswered questions about its FDASIA report, such as how to submit the comments the report solicits. The agency announces a free, three-day public workshop May 13-15 at NIST in Gaithersburg, MD that will also be presented via webcast. Comments on the FDASIA report can be left here.

    Reader Comments

    From Lois Lane: “Re: short label names for ICD-9, CPT, and MS-DRGs. Any source for these other than an EMR vendor?” If anyone knows, please leave a comment.


    From Guillermo del Grande: “Re: signs that whoever is talking about Epic doesn’t know what they’re talking about.” GDG’s list:

    1. “Model the Model”
    2. “EPIC”
    3. They think NVTs are actually meaningful.
    4. They ask where they can buy Epic stock.
    5. They wonder why Epic doesn’t hire doctors and nurses to help improve their product.
    6. They don’t know that the god-awful screen they are looking at is customizable.
    7. They think Epic was born as a billing product.
    8. They don’t know real people work there, just implementers.
    9. They actually think there’s no internal politics at Epic.
    10. They think Epic’s the only software running a MUMPS descendant.

    From Bill Kilgore: “Re: VerbalCare. I think you might like these guys. Very cool product.” Inpatients get an VerbalCare icon-driven tablet instead of the 1950s-era call button, allowing them to choose the icon describing their need instead of just pushing a call button or trying to communicate through a drive-through quality speaker-microphone. Employees can receive and acknowledge requests on their smartphones or from a central console. The interactions are also tracked for later analysis. VerbalCare offers a commitment-free pilot. Everything looks good except they spelled HIPAA as “HIPPA” on their site, which is almost unforgivable. You should at least correctly spell the name of the requirement with which you are claiming compliance.

    HIStalk Announcements and Requests


    Ms. Dayton, a Teach for America teacher in Arizona, sent pictures and her thanks to HIStalk readers for supporting her magnet school sixth graders by providing them with math stations. She explains, “You have truly transformed my classroom. My students now look forward to math and enjoy the time spent playing the wonderful games that you donated. On a daily basis I hear from my students, ‘Ms. Dayton, can we play the games today?’ or ‘Ms. Dayton, can we skip writing and do math all day?’ I hear these things because of you!”

    Upcoming Webinars

    April 16 (Wednesday) 11:00 a.m. ET. Panel Discussion: Documents, EMRs, and Healthcare Processes. Sponsored by Levi, Ray & Shoup. Presenters: Charles Harris, senior technical lead, Duke University Health System; Ron Peel, technical advisor, LRS; and John Howerter, SVP of enterprise output management, LRS. IT department in hospitals implementing EMRs often overlook the role of document-driven workflows. Prescriptions, specimen labels, and discharge orders, and other critical documents must be reliably delivered with minimal impact on IT and clinical staff. This panel discussion will discuss the evolving use of documents in the “paperless/less-paper” environment.

    May 1 (Thursday) 1:00 p.m. ET. Think Beyond EDW: Using Your Data to Transform, Part 2 – Build-Measure-Learn to Get Value from Healthcare Data. Sponsored by Premier. Presenters: Alejandro Reti, MD, senior director of population health, Premier; and Alex Easton, senior director of enterprise solutions, Premier. Once you deploy an enterprise data warehouse, you need to arrive at value as quickly as possible. Learn ways to be operationally and technically agile with integrated data, including strategies for improving population health.

    Acquisitions, Funding, Business, and Stock


    Truven Health Analytics acquires Simpler Consulting, a provider of Lean enterprise transformation services to healthcare, government, and other commercial organizations.


    Struggling BlackBerry invests in Patrick Soon-Shiong’s NantHealth. The companies are jointly developing a smartphone optimized for viewing diagnostic images, scheduled for a late 2014 release.


    Vocera opens an innovation center in Bangalore, India.


    4-15-2014 11-28-31 AM

    Lahey Health (MA) selects Phytel’s population health and engagement platform in support of its ACO.

    Dialysis Clinic, Inc. will implement Sandlot Connect and Sandlot Dimensions from Sandlot Solutions for care coordination and analytics.


    Shenandoah Medical Center (IA) will deploy Allscripts Sunrise solutions for its 78 beds.

    The 260-provider Phoebe Physician Group (GA) selects athenahealth for EHR/PM and care coordination.


    Citizens Medical Center (TX) will implement T-System’s EV emergency department information system and Care Continuity patient transition management solution.


    4-15-2014 11-32-14 AM

    Explorys appoints Tom Chickerella (Vanguard Health) COO.

    4-15-2014 1-11-16 PM 4-15-2014 1-12-15 PM

    Precyse promotes Christopher A. Powell from president to CEO, replacing company founder Jeffrey S. Levitt, who will assume the role of executive chairman of the board.

    4-15-2014 12-41-48 PM image 

    ESD promotes John Alexander to testing practice director and hires Mia Erickson (Epic) as Epic practice director.


    CHIME names George McCulloch (Vanderbilt University Medical Center) as EVP of membership and professional development.

    image image

    Edifecs names Dave Arkley (Parallels, Inc.) CFO and Michiel Walsteijn (Oracle) EVP of international business.


    Health Data Specialists promotes Angie Kaiser, RN to clinical informatics officer.


    Donna Scott (McKesson Health Solutions) joins USA Mobility as SVP of marketing.

    MHealth Games names investor Keith Collins, MD as its board chair. He was at one time CIO of the University of Massachusetts Medical School.

    Medicomp appoints Michael Cantwell, MD (National Library of Medicine) to its MEDCIN terminology team.

    Healthcare technology services provider CitiusTech names Gary Reiner and Cory Eaves (both of its recent investor General Atlantic) to its board.

    Announcements and Implementations

    4-15-2014 11-38-14 AM

    Kids First Pediatrics Group (GA) integrates PatientPay’s electronic billing and payment solution with its Greenway PrimeSUITE practice management system.

    Memorial Community Hospital & Health System clinics (NE) will transition to Epic starting June 25.

    The HEALTHeLINK clinical information exchange launches an automated syndromic surveillance state reporting service.


    North-Shore-LIJ (NY) rolls out the Allscripts FollowMyHealth patient portal for its Plainview and Forest Hills hospital patients.


    Geisinger Health Plan (PA) implements Caradigm Care Management for population health.

    Government and Politics

    4-15-2014 11-58-28 AM

    CMS introduces a Code-a-Palooza Challenge to encourage developers to create apps that use the new Medicare payment data to help consumers improve their healthcare decision-making.

    4-15-2014 1-46-19 PM

    CMS, which has been strangely quiet about the implementation delay for ICD-10, finally acknowledges the legislation but notes only that it “is examining the implications of the ICD-10 provision and will provide guidance to providers and stakeholders soon.” Meanwhile, CMS still lists October 1, 2014 as the date ICD-9 will be replaced by ICD-10.


    ONC invites voting for ideas submitted in its Digital Privacy Notice Challenge, which include games, responsive templates, a Web widget, and an NPP generator.

    Innovation and Research

    Meaningful Use of EHRs was not found to be correlated with performance on clinical quality measures in a study published in JAMA Internal Medicine. The  research compared quality scores of 540 physicians affiliated with Brigham and Women’s Hospital who achieved MU with those of 318 physicians who did not. Critics note several factors making the validity and applicability of the study difficult to evaluate, including the fact that MU quality metrics are so specific that they exclude many patients with particular conditions.


    4-15-2014 9-16-13 AM

    inga_small Google files a patent for a contact lens system that would include a built-in camera and could potentially be used as an alterative to Google Glass. That’s technology I could embrace since I don’t see myself as one of those nerdy hipster-types that Dr. Jayne and I continually made fun of as we walked the HIMSS exhibit floor.

    Awarepoint introduces an RFID tag that monitors room humidity.



    The Coalition for ICD-10, an industry advocacy group whose members include CHIME, AHA, and AHIMA, calls on HHS to establish October 1, 2015 as the new ICD-10 implementation date.

    The Oklahoman looks at the soon-to-be-launched Oklahoma City-based Coordinated Care Oklahoma HIE and the more established Tulsa-based MyHealth Access Network and considers the impact of having two competing networks in the state. It’s a scenario that will undoubtedly be repeated numerous times in coming months as funding disappears for older HIEs and newer organizations emerge.

    An InstaMed report on trends in healthcare payments finds that patient payments to providers jumped 72 percent from 2011 to 2013, with the average amount increasing from $110.86 to $133.15.

    Attorneys specializing in representing whistleblowers in healthcare pounce on the newly published Medicare data to search for evidence of fraud.


    Travelers who pass through Madison, WI’s Dane Country Regional Airport (MSN) can now enjoy free Wi-Fi courtesy of Nordic.


    The SMART project at Boston Children’s Hospital, which has been pretty quiet since its big “EMRs should work like smartphone apps” announcement four or so years ago, names a 14-member advisory board to promote its mission.

    inga_small I paid a visit to my neighborhood ER over the weekend. Despite being the patient, I couldn’t help but check out their use of IT systems. It’s a boutique ER attached to a surgery center about two miles from my house. I was the only patient at the time (good to know that all my neighbors had better things to do on a Saturday night.) In terms of IT, what surprised me the most was the lack of it, at least at the point of care. They must have some sort of EMR because they printed out all my information from a visit last year, but everyone who treated me used pen and paper to note my vitals and whatnot. At discharge they handed me a generic patient education sheet with aftercare instructions, but no details on what meds they gave me (I recall one was a narcotic) and no medication information sheet warning me about possible side effects. They advised me to follow up with my regular doctor, but I’m now realizing that in my narcotic-induced haze I didn’t ask anything about the results of the tests from my blood draw. I’m sure if I had gone to the ER at the big chain hospital another 10 minutes away I would have left with more complete information, but I chose (and probably would again) the more convenient ER that otherwise provided good care. For all the great stories we constantly share about the amazing strides in automating healthcare, I’m sure there are just as many anecdotes that serve as a reminder that we are not “there” yet.

    Sponsor Updates


    • Talksoft Corporation makes its appointment reminder app Talksoft Connect available for Android devices.
    • Columbus CEO magazine profiles CoverMyMeds in an article highlighting characteristics of top workplaces.
    • The AHA exclusively endorses MEDHOST PatientFlow HD patient flow management solution.
    • LifeIMAGE celebrates the growth of its network, which connects 533 hospitals and has exchanged 1.1 billion images over the last five years. 
    • Health Catalyst releases a free eBook that explores common approaches to data warehousing in healthcare.
    • AdvancedMD introduces the 1.5 version of its iPad app.
    • A NueMD ICD-10 survey conducted prior to the official delay shows that the majority healthcare professionals participating wanted the ICD-10 transition to be pushed back or canceled.
    • The Boston Business Journal ranks Nuance number two on its list of  top publicly traded Massachusetts software companies based on its $5.2 billion market capitalization.
    • Kareo CMIO Tom Giannulli will discuss the role of technology in improving patient care at UBM Medica’s Practice Rx conference May 2-4 in Newport Beach, CA.
    • Madhavi Kasinadhuni, consultant for The Advisory Board, explains the importance of measuring care episodes and not just individual encounters when identifying missed revenues.


    Mr. H, Inga, Dr. Jayne, Dr. Gregg, Lt. Dan, Dr. Travis, Lorre.

    More news: HIStalk Practice, HIStalk Connect.


    News 3/28/14 | HIStalk

    Top News



    The House of Representatives approves, by an unusual voice vote, a hurriedly presented bill that would delay the mandatory implementation of ICD-10 until at least October 1, 2015. The bill, presented Wednesday and approved Thursday, primarily addresses a Sustainable Growth Rate fix that would prevent the 24 percent reduction in physician Medicare payments that will otherwise occur on April 1. The ICD-10 date change was contained in a single sentence in the bill, which will become law if it’s approved by the Senate on Monday and then signed by the President. HHS has been insisting the deadline wouldn’t change after two previous delays, providers and vendors should have been ready given the generous lead time and remaining six months, and most organizations agreed that it was time to rip the Band-Aid off and just do it. Now a delay gets snuck into an unrelated bill and pushed to approval in less than 24 hours, most likely by politicians who didn’t have a clue about what they were voting for. The bill proves how ineffective Congress can be – they can’t figure out how pay for fixing SGR, so they delay its implementation, and despite HHS claims that ICD-10 is vital, it’s easier to keep delaying it than to reach an actual decision about its merit.


    Reader Comments

    3-27-2014 11-22-52 AM

    From The Reverend: “Re: another MU question. Thanks for posting question about the exemption letter. I’m also confused by the statement at the top of the exemption form that, ‘If you successfully met Meaningful Use in 2013, you will be excluded from the payment adjustment and do not need to submit a Hardship Exception Application for Payment Year 2015.’ I betcha this is a brilliant tactic to bring costs for the program under control. Providers current with MU will see an opening to ignore this year’s reporting period since the one percent penalty is off the table and ultimately fewer providers will get that final year payment.” I’m not sure what CMS’s intentions were with its handling of the exemption process, but I bet plenty of providers will take advantage of the reprieve.From Seymour Bush:

    “Re: Atlantic article series on EHRs. This gentleman’s comments are a fun counter to industry hype.” According to Nebraska-based family practice doc Creed Wait, MD:

    From Dim-Sum: “Re: DoD EHR. DoD looked at Judith’s big Kaiser win, calculated additional funds for development of a down range medicinal solution, and added a chunk for COTS vendors to certify their teams for Tier 1,2 & 3 support. That figure, for all practical purposes, is $5.5 billion USD. The SI prime wants 40 percent of the pie. COTS EHR vendors will want $1.8 billion USD . Does anyone see the math does not add up? To add to the confusion and muffled numbers is the fact that a CMMI 3 firm will come in and state that COTS can’t create or engineer a down range solution, so they will want $500M – are we seeing a trend here? COTS EHR vendors cannot fathom Agile Scrum, let alone CMMI 3 mediocre results, Everyone forgets that software vendors in the US usually charge 16-20 percent of original software list for ongoing annual support — those numbers are included, so the hopes and dreams of the average EHR vendor is shattered. They will have to come down by $0.5 billion, round down their fee so they can recoup recurring revenue of 20 percent ($200 million a year) of the leftover amount to secure a more realistic number of $800 million. Your SI buddies want COTS vendors to be realistic, stop your silly dreams – you never heard of SPAWAR (Latin meaning “Beltway ONLY.”) SIs deserve the cash because they have no idea how to develop competitive software, so they want your knowledge on the cheap, they are program managers, they are the conduit in to the psyche of the DoD. The DoD does not value software, they value stability and sustainability and salute predictability. That is why it is so hard for COTS vendors to believe that the DoD blew $10+ billion USD for the monstrosity they have today and are hoping COTS EHR vendors can save the day.”

    From Bill O’Sayle: “Re: FDA recalling McKesson’s anesthesia software. Both Cerner and Epic (for example) now have products to consume medical device data straight into their EMRs (i.e. Cerner iBus). Do you think this means then that EMRs with such capability are now at risk of such a recall? I can’t see Cerner putting their PowerChart install base at risk of a recall just so they (Cerner) can claim medical device integration. But if this is the logic of the FDA, then that seems to be the case, no?” The lab software model is that the instrument interface requires FDA’s approval, but the system that uses its information doesn’t (except for blood banking systems). I’m speculating, without knowing the details, that McKesson’s anesthesia product may have medical device integration built in, which puts the whole product within FDA’s purview. But given my “without knowing the details” disclaimer, I’d be interested to hear from someone who knows more than I.


    From HIMSS EHR Association: “Re: EHR Developer Code of Conduct. A correction to Mr. H’s thoughts on the McKesson/FDA matter. The EHRA  strongly recommends that all vendors developing EHR products, regardless of membership in the EHRA, adopt the Code of Conduct. However, it is not a condition of membership in the EHRA. The 17 vendors that  adopted the Code of Conduct as of February were recognized at HIMSS14. Since then, three additional vendors have adopted the Code. The EHRA is hosting a webcast on Friday, March 28 to educate more vendors on the elements included in the EHR Developer Code of Conduct and the benefits of adoption.”

    HIStalk Announcements and Requests

    inga_small Highlights from HIStalk Practice this week include: Dr. Gregg asks if being OK is OK and notes that the hard part isn’t achieving perfection but learning to be OK with OK. CMS warns EPs of possible system delays as providers submit MU attestation data by the March 31 deadline. The American Academy of Ophthalmology launches IRIS Registry, a centralized data repository that aggregates outpatient clinical data from EHRs. Epic, eClinicalWorks, and Allscripts claim the biggest shares of the ambulatory EHR market. Naval Branch Health Clinic Albany (FL) offers secure messaging services through RelayHealth. AHIMA warns that the use of copy and paste functionality in EHRs should be permitted only in the presence of strong technical and admin controls. While checking out these stories, why not sign up for the spam-free email updates so you won’t miss something important? Thanks for reading.

    This week on HIStalk Connect: Six senators send a letter to the FDA seeking clarification over medical app regulation. Beth Israel Deaconess Medical Center will expand the use of Google Glass by ED clinicians after finishing a successful three-month trial. Reflexion Health raises $7.5 million to expand development of a Microsoft Kinect-based platform designed to support physical therapists and their patients.

    I had some site problems over the weekend through Wednesday, which caused some downtime and the temporary disappearance of some posts and comments. Hopefully it’s all fixed now. Geek details: the webhost monitors web traffic and noticed IP traffic containing HIStalk’s server password, leading them to discover a root trojan that would have allowed its creator to take control of the server. That required building a new virtual server and migrating all the settings and large MySQL databases over to an environment containing fresh installs of PHP and Litespeed, which often brings up odd permissions and database problems. It’s been quite a pain – I watched the site and the open support ticket for 15 hours on Saturday alone and slept only a couple of hours, but problems delayed the actual migration until Tuesday evening.

    Upcoming Webinars

    April 2 (Wednesday) 1:00 p.m. ET. A Landmark 12-Point Review of Population Health Management Companies. Sponsored by Health Catalyst. Presenter: Dale Sanders, SVP, Health Catalyst. Learn the 12 criteria that a health system should use to evaluate population health vendors and to plot its internal strategy, then see the results of grading seven top PHM vendors against these criteria. No single vendor can meet all PHM needs. The most important of the 12 criteria over the next three years will be precise patient registries, patient-provider attribution, and precise numerators in patient registries.

    April 16 (Wednesday) 11:00 a.m. ET. Panel Discussion: Documents, EMRs, and Healthcare Processes. Sponsored by Levi, Ray & Shoup. Presenters: Charles Harris, senior technical lead, Duke University Health System; Ron Peel, technical advisor, LRS; and John Howerter, SVP of enterprise output management, LRS. IT department in hospitals implementing EMRs often overlook the role of document-driven workflows. Prescriptions, specimen labels, and discharge orders, and other critical documents must be reliably delivered with minimal impact on IT and clinical staff. This panel discussion will discuss the evolving use of documents in the “paperless/less-paper” environment.

    Acquisitions, Funding, Business, and Stock


    AirStrip acquires the assets of wireless fetal/maternal monitoring provider Sense4Baby and licenses the technology from the Gary and Mary West Health Institute.


    3-27-2014 10-15-05 AM

    Southern Illinois Healthcare selects CPM CarePoints, ExitCare, Mosby’s Nursing Consult, and Mosby’s Skills from Elsevier.

    Gracepoint Management (FL) will implement the Plexus Revenue Cycle Management service from Netsmart across its network of 48 behavioral health and drug and alcohol treatment centers.


    3-27-2014 12-42-12 PM

    TeleTracking Technologies hires Susan Whitehurst (Joint Commission Resources) as managing director of consulting services.


    Innovative Consulting Group names David Kissinger (Leidos Health) regional VP.


    Wellspring hires Matthew Joyce (Stout Risius Ross) as SVP of sales.

    Announcements and Implementations

    3-27-2014 8-34-30 AM

    Bradley Healthcare and Rehabilitation Center (TN) begins transitioning to PointClickCare EMR.


    Henry Ford Health System (MI) joins the Michigan Health Connect HIE.

    Government and Politics

    3-27-2014 1-49-32 PM

    The HHS OIG finds that a federal database for tracking Medicaid fraud isn’t working as intended, with 17 states and the District of Columbia failing to provide information on providers banned from billing Medicaid. The database also contains missing National Provider ID numbers and  names of “terminated” providers who are actually dead.


    Medicity earns a patent for its technology for connecting referral networks and another for its technology to centralize communications between providers and patients using cloud-based mobile technology.



    Continua Health Alliance announces availability of its 2014 Design Guidelines.

    The eHealth Initiative launches its 2020 Roadmap to guide the transformation of the nation’s healthcare system by 2020. The roadmap will focus on recommendations tied to Meaningful Use, system interoperability, care delivery transformation, and a balance of innovation and privacy.


    Online second opinion service Best Doctors launches the Medting medical exchange.

    Weird News Andy calls this story “dueling paramedics.” A woman being transported by ambulance for possible stroke gets out of the ambulance after the two paramedics started arguing bitterly about a personal issue. WNA also observes the skyrocketing healthcare salaries in Cuba, where huge percentage boosts will give nurses an income of $25 per month, while physician specialists will earn $67 per month, up from $26.

    Sponsor Updates

    • HealthMEDX hosts its user group meeting next week in Branson, MO.
    • CommVault publishes a white paper highlighting findings of a nationwide survey of healthcare IT managers, which suggest that healthcare data from a variety of sources could overwhelm the healthcare delivery system.
    • HCS announces that all of its Interactant modules meet ICD-10 standards.
    • Craneware hosts a series of one-day user group meetings in advance of its October Revenue Integrity Summit in Las Vegas.
    • PDS provides details of its 2014 Tech Conference October 22-23 in Madison, WI.
    • Nordic Consulting CEO Mark Bakken will deliver the keynote address at Madison’s startup incubator Gener8tor’s winter premiere night on April 3.
    • Wolters Kluwer Health enhances its UpToDate App for the Android mobile platform.
    • Kareo CEO Dan Rodrigues discusses his company and the power of cloud computing for small- to medium-sized practices.


    EPtalk by Dr. Jayne

    Everyone at the hospital is buzzing about the possibility that ICD-10 will be delayed as part of the legislation addressing the Medicare physician payment cut. Both CHIME and AHIMA have come out against the ICD-10 provision, stating that delaying it would negatively impact innovation and health care spending.

    Athenahealth’s VP of government affairs, Dan Haley, quickly blogged about it in response. His main assertion is that a delay would only reward vendors who didn’t work hard enough to meet deadlines which have been published well in advance. His secondary point is that for the legislature to delay ICD-10 after the head of CMS has said multiple times that there will be no further delays is akin to a child receiving dessert after his parent had previously told him no.

    As much as I’d hate to see my colleagues and their employers suffer when their vendors are not ready, it may take something this dramatic to really thin out the vendor herd. We’ve known this deadline was coming for a very long time and for vendors to still be unable to meet it is inexcusable. We can blame it on MU and the fact that we have a perfect storm of governmental requirements massing to hit us all at once. We can blame it on all kinds of things but the bottom line is that many vendors have delivered despite all those factors.

    I don’t have a crystal ball to see how this is going to morph as it works its way through Congress, but it just goes to show that there’s never a dull moment in health IT. Many of my colleagues are already using it as an excuse to stop working on ICD-10 even though the legislation hasn’t been signed. In the words of Julia Roberts as Vivian Ward: “Big mistake. Big. Huge.”

    Speaking of mistakes, several readers have written about the issues mentioned in Monday’s Curbside Consult. One of the problems I encountered was an issue with having multiple aliases in a hospital’s patient portal. A reader pointed out that issues like this are not only patient safety issues, but can also play into national safety:

    I’m sure you’ve seen the articles about the so-called “Boston Bomber” entering the US undetected because he spelled his name differently than what was on the official watch list (Tsarnayev v. Tsarnaev). Seriously? The CIA was confounded by the unexpected insertion of the letter “y” into a person’s name … a person on a monitored watch list?  Seems incredible. If the CIA can’t figure out how to address probable name variances, then I’m not so surprised that your large academic medical center can’t figure out how to fix an alias name in its EMPI.

    Other readers sent their own stories of IT systems run amok not only in healthcare, but in other industries as well. The pace of change is so great that little things like accuracy and completeness can’t seem to keep up. As long as the majority of people think technology is the solution to everything, I don’t see things slowing down.


    I haven’t mentioned shoes or wine in a while, so I was excited to find this piece about a way to remove the cork from a wine bottle using only a man’s dress shoe.  The article contains an engineering explanation of the fluid dynamics responsible for it working. Unfortunately ladies’ heels don’t work well due to the angle of the sole, so Inga and I are out of luck. If you’re looking for a few good laughs, however, make sure you check out the comments section.


    Mr. H, Inga, Dr. Jayne, Dr. Gregg, Lt. Dan, Dr. Travis, Lorre.

    More news: HIStalk Practice, HIStalk Connect


    Ambulance and EMS Transport Medical Coding: Cheat Sheet and Tips

    ambulance-coding-expertsEmergency situations call for unique medical coding of non-physician provider services

    Ambulance codes and guidelines are uniquely applicable to non-physician providers. To make coding these services even more of a challenge, procedure codes relevant to emergency medical service (EMS) providers aren’t found in the CPT® codebook. Instead, coding guidelines for ambulance and EMS transport codes come primarily from Medicare transmittals and MedLearn updates.

    Payers generally cover ambulance services, including fixed and rotary wing services, for patients whose medical condition is such that air transport is medically necessary. To assure transport is medically necessary, you must consider both the patient’s condition and the method of transportation. This can be a challenging process, which depends on the documentation paramedics and emergency medical technicians (EMTs) provide in the field.

    Differentiate Emergency vs. Non-emergency Response

    To prevent coding errors, use extreme care when differentiating emergency from non-emergency transports. This often requires additional education for ambulance providers to assure their documentation of a patient’s conditions accurately describes when an emergency condition existed, or when an emergency transport was required.

    CMS defines an emergency response as, “responding immediately at the BLS or ALS1 level of service to a 911 call or the equivalent.” An immediate response is defined as a response by the ambulance supplier that begins as quickly as possible to the call. Emergency response is based on internal protocols, which consider the information received during the call. The call does not have to come through a 911 system.

    All scheduled transports are considered non-emergency, and include routine transports to nursing homes, patient homes, and end-stage renal disease (ESRD) facilities.

    Break Down Ambulance Services Categories

    In the Ground Ambulance Services section of the ambulance fee schedule, there are seven categories of ground ambulance services (“ground” refers to both land and water transportation) and two categories of air ambulance services. The level of service is based on the patient’s condition, not the vehicle used. This is a challenge for many coders.

    In addition to the HCPCS Level II procedure codes and standard set of modifiers (see Chart A), a unique set of modifiers (see Chart B) are required to identify the origin and destination, which are affixed to the procedure code. Mileage must also be calculated, which presents additional challenges if this information is not clearly documented (ambulance coders are all too familiar with programs that estimate mileage between pick-up and drop-off points to assure accuracy for mileage calculations).

    Chart A: Common modifiers for ambulance services


    Chart B: Specialty modifiers for reporting ambulance services (including origin and destination codes and their descriptions)



    Ground Ambulance Services

    A0425 Ground mileage, per statute mile requires documentation and/or calculation of mileage between sites.

    A0426 Ambulance service, advanced life support, nonemergency transport, level 1 (ALS1) includes transportation by ground ambulance and medically necessary supplies and services. The response personnel are required to document an ALS assessment, or to provide at least one ALS intervention.

    Advanced life support assessment is defined as:
    1. Assessment performed by an ALS crew as part of an emergency response that was necessary; or
    2. The patient’s reported condition at the time of dispatch was such that only an ALS crew was qualified to perform the assessment.  An ALS intervention includes procedures that are beyond the scope of an EMT-basic. Personnel qualified for ALS are trained EMT-intermediates or paramedics.

    Often, the ALS assessment does not indicate that the patient required a level of service consistent with ALS, but that is only determined after the assessment is performed. Documentation is critically important to identify signs and symptoms that required the assessment and the results of the assessment, including the condition of the patient prior to and during transport.

    • A0427 Ambulance service, advanced life support, emergency transport, level 1 (ALS1 – emergency): The provision of ALS1 services as an emergency response applies. For ALS1, ALS2, and specialty care transport (SCT), the emergency condition is assumed, but documentation is critical to support these services.
    • A0428 Ambulance service, basic life support, nonemergency transport (BLS) defines transportation by ground ambulance vehicle, with medically necessary supplies and services, as well as BLS services. The ambulance must be staffed by a qualified EMT-basic consistent with state rules and regulations, which may vary from state to state. Coding for these services requires an understanding of state regulations and the ambulance provider’s assurance that providers meet the criteria for each level of transport. For example, only in some states is an EMT-basic permitted to operate limited equipment on board the vehicle, assist more qualified personnel in performing assessments and interventions, and establish a peripheral intravenous (IV) line.
    • A0429 Ambulance service, basic life support, emergency transport (BLS emergency) describes the provision of BLS services, but for response to an emergency. Emergency response is defined as immediate response to a 911 (or similar) call. A call is determined to be an emergency based on the information available to the dispatcher, who is expected to follow existing protocols. Be familiar with these protocols for ambulance providers to assure coding is consistent with dispatch and emergency criteria.
    • A0433 Advanced life support, level 2 (ALS2) requires three or more different administrations of medications by IV push/bolus or by continuous infusion, excluding crystalloid, hypotonic, isotonic, and hypertonic solutions (dextrose, normal saline, Ringer’s lactate), or medically necessary ground transportation, supplies and services, and the provision of at least one of the following ALS procedures:

    • Manual defibrillation/cardioversion
    • Endotracheal intubation including the monitoring and maintenance of an endotracheal tube that was inserted prior to the transport, which also qualifies as an ALS2 procedure.
    • Central venous line
    • Cardiac pacing
    • Chest decompression
    • Surgical airway
    • Intraosseous line

    • A0434 Specialty care transport (SCT) is an interfacility transportation of a critically injured or ill beneficiary by a ground ambulance, including the provision of medically necessary supplies and services, at a level of service beyond the scope of the EMT paramedic. SCT is required when a beneficiary’s condition requires ongoing care that must be provided by one or more health professionals in an appropriate specialty area (e.g., emergency, critical care nursing, emergency medicine, respiratory care, cardiovascular care, or a paramedic with additional training).

    Be cautious when using this code for chronic ventilator-dependent patients whose transport would not qualify for SCT unless their condition is considered acute or the patient has developed emergency signs and symptoms for other conditions.

    Air Ambulance Services

    The two categories of air ambulance services are fixed wing (airplane) and rotary wing (helicopter). The air ambulance mileage rate is calculated per actual loaded (patient onboard) miles flown, and is expressed in statute miles (not nautical miles).

    • A0430 Ambulance service, conventional air services, transport, one way (fixed wing). Fixed wing air ambulance (FW) is used when the patient’s medical condition requires immediate and rapid transportation that can’t be provided by ground ambulance either because the point of pick-up is inaccessible, the nearest hospital with appropriate facilities is far away, or the road is impassable due to heavy traffic or other obstacles. Mileage is identified with A0435 Fixed wing air mileage, per statute mile.
    • A0431 Ambulance service, conventional air services, transport, one way (rotary wing). Rotary wing air ambulance (RW) service is used when a patient requires rapid transportation due to medical condition, and there are transportation challenges applicable to fixed wing transportation (traffic, distance, etc.). Report mileage using A0436 Rotary wing air mileage, per statute mile.
    • A0888 Noncovered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility). Report this code when the reason for the ambulance trip is not covered by Medicare, and you do not expect Medicare payment.

    Non-covered Services

    Effective Jan. 1, 2012, CMS allows ambulance providers to bill procedure codes for non-covered ambulance services. This does not include supplies associated with a covered ambulance transport. Per CMS Internet Only Manual (publication 100-04, chapter 15, section 30.1), those supplies are included in the base rate.
    If the supplies are associated with a non-covered service, they are billable to Medicare with modifier GY Item or service statutorily excluded, does not meet the definition of any Medicare benefit or for non-Medicare insurers, is not a contract benefit. Procedure codes A0021-A0424 and A0998 Ambulance response and treatment, no transport are billable procedure codes and must include modifier GY; however, they are not payable by Medicare.
    Effective for claims with dates of service on and after Oct. 1, 2013, payment for non-emergency BLS transports of individuals with ESRD to and from renal dialysis treatment facilities will be reduced by 10 percent. The reduced rate will be calculated and applied to HCPCS Level II code A0428 when billed with destination modifier code “G” or “J,” and the associated mileage (code A0425). A claim adjustment reason code of 45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement and group code CO Contractual obligation will be on the remittance advice notice.

    Make sure your coding and billing staffs are aware of these changes. The 10 percent reduction applies to beneficiaries with ESRD who are receiving a non-emergency BLS transport to and from renal dialysis treatment.

    A Medicare beneficiary receiving maintenance dialysis on an outpatient basis does not ordinarily require ambulance transportation for dialysis treatment, whether the facility is independent or part of a hospital. Ambulance services furnished to a maintenance dialysis patient are not payable unless documentation submitted with the claim shows that the patient’s condition requires ambulance services and the facility meets the destination requirements. Medical necessity must be documented for claims for non-routine round trip ambulance services to outpatient dialysis facilities. Medicare has discretion to override or reverse the reduction on appeal, if they deem it appropriate, based on supporting documentation.