Billing, Coding, and Reimbursement

Transport teams can establish various types of relationships with institutions in the region they serve. One approach is interfacility agreements, which the institutions enter into with the understanding that the patient's transfer to the tertiary institution will be streamlined, as long as there are no insurance or other operational restraints.

A second type of arrangement can be made whereby a tertiary transport team may contract with other institutions that have smaller units and may not have the volume necessary to maintain the skills or to make a transport program cost-effective. These contractual agreements may be made on a fixed dollar amount per transport or prorated on an hourly rate plus replacement of supplies.

When establishing a fixed rate per transport or an hourly rate, actual costs, depreciation of equipment, goodwill, and missed opportunities need to be accounted for and factored into the respective charges. The tertiary institution must be thorough and well versed on the appropriate billing codes, charges, and reimbursement opportunities for critical care transport. Depending on the transport team staff, there may be different potential charges that can be applied to each transport. If there is a supervising physician overseeing medical control or present on the transport, there are specific Current Procedural Terminology (CPT) transport codes that can be applied; they are noted here and summarized in Table 15.2:

• 99485: Supervision by a control physician of an interfacility transport care of the critically ill or critically injured pediatric patient, 24 months of age or younger, includes 2-way communication with transport team before transport, at the referring facility and during the transport, including data interpretation and report; first 30 minutes.

• 99486: Same as 99485 but used for each additional 30 minutes; list separately in addition to code for primary procedure.

• 99466: Physician constant attention of the critically ill or injured patient, younger than 24 months of age, during an interfacility transport (the first 30-74 minutes of direct contact [face-to-face] with the transport patient). Care of less than 30 minutes should not be reported with this code (instead use appropriate evaluation and management code).

• 99467: Physician constant attention of the critically ill or injured patient, younger than 24 months of age, during an interfacility transport (for each additional 30 minutes of direct care with the transport patient; use in conjunction with 99466)

• 99291: The first 30 to 74 minutes of critical care services provided by a physician to a patient older than 24 months. Care of less than 30 minutes should not be reported with this code (instead use appropriate evaluation and management code).

• 99292: Physician-provided critical care services for each 30-minute period beyond 74 minutes to a patient older than 24 months (for each additional 30 minutes of direct care with the transport patient; use in conjunction with 99291)

Table 15.2: CPT Codes for Transport Physician Involvement

Code

Service Provided

Time

Requirements to Bill for Service*

99485

Physician supervision of transport team (patient the hospital may bill a flat hourly fee for the nursing personnel as well as for respiratory care personnel. In addition, supplies and equipment used during the transport may be billed according to the hospital’s respective charges, individually or in prebundled sets.

The Center for Medicare and Medicaid Services (CMS) provides payment for qualified emergency care at this writing. However, new payment plans are likely to have an effect on revenue generated by transported patients that will likely change the “value paradigm” under which most transport teams contribute to sponsoring institutions.

Some time ago, the concept of downstream revenue provided an important justification for the institutional costs born by the sponsoring institution. As DRG-based payments become adopted by many third-party payers, additional downstream revenue is realized less frequently.

“Given that CMS policies have a transformative effect on the health care system, it is important to develop the tools necessary to create rational approaches to lessen health care cost growth and to identify and encourage care delivery patterns that are not only high quality, but also cost-efficient. To help address these concerns, CMS, during the current Administration and with direction from Congress (eg, through enactment of provisions in the Medicare Modernization Act, Deficit Reduction Act, and other provisions) has begun to transform itself from a passive payer of services into an active purchaser of higher-quality, affordable care. Further future efforts to link payment to the quality and efficiency of care provided would shift Medicare away from paying providers based solely on their volume of services. The catalyst for such change would be grounded in the creation of appropriate incentives encouraging all health care providers to deliver higher quality care at lower total costs. This is the underlying principle of valuebased purchasing (VBP). The cornerstones of VBP are the development of a broad array of consensus-based clinical measures, effective resource utilization measurement, and the payment system redesign mentioned previously. The overarching goal would be to foster joint clinical and financial accountability in the health care system.”¹

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Source: AAP. Guidelines for Air and Ground Transport of Neonatal and Pediatric Patients. 4th edition. — American Academy of Pediatrics,2015. — 488 p.. 2015

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