HomeMy WebLinkAboutDocumentation_Regular_Tab 7-11_3/8/2001 ( 1
Memorandum
To: Michael R. Couzzo, Jr., Village Manager
From: Joann Manganiello, Assistant Village Manager/Village Clerk
Date: March 2, 2001
Subject: Bid Award for Demolition of Village of Tequesta Buildings and
Appurtenances; Resolution No. 31-00/01;Agenda Item
Attached is the contract proposal for the demolition of Village of Tequesta buildings and
appurtenances, located at 357 Tequesta Drive, which includes an asbestos survey and temporary
fencing, submitted by Thomas B. Cushing Demolition of West Palm Beach,Florida, in the amount
of$54,786. Cushing Demolition has been awarded the annual Palm Beach County Demolition
Contract (Contract No. R99740-D) and, therefore, the Village was able to piggyback the
County's Contract pricing resulting in a very favorable proposal.
Cushing Demolition is a well-known, reputable demolition company and has completed many
demolition projects throughout Palm Beach County including the demolition of the Lighthouse
Plaza.in Tequesta(current site of Tequesta Oaks) and, most recently, the demolition of Phase I of
Tequesta Plaza. As you can attest, Cushing Demolition did an exceptional job in demolishing the
Tequesta Plaza retail building and left the site in excellent condition. ,
Additionally, I am looking into the possibility of salvaging the marble facade on the portico of the
Village 1;Iall building, perhaps for use in the new Municipal Center.
„
It is recommended that the Village Council approve the.Contract Proposal for the Demolition of
Village, Tequesta Buildings and Appurtenances, etc., to Thomas B. Cushing Demolition of
West Palm Beach, Florida. Please place this item on the March 8, 2001, Village Council Meeting
agenda for consideration by the Village Council. Thank you.
Enclosures
amipro/files/asstmgr/priority/votdemo
1
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RESOLUTION NO. 31-00/01
A RESOLUTION OF THE VILLAGE COUNCIL OF
THE VILLAGE OF TEQUESTA, PALM BEACH
COUNTY, FLORIDA, APPROVING THE CONTRACT
PROPOSAL FOR THE DEMOLITION OF VILLAGE
OF TEQUESTA BUILDINGS AND
APPURTENANCES, LOCATED AT 357 TEQUESTA
DRIVE, INCLUDING ASBESTOS SURVEY AND
TEMPORARY FENCING, TO THOMAS B. CUSHING
DEMOLITION OF WEST PALM BEACH, FLORIDA,
PIGGYBACKING PALM BEACH COUNTY
DEMOLITION CONTRACT NO. R99740-D, IN
THE AMOUNT OF $54,786, WITH FUNDS BEING
APPROPRIATED AND TRANSFERRED FROM THE
$5, 000, 000 LINE OF CREDIT (BANK OF
AMERICA) , AND AUTHORIZING THE VILLAGE
MANAGER TO EXECUTE THE APPLICABLE
CONTRACT ON BEHALF OF THE VILLAGE.
NOW, THEREFORE, BE IT RESOLVED BY THE VILLAGE COUNCIL
OF THE VILLAGE OF TEQUESTA, PALM BEACH COUNTY,
FLORIDA, AS FOLLOWS:
Section 1. The Contract Proposal For the Demolition
of Village of Tequesta Buildings and Appurtenances,
Located at 357 Tequesta Drive, including asbestos
survey and temporary fencing by Thomas B. Cushing
Demolition of West Palm Beach, Florida, Attached
Hereto as Exhibit "A" and incorporated by reference as
a part of this Resolution is hereby approved and the
Village Manager of the Village of Tequesta is
authorized to execute the applicable contract on
behalf of the Village of Tequesta.
THE FOREGOING RESOLUTION WAS OFFERED by Councilmember
, who moved its adoption. The motion was
seconded by Councilmember , and upon
being put to a vote, the vote was as follows :
1
FOR ADOPTION AGAINST ADOPTION
The Mayor thereupon declared the Resolution duly
passed and adopted this 8th day of March, A.D. , 2001 .
MAYOR OF TEQUESTA
Joseph N. Capretta
ATTEST:
Joann Manganiello
Village Clerk
Word\Resolutions\Demolition of Village Hall
I _ EXHIBIT "A'.'
THOMAS B. CUSHING DEMOLITION
8210 8th Road North Westoalm Beach, Florida 33411 •
Phone i561)793-6173 -
FAX (061)790-2297
THE VILLAGE OF TEQUESTA 575-6200 ,1AN�:,26,2001
sYwrui - J01 NOIMf . ..r.r�.... . ��.
357 TEQUESTA DRIVE " .
OI Y.�TATL ANO tl/C00t -- JN\IOCII,IOM
Il'EQUESTA.FL.33469 357 TEQUESTA DRIVE
AiICNITLCT WI Or MANE •••- ••< •• rOlOrFAX 57 5-6245 �
.'.�
THE FOLLOWING 1S A PRICE FOR DEMOLITION WORK TO BEI'ERRORMEI) AT 357 TEQUESTA DRIVE TEQUESTA.
THE WORK INCLUDES THE :TOTAL. DEMOLITION OF THE 70.1.J.(�I�t STATIQN,FIRL STATION ANA 4AYS,
(XIMMUNITY DEV.OFFJCg.YORTICO.ASPHALT pAgunO 1ATP_ONCR1s'TE DRIVEWAY.ALL SLABS Op FOOTERS.
ONLY TflLSE•TREES AN BJJSI ES j ECESSARYHE C:OMPI.ETION OF THF. DEMC)I ITION WILL I. REMUV? •
NO FILL DIRT WILL BE REMOVED PROM THE SITE AND NO FILL DIRT WILL BE HAULED 7N TO PILL ANY DE—
PRESSION LEFT AS A. RESULT OF THE DEMOLITION. WE WILL NOT BE RESPONSIBLE FOR THE REMOVAL OF
ANY TANKS (EXCEPT SEPTIC) TIRES OR HAZARDOUS MAZ4$, ALL PREON MUST BE EVACUATED FROM
ALL AIR CONDITIONING UNITS PRIOR TO 1) OLI77:CNN: WE WILL NOT 1W R1'SPONsIRLE FOR THE REMOVAL
OF ANY ASBESTOS W1 SILL INCLUDE A P 1(`t? 'I711? ASBFR9`[)S •ifRVlr. Ad * _ -.
ALL UTILITY DISCONNECTIONS.CAPI'INOS AND RELOCATION4V ARR THE OWNER'S RESPONSIBILITY. w „•TM�
THE DEMOLITION AREA WILL B LEFT IN Alma' ARD CLEAN CON1T1TION AND ROACH QBAD,I„[JON
COMPLETION. - .. ....�.�.,.._._..�.�
- ONE STORY CBS POLICE STATION/VILLAGE HALL 81.00 BJ, X $I_oO $15,390.00
ONE STORY CBS COMMUNITY DEV.131,DG. 34(00 S.F. X $1.90 - $500.00
ONE STORY CBS 3 DAY FIRE RESCUE BLDG. 2700 S.F. X $1 .90 $5130.00
ONE STORY MODULAR BLDG. AND TIN SHED 1300_0-(O
2025 S.F. OP CONCRETE SLAB THAT OLD WATER TANK PT:o r 2025 S.F. X $1 .90 $3 47..5.0
1215 S.F. OF CONCRETE AND, BLACKTOP DRIVEWAY 1215 R.F. X .50 $607.0.,
29340 S.F. OF ASPHALT PAVING _ 29340 S.F.X - .iO J 14.(70.Q()
1148 S.F. OF CONCRETE PORTIC[1 11.4H S.F.X $3 .90 $2101.20
FENCING ENTIRE SITE T ' 1'ORARY -,-• $7..000.00
SEPTIC PUMPS SN1) R1 1OVAL $200,00 PER ,S Y..11C:- -. __:. •
-
..._,...,...............„,
TOTAL AMOUNT FOR ABOVE. . ..$53,286.20 ,„,
ASBESTOS SURVEY $1500.00
LINTY DEMOLITION CONTRACT N0. R99740-D .
Memorandum
To: Michael R. Couzzo, Jr., Village Manager
From: Gary Preston, Director of Public Works & Recreation
Date: February 27, 2001
Subject: Village Council Agenda Item for March 8, 2001;
Consideration of Contract Award to Terracon Services, Inc.,
,in.the Amount of$76,490.00 for Streetlight Conduit Installation
and Landscape Improvements on Seabrook Road, Having a
FY 2000/2001 Budget Allocation of$138,000.00
•
Please find attached, the following support documents for Councilmembers' review for the
above referenced agenda item:
• A qualified bid tabulation sheet.
• A single project bid in the amount of $76,490.00 from Terracon Services, Inc., for
Seabrook Road Streetlight and Landscape Improvements.
♦ A letter dated January 25, 2001 from Village Engineer Mitchell D. Thomas, Vice President
recommending contract award to Terracon Services, Inc
♦ A letter dated January 8, 2001 from John C. Randolph, Esq., approving bid document for
legal form and sufficiency.
During the past two (2) budget years, the Village Council has allocated funding for this project
and these funds are in the undesignated fund balance. Should the Village Council approve this
contract, these funds would be transferred from the undesignated fund balance to the.Seabrook
Road South account.
Please place this item on the March 8, 2001 Village Council Meeting Agenda for
Councilmembers' consideration.
GP/mk
Attachments
Agendaltem.CouzzoTerraconServices 3.8.01
RESOLUTION NO. 32-00/01
A RESOLUTION OF THE VILLAGE COUNCIL OF THE
VILLAGE OF TEQUESTA, PALM BEACH COUNTY,
FLORIDA, AWARDING A CONTRACT TO TERRACON
SERVICES, INC. , OF JUPITER, FLORIDA, IN THE
AMOUNT OF $76, 490 . 00 FOR STREETLIGHT CONDUIT
INSTALLATION AND LANDSCAPE IMPROVEMENTS ON
SEABROOK ROAD, AUTHORIZING AN INTRA FUND
TRANSFER OF $138, 000, 00, TO FUND THIS PROJECT,
AND AUTHORIZING THE VILLAGE MANAGER TO EXECUTE
THE APPLICABLE CONTRACT ON BEHALF OF THE
VILLAGE.
NOW, THEREFORE, BE IT RESOLVED BY THE VILLAGE
COUNCIL OF THE VILLAGE OF TEQUESTA, PALM BEACH
COUNTY, FLORIDA, AS FOLLOWS:
Section 1. Consideration to award a contract to
Terracon Services, Inc. , of Jupiter, Florida, in
the amount of $76,490 . 00 for streetlight conduit
installation and landscape improvements on
Seabrook Road, authorizing a Intra Fund Transfer
of $138, 000, 00 attached hereto as Exhibit "A" and
incorporated by reference as a part of this
Resolution is hereby approved and the Village
Manager of the Village of Tequesta is authorized
to execute the same on behalf of the Village.
THE FOREGOING RESOLUTION WAS OFFERED by
Councilmember , who moved its
adoption. The motion was seconded by
Councilmember , and upon being
put to a vote, the vote was as follows :
FOR ADOPTION AGAINST ADOPTION
The Mayor thereupon declared the Resolution duly
passed and adopted this 8th day of March, A.D,
2001 .
MAYOR OF TEQUESTA
Joseph N. Capretta
ATTEST:
Joann Manganiello
Village Clerk
Word\
Resolution\TerraconServices
QUALIFIED BID
TABULATION SHEET
STREETLIGHTS, IRRIGATION AND LANDSCAPE
IMPROVEMENTS
SEABROOK ROAD
DAYS TO
BIDDER NAMES PROPOSAL COMPLETE
Aiello Landscape, Inc. $84,800 60
Terracon Services, Inc. $76,490 45
P
•
EXHIBIT "A"
SINGLE PROJECT BID •
SEABROOK ROAD STREETSCAPE IMPROVEMENTS
VILLAGE OF TEQTJESTA
BID QUOTATION OF: Name: Terracon Services , Inc.
Address: P .O. Box 2766, Jupiter, .Fl 33468
Telephone No. 5 6 1—7 4 3—112 9
to perform all work in accordance with the specifications and contract documents attached.hereto
for the:
Village of Tequesta
P.O.Box 3273
pp
Tequesta,FL 33469-0273
Gentlemen:
The undersigned Bidder has carefully'examined the plans, specifications, contract documents and
''" the site of the proposed work and is familiar with the nature and.extent of the work and any local
conditions that may in any manner affect the work to be done and the equipment and labor
required.
The undersigned agrees to do all work called for by said specifications and contract documents,in
the manner prescribed therein and to the standards of quality established by same at a cost to the
•— Village of Tequesta equal to the total amounts indicated below:
r►
BQ -4
•
•
ITEM DESCRIPTION ' QTY UNIT UNIT ESTIMATED
COST COST
1 ' East Palatka Holly 3 Ea. 450.00 1 ,3 5 0: 0 0
2 I Live Oaks 22 Ea..
800.00 17,600. 00
3 Cabbage Palms 33 Ea.
180.00 5 ,940 . 00
4 Sod 25,000 SF . 28 7,000 . 00
•
5 Irrigation System Installation --- LS ---
34,500.00
6 Install conduit for FPL street lights -- LS ---
perplan • 9,700.00
7 One Year Maintenance&Warranty --- LS • ---
(as described) 400.00
Note:
1 Incidentals such as staking trees,fertilizer,mulch, soil,etc.to be included in the price of
the related item. •
TOTAL BID QUOTATION AMOUNT LN WORDS AND N'UMBERS__$76,490 .00
Seventy-six thousand four hundred ninet,v---00 1100DOLLARS
$ 76 ,490.00
ALTERNATE BIDS .
ALTERNATE NO. 1 - Live Oak trees 18'x.11';4-1/2"cal.; 100 gal container in lieu of 16'x9';
4" cal.; 100 gal container (ADD)
ALTERNATE BID NO. 1 BID QUOTATION AMOUNT IN'WORDS AND NUMBERS$8 9, 6 9 0.00
Eighty-nine thousand six hundred ninety---00 /100DOLLARS
$ 89 ,690.00 •
Deduct $586..00 if permit fees for landscape are not. required for
Village of Te.questa.
i.o
•
.r.
r-
BQ-5
•
The undersigned also agrees as follows:
1. To perform additional services and provide necessary equipment, facilities,and
materials for work not covered by the above Bid Quotations, which may be
authorized by the Village and to accept as full compensation, therefore,such
prices as may be agreed upon in writing by the Village and the Contractor in
accordance with Item 15 of the General Conditions.
2. To commence work on or about April 2,2001 within 10 days after the date of
written Notice to Proceed,to substantially complete the entire Work within
(indicate No) 45 consecutive calendar clays after the date of written Notice
to Proceed, subject to such extensions of time allowed by the Conditions of the
Contract,and to achieve Final Completion of the Work by no later than 30 days
after the actual date of substantial completion.
MEM
Accompanying this proposal is a certified check or a BicdBond in the amount of$8 ,750. 00
(not less than five percent(5%)of the base bid),made payable to the Village of Tequesta,which
is to be forfeited as liquidated damages,if,in the event this proposal is accepted,the undersigned
shall fail to execute the contract and furnish satisfactory contract bond under the conditions and
within the time specified in the proposal;otherwise said certified or cashier's check or Bid Bond
is to be returned to the undersigned. •
• Dated this 22 day.of. January ,2001
.CONTRACTOR: Terracon Services , Inc:
ADDRESS: P.O. Box 2766
•
Jupiter, FL 33468 •
BY: �t`w,C J& Q -
(Signature' d Title)
•
•
•
BQ-6
• GEE&JENSON
Engineers•Architects•Planners,Inc.
r SINCE 1951
} One Harvard Circle
West Palm Beach,FL 33409
January 25, 2001 Telephone(561)515-6500
Executive Fax(561)515-6503
Fax(561)515-6502
Gary Preston Fax No. (561) 575-6245
'
Director of Department of Public Works
Village of Tequesta
P.O. Box 3273
Tequesta, FL 33469 •
Re: Country Club Drive Phase III and Seabrook Road Streetscape Projects
Dear Mr. Preston:
•
We have reviewed the bids received from interested bidders for the subject projects. Three
sealed bids were submitted by the 2:00 p.m. deadline. One additional bid was received by fax
rather than in a sealed envelope as required and, therefore, we recommend that it be rejected.
All three of the bidders submitted bids for the Seabrook Road project,however, only two bids
were received for Country Club Drive Phase III. One of the bidders chose to offer a 2.5%
reduction in the total bid amount if selected for both projects. The reduction amounts to
approximately$5,000.00.
As indicated on the attached bid tabulation, the low bid for both projects (individually and
combined) was submitted by Green Acres LIST Service, Inc., a landscape construction firm
located in Fort Lauderdale. Their bid is as follows:
A. Country Club Drive Phase III $120,533.00
B. Seabrook Road Streetscape $ 74,035.00
C. Country Club Drive Phase III and Seabrook Road Streetscape $189,443.00
The combined bid submitted for both projects is S 189,443.00.
Several matters regarding this bid should be noted as follows:
1. Green Acres does not hold a Certified Landscape Contractors License as required by
the bidding documents. The firm also does not have a certified arborist or pesticide
applicator as required.
2. The time period indicated by Green Acres for completing both projects is 150 days or
5 months.
3. The bid cost breakdown indicates a total amount of$4,500.00 for the one-year
maintenance and warranty item for both projects. Green Acres advises that this figure
is in error and should have been doubled for a total of$9,000.00, however, the firm
will abide by the lower figure.
F:4\IDT\Ltr-GaryPreston-01-24-DI SeabrookStreetscapebids_mdt.doc
Engineering I ES 000293.1•Architecture I AA C000656•Landscape Architecture I LC CO00060•Land Surveying I LB 0002934•Interior Design M IB C001020
The only other bid received for the Country Club Drive project was submitted by Aiello
Landscape, Inc. at $126,092.00, it is $6,459.00 (about 5%)more than the Green Acres bid. The
firm holds a Certified Landscape Contractors License and has the services of a certified arborist
and pesticide specialist.
In addition to the bid of Green Acres, two bids were received for the Seabrook Road Project.
The lower of these bids was submitted by Terracon Services, Inc. and is $75,904.00. This bid is
$1,869.00 or 2.5%more than the low bid of Green Acres. The other bid, submitted by Aiello is
S10,765.00 or nearly 15% more than the low bid. Terracon holds a Certified Landscape
Contractors License and has the services of a certified arborist and pesticide specialist.
Analysis and Recommendation
• Unless the Village was to waive the requirement that bidders must hold a Certified Landscape
Contractors License, the bid submitted by Green Acres must be rejected. The requirement bas
been imposed by the Village on all recent landscape-related projects at time of bidding and is •
considered very desirable in assuring competent services. That view is shared by the designers
of the two projects in question.
It is, therefore, recommended that the Country Club Drive project be awarded to Aiello
Landscape, Inc. by acceptance of its bid $126,092.00. The projected construction timeframe is
indicated as 90 days.
It is further recommended that the Seabrook Road project be awarded to Terracon Services, Inc.
•
by acceptance.of its bid of$75,904.00. The projected construction timeframe is 45 days. This
bid is approximately 11% less than the Aiello bid for the project and offers a 25% reduction in
the construction timeframe indicated by Aiello.
Only one alternate bid was received for substituting larger oak trees for those specified in the
base bid. The cost of that alternate bid submitted by Terracon for the Seabrook Road project
added approximately S13,000.00 or 18% to the Seabrook Road project. No alternate bid was
submitted for Country Club Drive. Availability of quality trees at the larger size is limited and
the quality of those trees may be marginal. The additional cost does not appear justified and the
alternate is, therefore, not recommended. The recommendations are based on approval by the
Village attorney, that insurance and bonding requirements are met. As you know,both firms
have performed satisfactorily under previous contracts with the Village.
Very truly yours,
Mitchell D. Thomas
Vice President
Lc
21-004.01
a`; One Harvard Circle•West Palm Beach,FL 33409•Telephone(561)515-6500•Fax(561)515-6502
Engineering a EB 00029'.a•Architecture a AA COOOESE•Landscape Architecture I LC CcocodO•Land Surveying I LB C002934•Interior Design a 10 0001020
JONES
FOSTER ER Flagler Center Tower,Suite 1100 Mailing Address
JOHNSTON 505 South Flagler Drive Post Office Box 3475
UC
Q� STUBBS P ^ West Palm Beach,Florida 33401 West Palm Beach,Florida 33402-34
1Jl .ri. Telephone(561)659-3000 Facsimile(561)832-1454
4IPAttorneys and Counselors
John C.Randolph,Esq.
Direct Dial: (561)650-0458
E-mail:jandolph@jones-foster.com
January 8, 2001 VIA FAX: 575-6245
•
Mr. Gary Preston
Village of Tequesta
Public Works Department
Post Office Box 3273
Tequesta, Florida 33469-9273
RE: Village of Tequesta
Country Club Drive Phase III/Seabrook Road Improvements
Our File No. 13153.1
Dear Gary:
I have reviewed the documents you submitted to me under your letter of January 3,.2001,relating
to Country Club Drive Phase III/Seabrook Road Improvements and have approved same as to legal
form and sufficiency.
Sincerely,
•
JONES, F TER, JOHNSTON & STUBBS, P.A.
C. Randolph
JCR/ssm
Sr"\ C`E 1924
•
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Services, LearnX.com delivers online practice tests Qi t
11 and offers a comprehensive library of test preparation, the prehospital environment. Many EMS owners at+-ci,4.-
skill building and career guidance books-all designed '' managers are having trouble coming to terms wt€+ t,
to improve your test score. •
stocking this new drug with its related cost, while th`'wA
1IFor More Information Circle#65 On Reader Service Card . t
•
__ often considered the preferred method of heart rate acceleration
while attempting IV access or waiting for atropine to take effect.
i do Bradycardia unresponsive to fluid boluses or with profound
a hypotension may require further support with vasopressors.2
or Advance
inci m atodarone administration and is possibly due to the �Y � � `�
polysorbate 80 additive.Mild hypotension may respond to Emergency Respiratory Care
tiple fluid boluses (150-500 mL of normal saline) in the
eph- absence of overt heart failure,whereas profound hypo ten-
' 'hen sion may require further support with vasopressor agents
slow (e.g.,dopamine,norepinephnne,etc.).2 Rie P RO Re S p i rTe e h PRO'
' con- Persistent ventricular arrhythmias may necessitate initiation
cute of a postresuscitative infusion of an antiarrhythmic. A main-
ven- tenance infusion of amiodarone following a 300 mg bolus
j :ing, isn't usually required because blood levels remain elevated
tg is continued on p.73 rQ'
` r
j `• face an uncertain ALS relmbursept,ent future. •
•
} Although amiodarone is expensive;it may well repre-
sent an important turning..point in the evolution:of out-
of hospital care—,placing expensive, cutting-edge mea-
1
ications.into drug boxes that have changed little in the
- past two decades. hi•the context of cardiac,attest
patients, such.new interventions are sotely:nceded
because the survival rate of arrest patients has also is O S a iJ f e
•
changed little during the same period. The optimisticp
, view is that by placing prehospital ntedicine.in the loop u t O rTl a t 1 C
1 • of newly.evolving.interventions we d `j
may�,vSe�he Resuscitator
_ quality.of care we .bring to our patients-at an
increased,but necessary,cost. PATAWI
ce For years, EMS has enjoyed relative insulation from
the world of expensive patented-drugs.The reason:Most
drugs we've used are inexpensive,simple;fasy to manu-
_ _ ia of
p y facture, generic compounds. A re-filled syringe g .4 Price comparable to manual resuscitate
a 1:10,000 epinephrine costs about$3.In the early 1990s
we added adenosine (Adenocard) to our drug boxes. At • For breathing or non-breathing patients-
reral $30 fora 6 mg bottle, that seemed expensive back then,
; the but its impact of providing a-much safer and effective ® Consistent hands-free ventilation
treatment for SVTs than previous medications has been • Single patient & easy to u s e
,onse unquestionable..
h-up A decade later, enter amiodarone—at about $180 per • Pressure limited safety feature
Wier (300 mg)dose.A hefty price as prehospital drugs go;but 4 Anti-asphyxiation port
es of to fully appreciate the drug's price tag you need to con-
sider the components of modern drug development,mar- • Compatible with M R I and CT Scans
n.30 keting and the associated costs that drug companies incur.
• Constructed of lightweight plastic
pt is Factors that influence the costs of newly releaseddrugs • Meets ASTM requirements
cost • •Research and development costs;
i d the •Drug development in the laboratory;
oney •Legal and administrative costs to obtain patent(s); a
•Costs of federal FDA-Mandated studies; Call (800) 434-4034 to order or 1
rem '•Costs of clinical trials; visit our website at httpa1www,vortran.corY1
drug- •Advertising;
•Mailings to individual providers' For More Information Circle 466 On Reader Service Card
.Aik •Print advertising in medical journals ---`VOR:,- M dfi•'`' 3- . r n
' 'rechjttkf9 tife t ,
and •Detailingby regional drug representatives; a x
r 1 3941 J Street.Suite 354
with On-site displays at major medical meetings;
they •Miscellaneous educational materials(videotapes); Sacramento,CA 95819-3633
TEL: (800)434-4034
continued on p. 70 FAX: (916)454.0490
r ._ _ �.; fi } ;Y Amiodarone:The Cost of Doing Business continued from p.69 - '.
Y
•Profit margin;and
q _ •Need to maximize profits while drug is patent- .,'`
.. protected.
(?.(e) First approved for use in the United States in its oral
form in 1985, an 1V form of amiodarone was subse 1.
-
1 quern!),developed by Wyeth-Ayerst (at the FDA's .
* request) and released a decade later'in 1995. That
process,as well as the funding of ongoing drug studies,
j educational programs and marketing, has represented
an expenditure of "hundreds of millions of dollars,"
4 _ according to Philip de Vane,MD,vice president of clini-
i, s - cal affairs for Wyeth-Ayerst, Despite a need to recoup �"
_ zoos ••
these expenditures, Wyeth-Ayerst has pledged to
- _ - -- , dampen associated costs of stocking amiodarone by ,,, ;
� _ :. = •_ exchanging drug vials as they expire.
- •-•- , , It would be naive to ignore the fact that the pharma-
1=__: i. - • cetitiital industry is big business.The companies have an
I — _ -—
_ - j obligation to their stockholders to make profits from the z;
r lR . drugs theydevelop and manufacture.When a new drug f:
�� r , is released onto the prescription market it almost -
-� - P P
� `_ always arrives with a hefty price tag. ,
x _ Newly developed drugs are protected by patents to -_
i y _. ensure that only the pharmaceutical company that level-
F • • - = oped them can produce them_During this period,which
I : typically.lasts five to seven years, drug costs tend to be >;
high because coin antes maximize profits while having
' 14:1 ._ . -
the luxury of no market competition. When the drug
loses its paten proteotion,other drug manufacturers can
," , - produce generic equivalents, which results in a signifi x;
cant price decrease. Wyeth-Ayerst'satn[odarone patent,
under the brand name Cordarone;expires in 2002. :s.
1 So what challenges does amiodarone pose to EMS?
' CM • -
First, services must consider the economic impact. ;---
- Clearly,when an extra$180 is added to every v-fib cardiac
Iarrest,profit margins narrow or can become non-existent- •s
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For More Information Circle N68 On Reader Service Card
AN OLD DRUG WITH NEW TRICKS CONTINUED FROM P.69
= for 20-30 minutes,which in most cases provides adequate
I.- time to reach a hospital in most urban systems.13 Systems , - _-
with longer transport times may consider a maintenance
infusion of amiodarone during transport. (`, i j , -
= f}
1?. Earty hospital notification .
tx, t Early hospital notification is extremely important to allow
emergency department (ED) staff to mobilize additional
resources to properly handle a patient who has received '
prehospital IV amiodarone. Hospitals may not routinely
_1 stock amiodarone in their ED crash carts. If repeat boluses
of the drug are required, a significant delay can occur '
while awaiting delivery from a hospital's pharmacy.
Complications in drawing up amiodarone
t -' Because amiodarone comes packaged in 3 mL glass
;,." , ampules, the EMS provider must break the ampule and
`_'' carefully withdraw the drug using a needle and syringe-
?:; This is a difficult task when attempting to rapidly adminis-
.1
rs?4 - ter a medication to a patient in cardiac arrest.
w4;F ' In addition, the conventional method of circular
swirling of an ampule to ensure complete medication
c,'3 transfer to the ampule's main body is not advised when , -
y ` using amiodarone. Amiodarone's soap-like consistency
s�x;n k. causes excessive foaming to occur when agitated, which d
'% can make medication removal difficult and reduce the -
k.. overall amount of drug within the ampules main body.
Tap the ampule neck lightly to ensure medication transfer °
q to the ampule's body and avoid excessive shaking prior to
- ;, use to reduce foaming.
P ;'� The slow but steady adoption of amiodarone
°r The addition of amiodarone to EMS vehicles has been
slow.This may be due in part to cost and the limited sur-
vival data derived from the ARREST trial. Several larger ° -
1;`t°= EMS systems have jumped on the bandwagon and now
stock amiodarone. Also, several states have added amio-
darone to their oflists approved prehospital medications. •
See Figure 2 for a sampling of EMS systems currently
stocking amiodarone for use in modified VF/VT protocols.
A local experience:The Austin/Travis County EMS System A fall conference date is planned.
• The addition of IV amiodarone (single 300 mg bolus) for Watch future issues ofJ 1is for _
shock resistant VF/pulseless VT was implemented in the more information.
Austin/Travis County (Texas)EMS System Nov. 1, 1999.
From the implementation date to March 1, 2000, 26 -
patients were treated for VF-Fourteen patients(54%)were
initially converted into a rhythm other than VF from defib- -.-.. . - . -_ .. •-.
dilation alone- --,-,,
The remaining 12 patients remained in VF despite initial •.,;-1-
'countershocks and received 300 mg of IV amiodarone dur-
ing additional resuscitation attempts. Of these 12 patients,
three were discharged alive from the hospital (25%sur-
vival rate in the subgroup). `
The combined overall survival-to-discharge rate For both-
patient groups was 27% compared with a previously docu-
`:` mented(1999 Austin/Travis County Cardiac Arrest Statistics)VF
survival rate of 20%.This equates to an overall increase of 7% <, t •
in the VF survival rate and a 5%increase in the group receiving •
Y ' y --- ______
� t .. r 5 w y w+ AN OLD DRUG WITH NEW TRICKS
{"r' v l' r r y
=;x , z. amiodarone.Although these data are promising, the over-
j all VF patient population is small and continued data col-
PAI1AMEDIC .
lection is needed to reach a definitive conclusion about
amiodarone s effectiveness.
i
' Refresher and Review Conclusion
Although IV amiodarone is not included in the current
Case-Based Approach • ACLS guidelines for the treatment of VT/VF,the American
College of Cardiology/AHA committee on management of
tEl acute myocardial infarction has recommended the drug's
- use.The committee has identified amiodarone as a bench-
j
t.;,�sa�'s • cial, useful and effective agent for the treatment of sus-
�{ C { mined monomorphic VT in patients with AM1 when VT is
y•
P a 1-ams her ;,. not accompanied by chest pain,pulmonary congestion or
t B e,f I'e ' 1` t ` • hypotension.1334
I evlew -
f 3
R - .- P t Data from the ARREST trial and other studies suggest
,?. that 1V amiodarone should become an option for manage-
ment of the patient in refractory VF/VT. Although the
1 1,,•, - e than
tOr d 2000 ACLS guidelines are yet to be published, many sys •
-
7 5 case s all terns have already opted on the basis of available data to
tj0ll5 - add 1V amiodarone to their guidelines for shock refractory
:4114'1%.
::::-IC:rt.U...•.71;E:1.:T.gi.i.
l VF/VT. Ul5Ronny Taylor,Lic-P,is clinical develo' r ,F-ca sV,^y arpmrnt and special projects on an-
r Y- ra nator for the City of Austin (Texas)EMS clinical practice division and
,,,.r f ra a-F� ' s-.+ t * ,� a z,l' AustinfTravis County EMS System.
' ` T 7l , 14 3¢s 9. i-� :4-tg Edward Racist, MD, is the medical director for the City of 4
Nt'a.3 r - :t i. r h ! y Austin/Travis County(Texas)EMS Clinical Practice.
tab, t ok S .a, 0 c
1 + .fig ".s. fJ r a s i.fin ( r tb 3
"#1 c Ks a m rs a� � r f
-�-01ti . c r w " <.'c i "4 t''s ryl, e Ili; References
s` r At 1. � z,_ t , eikti,F F -k -, R 1_Cummins RO,Ornato JP,et al:"Improving survival from sudden
'y-4 j ll' i' ( 1 r att tC i,Cr�trei a i 1i tar. t t ; Pro g -
�za SMiel", 4 cardiac arrest The'chain of survival'concept." Circulation.
±� 3 a - 4.,. - -" 22(1):86-91,1991.
+ 1 1 rs :'i �1 tom+ It" c 1 r r s e r ki`}a 1.
�+A - 2.Cummins RO,eel Advanced Cardiac Life Support.American Heart
F tx11 1 fi .�Yr/ 1 tf fY#�.rl t t1it 1 L � i l-}'.
i ytl4�i` t 4 r`" ; � . � � v..,,r t 1 Av1- Association.Dallas,1997..
t "r .1 , , s�-� AEr, 3.Harrison EE: "Lidocasne in prehospital countershock refractory
7 11` pt , ,spay' ventricular fibrillation." Annals of Emergency Medicine.
1.111,1.ri, t� t1K,+ j�t� s itf 10:420-423,1981.
,,�} t`{pa sy , ,., 4.Nowak RM,Bodnar TJ,et al: "Bretylium tosylate as initial treat-
e p" ,. rnl � 1i - ment for cardiopulmonary arrest:Randomized comparison with
:ill -'E41ip ss' y 011E 410�ltt(flake th placebo."Annals of Emergency Medicine.10:404-407,1981.
I fe sf;
r ti fftf� ��1 �: Il!�;, � 5_Haynes RE, Chinn TL,et aL- "Comparison of bretytium tosylate
and lidocaine in management of out of hospital ventricular fibril-
Questlo[sand;answers(wit)irationales)folld the i • lation: A randomized clinical trial." American Journal of
giving students a chance to`apply their k npwledge as if they Cardiology.48:353-356,1981.
were at the scene. 6.Marriott HJL,Conover MB:Advanced Concepts in Arrhythmias,
■A cross reference for scenarios dealing with trauma, third edition.Mosby.St.Louis,1998.
pediatrics,geriatrics,chief complaint,and specific diagnosis 7.Kudenchuk PJ, Cobb LA,et al: "Amiodarone for resuscitation
is included. after out-of-hospital cardiac arrest due to ventricular fibrillation."
Illi Hot topics include:pediatric trauma,endocrine emergencies New EnglandJournal of Medicine.341:871-87B,1999. .
8.Gonzalez E:"Pharmacologic interventions for refractory ventricu-
(other than diabetes),neonatal emergencies,and patients- lar fibrillation."Pharmacist Reporter.4(5):49-52,1999.
with tubes and shunts. 9.Physician's Desk Reference, 54th ed. "Cordarone Intravenous."
May 1999. USb Montvale,NJ.3,229-3,231,2000.
Approx.288 pp./Approx.5D illus. v4 Y 10.Gonzalez E,Kannewurf B,Ornato J:"Intravenous amiodarone for
ISBN:O-8151-1729-9(303521 ventricular arrhythmias:overview and clinical use."Resuscitation-
39:33-12,1998.
'69, _
41 rii * 11.Bauman JL: "introduction: Amiodarone from last to first-line
antiarrhythmic therapy."Wyeth-Ayerst Laboratories educational
Call
tO6a� to order/
rde__® Hoyt
ucatio 17�,1999.
12.H t BT:"Intravenous amiodarone:Advances in treating ventricu-
lar tachycardia/fibrillation."Resident Reporter.4(2):23-28,1999.
Call toll-free: rrz ` -ta � '. 13.Peter).Kudenchuk,MD:Report given at the 70th Scientific Ses-
sions of the American Heart Association.Orlando.Nov.12,1997.
or (314) 872-8370 14.Ryan TJ,Anderson IL,et al: "ACCIAHA guidelines for the man-
Or order by website: www:rlosby.co ill agement of patients with acute myocardial infarction."Circulation.
FSF-556 94:2,341-2,350,1996.
For More Information Circle 1169 On Reader Service Card 15.Package insert. Cordarone(amiodarone HCI). Wyeth Laborato-
ries,Revised May 7,1999.
Chapter I Overview of Ambulance Fee Schedule 1
CHAPTER I: OVERVIEW OF AMBULANCE FEE SCHEDULE
OBJECTIVE 2
BACKGROUND 2
Current Payment System 2
BBA 3
Negotiated Rulemaking Process 4
PROPOSED RULE 5
Negotiated Rulemaking Committee's Recommendations 5
Other Items Included in Proposed Rule 5
PROGRAM MEMORANDUM AB-00-88 6
NEW CATEGORIES OF AMBULANCE SERVICES 7
Ground Ambulance Services 7
Air Ambulance Services 9
Changes Related to the Fee Schedule 10
OVERVIEW OF THE TRANSITION TO A FEE SCHEDULE 11
Transition Schedule 11
Calculating the Blended Rate During the Transition 11
COMPONENTS OF THE AMBULANCE FEE SCHEDULE 12
Ground Ambulance Services 12
Air Ambulance Services 13
DESCRIPTION OF FEE SCHEDULE COMPONENTS 13
Ground Ambulance Services 13
Air Ambulance Services 15
ZIP CODE DETERMINES APPLICABLE FEE SCHEDULE AMOUNT 17
1
December 2000
Chapter I Overview of Ambulance Fee Schedule 2
• OBJECTIVE
This chapter provides an overview of the Ambulance
Fee Schedule. It also introduces terminology and
concepts that will facilitate understanding of the
detailed discussion in later chapters.
BACKGROUND
Current Payment System
The Medicare program pays for ambulance services
Medicare program on a reasonable cost basis when furnished by a
pays for ambulance provider and on a reasonable charge basis when
services on a furnished by a supplier. For purposes of this
reasonable cost basis discussion, the term "provider" means all Medicare-
when furnished by a participating institutional providers that submit claims
provider and on a for Medicare ambulance services, such as hospitals
reasonable charge (including critical access hospitals), skilled nursing
basis when furnished facilities (SNFs), and home health agencies (HHAs).
4-1110 by a supplier The term "supplier" means an entity that is
independent of any provider. The reasonable charge
methodology which is the basis of payment for
ambulance services furnished by ambulance
• The term "provider" suppliers is determined by the lowest of the
means all Medicare- customary, prevailing, actual, or inflation indexed
participating charge.
institutional Following are the current billing methods for
providers that submit ambulance services:
claims for Medicare
ambulance services: • Method 1 is an all-inclusive charge reflecting all
hospitals (including services, supplies, and mileage.
CAHs), SNFs, and
HHAs • Method 2 is one charge reflecting all services and
supplies (base rate) with a separate charge for
• The term "supplier" mileage.
means an entity that
is independent of any • Method 3 is one charge for all services and
provider mileage, with a separate charge for supplies.
• Method 4 is separate charges for services,
mileage, and supplies.
O 2
December 2000
Chapter I Overview of Ambulance Fee Schedule 3
All providers are currently billing Method 2.
Over the past 20 years, Congress has been moving
toward fee schedules and prospective payment
systems for Medicare payment. In the case of
ambulance services, the reasonable charge
methodology has resulted in a wide variation of
payment rates for the same service depending on
location. In addition, this payment methodology is
administratively burdensome, requiring substantial
recordkeeping for historical charge data. The
Balanced Budget Act of 1997 (BBA) mandated the
establishment of a fee schedule for payment of
ambulance services.
BBA
Section 4531 (b) (2)of the BBA added a new section
BBA-97 requires fee 1834 (I)to the Social Security Act, which mandates
schedule for all implementation of a national fee schedule for
ambulance services ambulance services furnished as a benefit under
Medicare Part B. This section requires that in
establishing the fee schedule, HCFA will:
• Establish mechanisms to control increases in
expenditures for ambulance services under Part B
of the Medicare program;
• Establish definitions for ambulance services that •
link payments to the type of services furnished;
• Consider appropriate regional and operational
differences;
• Consider adjustments to payment rates to account
for inflation and other relevant factors;
• Limit payment for ambulance covered services to
the lower of actual billed charges or the
Ambulance Fee Schedule amount;
• Phase in the fee schedule in an efficient and fair
manner; and,
3
December 2000
Chapter I Overview of Ambulance Fee Schedule 4
• Required mandatory assignment for all supplier
ambulance services.
Mandatory assignment
required for all BBA required that total payments under the
ambulance services Ambulance Fee Schedule be budget neutral.
• Negotiated Rulemaking Process
BBA provided that the Ambulance Fee Schedule be
BBA provided that the established through the negotiated rulemaking
Ambulance Fee process described in the Negotiated Rulemaking Act
Schedule be of 1990.
established through
the negotiated A committee chartered under the Federal Advisory
rulemaking process Committee Act conducted negotiations. HCFA used
described in the the services of an impartial convener to help identify
Negotiated interests that would be significantly affected by the
Rulemaking Act of proposed rule and the names of persons who were
1990 willing and qualified to represent those interests. The
• Negotiated Rulemaking Committee on the Medicare
Ambulance Services Fee Schedule consisted of
national representatives of interests that were likely to
be significantly affected by the fee schedule. The
committee recommendations have been included in
the proposed rule.
4
December 2000
Chapter I Overview of Ambulance Fee Schedule 5
•
Proposed Rule PROPOSED RULE
• Published On HCFA published a proposed rule in the Federal
9/12/00 Register on September 12, 2000. The proposed rule
• 60-Day Comment set forth requirements for the new Ambulance Fee
Period Schedule as required by BBA-97. HCFA plans to
implement the fee schedule effective for ambulance
services provided on or after January 1, 2001.
However, the number and content of comments as
well as proposed legislation could cause a delay.
Note: In the event the Ambulance Fee Schedule is
delayed, HCFA will announce a new effective date.
All other provisions in the proposed rule except for the
fee schedule and mandatory assignment will be
implemented on January 1, 2001.
Negotiated Rulemaking Committee's
Recommendations
• The definitions and RVUs for each category of
service.
• An emergency response adjustment factor.
• Application of Ambulance Fee Schedule to all
entities.
• Payment adjustments to reflect geographical
variations.
• Separate payment for mileage and base rate.
• Establishment of an overall structure of the fee
schedule.
• Ambulance inflation factor.
• A four-year payment transition period.
Other Items Included in Proposed Rule
110
5
December 2000
Chapter I Overview of Ambulance Fee Schedule 6
• Updated coverage of ambulance services.
• Revised Physician Certification Requirements.
• Development of a conversion factor.
• The base rate will include the transportation cost
and all items and services furnished with the
ambulance service.
• Regardless of local or state ordinances, payment
rates are based on actual service required for
condition of beneficiary.
• Mandatory assignment.
PROGRAM MEMORANDUM AB-00-88
Program Memorandum (PM)AB-00-88, dated
Program Memorandum September 18, 2000 instructs intermediaries and
AB-00-88 carriers about the Ambulance Fee Schedule. The PM
includes an effective date of January 1, 2001 with a
• Published on disclaimer that, the final rule implementing the fee
September 18, 2000 schedule had not been published. If the fee schedule
• Includes instructions is not implemented on January 1, 2001, HCFA plans
implementing the to implement all the provisions included in the PM
Ambulance Fee except for the fee schedule, mandatory assignment
Schedule for claims paid by suppliers and payment based on
beneficiary's condition.
The fee schedule is effective for claims with dates of
service on or after implementation of the fee
schedule. Ambulance services covered under
The fee schedule is Medicare will then be paid based on the lower of the
effective for claims with actual billed amount or the Ambulance Fee Schedule
dates of service on or amount. The fee schedule will be phased in over a
after the implementation four-year period. When fully implemented, the fee
of the fee schedule. schedule will replace the current retrospective
Payment based on lower reasonable cost reimbursement system for providers
of the actual billed and the reasonable charge system for ambulance
amount or the fee suppliers. The carrier reimbursement rate will be
schedule amount. based on the supplier's current billing methodology
during the transition period.
6
December 2000
Chapter I Overview of Ambulance Fee Schedule 7
• This manual provides payment and billing concepts to
implement the fee schedule that applies to all
ambulance services. This includes volunteer,
municipal, private, independent, and institutional
providers, e.g., hospitals, critical access hospitals,
skilled nursing facilities and home health agencies.
NEW CATEGORIES OF AMBULANCE SERVICES
Ground Ambulance Services
There are seven categories of ground ambulance
services and two categories of air ambulance
services under the fee schedule. (Note: "ground"
refers to both land and water transportation.)
a. Basic Life Support (BLS) -When medically
necessary, the provision of BLS services as
defined in the National EMS Education and Practice
Blueprint for the EMT- Basic, including the
establishment of a peripheral intravenous line.
b. Basic Life Support (BLS) - Emergency -
When medically necessary, the provision of BLS
services, as specified above, in the context of an
emergency response. An emergency response is
one that, at the time the ambulance is called, is
provided after the sudden onset of a medical
condition manifesting itself by acute symptoms of
sufficient severity such that the absence of immediate
medical attention could reasonably be expected to
result in placing the beneficiary's health in serious
jeopardy; in impairment to bodily functions; or in
serious dysfunction to any bodily organ or part.
An emergency response does guarantee that
Medicare will pay as emergency service. Medicare
pays for the appropriate services rendered for the
beneficiary's condition.
c. Advanced Life Support, Level 1 (ALS1) -
When medically necessary, the provision of an
assessment by an advanced life support (ALS)
provider or supplier or the provision of one or more
ALS interventions. An ALS provider/supplier is
defined as a provider trained to the level of the EMT-
. 7
December 2000
Chapter I Overview of Ambulance Fee Schedule 8
• Intermediate or Paramedic as defined in the National
EMS Education and Practice Blueprint. An ALS
intervention is defined as procedure beyond the
scope of an EMT-Basic as defined in the National
EMS Education and Practice Blueprint.
• d. Advanced Life Support, Level 1 (ALS1) -
Emergency- When medically necessary, the
provision of ALS1 services, as specified above, in the
context of an emergency response. An emergency
response is one that, at the time the ambulance
supplier is called, is provided after the sudden onset
of a medical condition manifesting itself by acute
symptoms of sufficient severity such that the absence
of immediate medical attention could reasonably be
expected to result in placing the beneficiary's health
in serious jeopardy; in impairment to bodily functions;
or in serious dysfunction to any bodily organ or part.
An emergency response does guarantee that
Medicare will pay as emergency service. Medicare
pays for the appropriate services rendered for the
beneficiary's condition.
e. Advanced Life Support, Level 2 (ALS2) -
When medically necessary, the administration of
three or more different medications and the provision
of at least one of the following ALS procedures:
Manual defibrillation/cardioversion
Endotracheal intubation
Central venous line
Cardiac pacing
Chest decompression
Surgical airway
Intraosseous line
f. Specialty Care Transport(SCT) -When
medically necessary, for a critically injured or ill
beneficiary, a level of inter-facility service provided
beyond the scope of the paramedic as defined in the
National EMS Education and Practice Blueprint. This
is necessary 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., nursing, medicine respiratory care,
• 8
December 2000
Chapter I Overview of Ambulance Fee Schedule 9
cardiovascular care, or a paramedic with additional
training.
g. Paramedic Intercept (P1) - Paramedic
intercept services are ALS services provided by an
entity that does not provide the ambulance transport.
Under a limited number of circumstances, Medicare
payment may be made for these services. No mileage
is paid for this benefit. For a description of these •
services see PM B-99-12 dated March 1999 and PM
B-00-01 dated January 2000, both titled Paramedic
Intercept Provisions of the BBA of 1997.
Air Ambulance Services
There are twd categories of air ambulance services:
fixed wing (airplane)and rotary wing (helicopter)
aircraft. The higher operational costs of the two types
of aircraft are recognized with two distinct payment
amounts for air ambulance mileage. The air
ambulance mileage rate is calculated per actual
loaded (patient onboard) miles flown and is
expressed in statute miles (not nautical miles).
a. Fixed Wing Air Ambulance (FW) - Fixed wing
air ambulance is furnished when the beneficiary's
medical condition is such that transport by ground
ambulance, in whole or in part, is not appropriate.
Generally, transport by fixed wing air ambulance may
be necessary because the beneficiary's condition
requires rapid transport to a treatment facility, and
either great distances or other obstacles, e.g., heavy
traffic, preclude such rapid delivery to the nearest
appropriate facility. Transport by fixed wing air
ambulance may also be necessary because the
beneficiary is inaccessible by a land or water
ambulance vehicle.
b. Rotary Wing Air Ambulance (RW) - Rotary
wing air ambulance is furnished when the
beneficiary's medical condition is such that transport
by ground ambulance, in whole or in part, is not
appropriate. Generally, transport by rotary wing air
9
December 2000
Chapter I Overview of Ambulance Fee Schedule 10
ambulance may be necessary because the
beneficiary's condition requires rapid transport to a
treatment facility, and either great distances or other
obstacles, e.g., heavy traffic, preclude such rapid
delivery to the nearest appropriate facility. Transport
by rotary wing air ambulance may also be necessary
because the beneficiary is inaccessible by a land or
water ambulance vehicle.
l
Changes Related to the Fee Schedule
• A base rate payment plus a separate payment for
mileage.
• Eventual elimination of a separate payment for
items and services furnished under the ambulance
benefit.
• Payment for items and services is included in the
fee schedule payment. Such items and services
include but are not limited to oxygen, drugs, extra
attendants, and EKG testing -- but only when such
items and services are both medically necessary
and covered by Medicare under the ambulance
benefit. An exception to this preclusion exists
during the transition period for those billing under
Methods 3 and 4 for carriers.
• Medicare pays only for the category of service
provided and then only when the service is
medically necessary and relevant to beneficiary's
condition.
• 10
December 2000
Chapter I Overview of Ambulance Fee Schedule 11
OVERVIEW OF THE TRANSITION TO A FEE
SCHEDULE
Transition Schedule
Payment under the fee schedule will be phased in
over a four-year period. In the first year, the fee
schedule amount will comprise only 20% of the
amount allowed from Medicare. The remaining 80%
of the allowed amount will be based on the provider's
reasonable cost or the supplier's reasonable charge.
The fee schedule amount will increase each calendar
year as a percentage of the total allowed amount
from Medicare until it reaches 100% in year 4. During
the transition, the amount allowed for an ambulance
service will be the lower of the submitted charge or a
blended rate that includes both a fee schedule
component and a provider's reasonable cost or a
supplier's reasonable charge. Payment amount is
subject to any remaining deductible and coinsurance.
The phase-in schedule is as follows:
9 Fee Schedule Cost/Charge
Percentage Percentage
Year 1 20% 80%
Year 2 50 50
Year 3 80 20
Year 4 100 0
Calculating the Blended Rate During the
For services furnished Transition
during the transition
• period, payment of Payment of ambulance services currently follows one
ambulance services will of two methodologies.
be a blended rate that
consists of a percentage Suppliers are paid based on a reasonable charge
of both a fee schedule methodology.
and a provider or
supplier's current Providers are paid based on the provider's interim
payment methodology rate (which is a percentage based on the provider's
historical cost-to-charge ratio multiplied by the
11
December 2000
Chapter I Overview of Ambulance Fee Schedule 12
submitted charge) and then cost-settled at the end of
' the provider's fiscal year.
For services furnished during the transition period,
payment of ambulance services will be a blended rate
that consists of a percentage of both a fee schedule
and a provider or supplier's current payment
methodology.
For suppliers, the blended rate includes both a
portion of the reasonable charge and the fee
schedule amount. To implement the transition to the
fee schedule, the reasonable charge for each supplier
is the reasonable charge for 2000 adjusted for each
year of the transition period by the ambulance
inflation factor as published by HCFA.
Intermediaries must determine both the reasonable
cost for a service furnished by a provider and the fee
schedule amount for the service, then apply the
appropriate percentage to each such amount to
derive a blended-rate payment amount applicable to
the service.
The following sections explain the items that are used
to arrive at a fee schedule amount The contractors'
systems will do this automatically. These sections
are presented to further your understanding of how
the fee schedule amount is derived.
COMPONENTS OF THE AMBULANCE FEE
Components of the SCHEDULE
Ground Ambulance Fee
Schedule Ground Ambulance Services
• Conversion Factor The fee schedule amount comprises:
• RVU
• GAF • A money amount that serves as a nationally
• Loaded Mileage Rate uniform base rate, called a "conversion factor"
Rural Mileage (CF), for all ground ambulance services.
• Adjustment
• A relative value unit(RVU) assigned to each
category of ground ambulance service.
• A geographic adjustment factor(GAF)for each
Ambulance Fee Schedule area (geographic
12
December 2000
Chapter I Overview of Ambulance Fee Schedule 13
practice cost index (GPCI)).
• A nationally uniform loaded mileage rate.
• A rural adjustment on loaded mileage for services
furnished in a rural area.
Air Ambulance Services
Components of the Air For air ambulance services, the fee schedule amount
Ambulance Fee includes:
Schedule
• A nationally uniform base rate for fixed wing and a
• Uniform Base Rate nationally uniform base rate for rotary wing.
for fixed wing and
rotary wing • A geographic adjustment factor(GAF)for each
• GAF Ambulance Fee Schedule area (GPCI).
• Uniform loaded
mileage rate for each • A nationally uniform loaded mileage rate for each
type of air service type of air service.
• Rural Mileage
Adjustment • A rural adjustment to the base rate and mileage
for services furnished in a rural area.
DESCRIPTION OF FEE SCHEDULE COMPONENTS
Ground Ambulance Services
Conversion Factor in
Proposed Rule is (1) Conversion Factor
$157.52
The conversion factor (CF) is a money amount used
to develop a base rate for each category of ground
ambulance service. The CF will be updated as
necessary. The CF included in the proposed rule is
$157.52.
13
December 2000
Chapter I Overview of Ambulance Fee Schedule 14
•
(2) Relative Value Units (RVU)
Relative value units (RVUs)set a numeric value for
The RVUs are as ambulance services relative to the value of a base
follows: level ambulance service. Since there are marked
differences in resources necessary to furnish the
Service Level RVU various levels of ground ambulance services, different
levels of payment are appropriate for the various
BLS 1.00 levels of service. The different payment amounts are
BLS - Emergency 1.60 based on level of service. An RVU expresses the
ALS1 1.20 constant multiplier for a particular type of service
ALS1-Emergency 1.90 (including, where appropriate, an emergency
ALS2 2.75 response). An RVU of 1.00 is assigned to the BLS of
SCT 3.25 ground service. Higher RVU'values are assigned to
PI 1.75 the other types of ground ambulance services, which
require more service than BLS.
(3) Geographic Adjustment Factor(GAF)
The GAF for the The GAF is one of two factors intended to address
Ambulance Fee regional differences in the cost of furnishing
411 Schedule uses the non- ambulance services. The GAF for the Ambulance
facility practice expense Fee Schedule uses the non-facility practice expense
of the geographic of the geographic practice cost index (GPCI) of the
practice cost index Medicare physician fee schedule to adjust payment to
(GPCI) of the Medicare account for regional differences. Thus, the
physician fee schedule geographic areas applicable to the Ambulance Fee
to adjust payment to Schedule are the same as those used for the
account for regional physician fee schedule.
differences The location where the beneficiary was put into the
ambulance ("point of pickup") establishes which GPCI
applies. For multiple vehicle transports, each leg of
the transport is separately evaluated for the
applicable GPCI. Thus,for the second (or any
subsequent) leg of a transport, the point of pickup
establishes the applicable GPCI for that portion of the
ambulance transport.
For ground ambulance For ground ambulance services, the applicable GPCI
services, the applicable is multiplied by 70% of the base rate. Again, the base
GPCI is multiplied by rate for each category of ground ambulance services
70% of the base rate is the CF multiplied by the applicable RVU. The
GPCI is not applied to the mileage factor.
• 14
December 2000
Chapter I Overview of Ambulance Fee Schedule 15
(4) Mileage
The Ambulance Fee Schedule provides a separate
The mileage rate for all payment amount for mileage. The mileage rate for all
categories of ground categories of ground ambulance services is $5 per
ambulance services is loaded statute mile. Paramedic Intercept has no
$5 per loaded statute mileage payment.
mile. Paramedic
Intercept has no mileage (5)Adjustment for Mileage for Services Furnished in
Rural Areas
payment.
Payment is adjusted upward for ambulance services
that are furnished in rural areas to account for the
higher costs per ambulance trip that are typical of
rural operations where fewer trips are made in any
given period. For ground ambulance services, the
rural adjustment is a 50% increase in the mileage rate
to $7.50 per loaded statute mile for the first 17 miles.
The point of pickup is identified by the zip code and
establishes whether a rural adjustment applies. The
point of pickup for each leg of a multi-leg transport is
separately evaluated for a rural adjustment
111 application. Thus, for the second (or any
subsequent) leg of a transport, the zip code of the
point of pickup establishes whether a rural adjustment
applies to such second (or subsequent)transport.
For all categories of ground ambulance services
except paramedic intercept, a rural area is defined as
a U.S. Postal Service zip code that is located, in
whole or in part, outside of either a Metropolitan
Statistical Area (MSA) or a New England County
Metropolitan Area (NECMA), or is an area wholly
within an MSA or NECMA that has been identified as
rural under the "Goldsmith Modification."
The paramedic intercept benefit is based on certain
services provided in a rural area. Though no mileage
is paid the zip code is required. See PM B-00-01 for
details.
HCFA will furnish contractors electronic files that
identify a zip code as rural or urban.
There is no conversion Air Ambulance Services
factor or RVU applicable
15
to air ambulance December 2000
services
Chapter I Overview of Ambulance Fee Schedule 16
,41) (1) Base Rates
Each type of air ambulance service has a base rate.
The base rate for a fixed wing ambulance service is
$2,213.00. The base rate for a rotary wing
ambulance service is $2,573.00. There is no
conversion factor applicable to air ambulance
services. Also, air ambulance services have no RVUs.
(2) Geographic Adjustment Factor
The GAF, as described above for ground ambulance
services, is applied in the same manner to air
ambulance services. However, for air ambulance
services, the applicable GPCI is applied to 50% of
each of the base rates (fixed and rotary wing).
The mileage rate for (3) Mileage
fixed wing ambulance
services is $6 per loaded The fee schedule for air ambulance services provides
statute mile flown. The a separate payment for mileage. The mileage rate for
mileage rate for rotary fixed wing ambulance services is $6 per loaded
wing ambulance statute mile flown. The mileage rate for rotary wing
services is $16 per ambulance services is $16 per loaded statute mile
loaded statute mile flown.
flown.
(4)Adjustment for Services Furnished in Rural Areas
Payment is increased for air ambulance services that
are furnished in rural areas. For air ambulance
services, the rural adjustment is an increase of 50%
of the base rate and mileage. A rural adjustment is
determined by the point of pickup.
• 16
December 2000
Chapter I Overview of Ambulance Fee Schedule 17
ZIP CODE DETERMINES APPLICABLE FEE
SCHEDULE AMOUNT
The zip code of the point of pickup determines both
The zip code of the point the appropriate payment and any rural adjustment. If
of pickup determines the ambulance transport required a second or
both the appropriate subsequent leg, then the zip code of the point of
payment and any rural pickup of each leg will determine both the applicable
adjustment payment for such leg and whether a rural adjustment
applies to such leg. Accordingly, the zip code of the
point of pickup must be reported on every claim to
determine both the correct payment and any rural
adjustment.
HCFA will furnish
contractors electronic HCFA will furnish contractors electronic files that
files that identify a zip identify a zip code as rural or urban.
code as rural or urban
17
December 2000
Chapter II Intermediary Coverage and Related Issues
CHAPTER II - INTERMEDIARY COVERAGE AND RELATED ISSUES FOR THE
AMBULANCE FEE SCHEDULE 1
OBJECTIVE 1
COVERAGE REQUIREMENTS 2
CATEGORIES OF SERVICE 2
Basic Life Support (BLS) 2
Basic Life Support— Emergency 2
Advanced Life Support, Level 1 (ALS1) 3
Advanced Life Support, Level 1 — (ALS1) Emergency 3
Advanced Life Support, Level 2 (ALS2) 4
Specialty Care Transport (SCT) 4
Paramedic Intercept 4
Fixed Wing Air Ambulance (FW) 4
Rotary Wing Air Ambulance (RW) 5
CERTIFICATION FOR HOSPITAL SERVICES 5
SPECIAL CIRCUMSTANCES 6
Pronouncement of Death 6
Multiple Patients 7
Multiple Arrivals 7
Service Provided 7
MEDICAL REVIEW OF AMBULANCE SERVICES 9
REVIEW CONSIDERATIONS RELATED TO THE AMBULANCE FEE SCHEDULE
9
Category of Service 9
Medical Conditions List 10
Non-Emergency Transports 10
December 3,2000
it
Chapter II Intermediary Coverage and Related Issues 1
CHAPTER II - INTERMEDIARY COVERAGE AND
RELATED ISSUES FOR THE AMBULANCE FEE
SCHEDULE
OBJECTIVE
The objective of the Coverage and Related Issues chapter is
to provide information on coverage criteria related to the
ambulance fee schedule.
Participants will learn about the following in the course of this
chapter:
1. Medicare coverage requirements for ambulance services.
2. New aspects of coverage related to the ambulance fee
schedule.
•
December 3,2000
Chapter II Intermediary Coverage and Related Issues 2
COVERAGE REQUIREMENTS
Many of the Medicare coverage requirements for ambulance
services have not changed under the ambulance fee
schedule. All of the requirements are included in the
following instructions:
Medicare Intermediary Manual, Pub. 13-3, Section 3114 and
Section 3322
Program Memorandum AB-99-94
Program Memorandum AB-00-88
Program Memorandum AB-00-103
Federal Register, Vol. 65, No. 177, 9/12/00, 55078—55100
42 CFR 410.40
CATEGORIES OF SERVICE
Categories of The new ambulance fee schedule has seven categories of
Service ground (land or water)ambulance services and two
categories of air ambulance services. Paramedic intercept,
1. Basic Life advanced life support level 2, fixed wing air ambulance, and
Support (BLS) rotary wing air ambulance assume an emergency condition
2. BLS-Emergency
3. Advanced Life Basic Life Support(BLS)
Support 1 (AL$1) The Basic Life Support category is the provision of BLS
services as defined in the National EMS Education and
4. ALS1-Emergency Practice Blueprint for the EMT- Basic, including the
5. ALS2 establishment of a peripheral intravenous line.
6. Specialty Care
Transport (SCT) Basic Life Support— Emergency
7. Paramedic The Basic Life Support— Emergency category is the
Intercept (PI) provision of BLS services, as specified above, in the context
8. Fixed Wing Air of an emergency response.
Ambulance (FW)
An emergency response is one that, at the time the
9. Rotary Wing Air ambulance supplier is called, is provided after the sudden
Ambulance (RW) onset of a medical condition manifesting itself by acute
symptoms of sufficient severity such that the absence of
immediate medical attention could reasonably be expected
to result in:
December 3,2000
Chapter II Intermediary Coverage and Related Issues 3
1. placing the beneficiary's health in serious jeopardy;
2. impairment to bodily functions; or
3. serious dysfunction to any bodily organ or part.
Advanced Life Support, Level 1 (ALS1)
The Advanced Life Support, Level 1 category is the provision
of an assessment by an advanced life support(ALS)
provider or supplier or the provision of one or more ALS
interventions.
An ALS provider/supplier is defined as a provider trained to
the level of the EMT-Intermediate or Paramedic as defined in
the National EMS Education and Practice Blueprint.
An ALS intervention is defined as procedure beyond the
scope of an EMT-Basic as defined in the National EMS
Education and Practice Blueprint.
ALS Assessment is an assessment performed by an ALS
crew that results in the determination that the patient's
condition requires an ALS level of care, even if no other
ALS intervention is performed.
In the above situation, the EMT-Intermediate or Paramedic
must actually ride on the BLS transport for the BLS
ambulance provider to bill an ALS service.
Advanced Life Support, Level 1 — (ALS1) Emergency
The Advanced Life Support, Level 1 — Emergency Response
category is defined as the provision of ALS1 services, as
specified above, in the context of an emergency response.
An emergency response is one that, at the time the
ambulance supplier is called, is provided after the sudden
onset of a medical condition manifesting itself by acute
symptoms of sufficient severity such that the absence of
immediate medical attention could reasonably be expected
to result in:
1. placing the beneficiary's health in serious jeopardy;
2. impairment to bodily functions; or
3. serious dysfunction to any bodily organ or part.
December 3,2000
Chapter II Intermediary Coverage and Related Issues 4
Advanced Life Support, Level 2 (ALS2)
The Advanced Life Support, Level 2 category is:
1. The administration of three or more different medications,
and
2. The provision of at least one of the following ALS
procedures:
Manual defibrillation/cardioversion
Endotracheal intubation
Central venous line
Cardiac pacing
Chest decompression
Surgical airway
Intraosseous line
Specialty Care Transport(SCT)
The specialty care transport category is a level of inter-
facility service provided for a critically injured or ill beneficiary
beyond the scope of the paramedic as defined in the
National EMS Education and Practice Blueprint. This is
necessary 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., nursing,
medicine respiratory care, cardiovascular care, or a
paramedic with additional training.
Paramedic Intercept
Paramedic intercept services are ALS services provided by
an entity that does not provide the ambulance transport.
Under a limited number of circumstances, Medicare payment
may be made for these services. For a description of these
services see PM B-99-12 dated March 1999 and PM B-00-
01 dated January 2000, both titled Paramedic Intercept
Provisions of the BBA of 1997.
Fixed Wing Air Ambulance (FW)
The fixed wing air ambulance (airplane) category is services
furnished when the beneficiary's medical condition is such
that transport by ground ambulance, in whole or in part, is
not appropriate.
December 3,2000
Chapter II Intermediary Coverage and Related Issues 5
Transport by fixed wing air ambulance may be necessary
because the beneficiary's condition requires rapid transport
to a treatment facility, and either great distances or other
obstacles, e.g., heavy traffic, preclude such rapid delivery to
the nearest appropriate facility.
Transport by fixed wing air ambulance may also be
necessary because the beneficiary is inaccessible by a land
or water ambulance vehicle.
Rotary Wing Air Ambulance (RW)
The rotary wing air ambulance (helicopter) category is
furnished when the beneficiary's medical condition is such
that transport by ground ambulance, in whole or in part, is
not appropriate.
Transport by rotary wing air ambulance may be necessary
because the beneficiary's condition requires rapid transport
to a treatment facility, and either great distances or other
obstacles, e.g., heavy traffic, preclude such rapid delivery to
the nearest appropriate facility.
Transport by rotary wing air ambulance may also be
necessary because the beneficiary is inaccessible by a land
or water ambulance vehicle.
CERTIFICATION FOR HOSPITAL SERVICES
Providers must meet the certification requirements in the
Medicare Intermediary Manual, Pub. 13-3, Section 3322.
This section states:
Certification by a physician in connection with ambulance
services furnished by a participating hospital is required.
In cases in which the hospital provides ambulance
service to transport the patient from the scene of an
accident and no physician is involved until the patient
reaches the hospital, any physician in the hospital who
examines the patient or has knowledge of the case may
certify as to the medical need for the ambulance service.
Therefore, providers are required to have a physician
certification for emergency and non-emergency transports.
December 3,2000
Chapter II Intermediary Coverage and Related Issues 6
SPECIAL CIRCUMSTANCES
In the regulation for the Ambulance Fee Schedule, Medicare
Special policies for some circumstances were clarified.
Circumstances
1. Multiple Patients Pronouncement of Death
2. Multiple Arrivals The following information explains Medicare policy related to
3. Service Provided the death of a patient and the resultant effect on payment for
ambulance services under the ambulance fee schedule.
The death of a patient is recognized when the
pronouncement of death is made by an individual legally
authorized to do so by the state where the pronouncement is
made. The following three scenarios that apply to payment
for ambulance services when the beneficiary dies.
1. If the beneficiary is pronounced dead after the
ambulance is called but before the ambulance arrives at
the scene, payment may be made; however, neither
mileage nor a rural adjustment would be paid.
If a ground vehicle is dispatched, payment is made for
a BLS service.
If an air ambulance is dispatched, payment is made at
the fixed wing or rotary wing base rate, as applicable.
2. Payment is made following the usual rules of payment
(as if the beneficiary had not died) when:
The beneficiary is pronounced dead after being
loaded into the ambulance, regardless of whether the
pronouncement is made during or subsequent to the
transport.
A determination of"dead on arrival" (DOA) is made at
the facility to which the beneficiary is transported.
3. No payment will be made if the beneficiary was
pronounced dead prior to the time the ambulance is
called.
December 3,2000
Chapter II Intermediary Coverage and Related Issues . 7
Multiple Patients
An ambulance may transport more than one patient at a
time, for instance, at the scene of a traffic accident. In this
situation the payment should be prorated by the number of
patients in the ambulance. The following are examples of
how to apply this policy.
1. Two patients are transported at one time, one is a
Medicare beneficiary and the other is not. Payment is
based on one-half of the allowed amount for the level of •
medically appropriate service furnished to the Medicare
patient.
2. If both patients are Medicare beneficiaries, payment for
each beneficiary is made based on half of the allowed
amount for the level of medically appropriate services
furnished to each patient.
Multiple Arrivals
When multiple units respond to a call for services, the entity
that provides the transport for the beneficiary should bill
Medicare for all services furnished.
For example, a BLS and ALS entities respond to a call and
the BLS entity furnishes the transport after an ALS
assessment is furnished. The EMT— Intermediate or
Paramedic from the ALS service accompanies the patient to
the hospital in the BLS ambulance. The BLS entity will bill
using the ALS1 rate since an ALS service was furnished.
Medicare will pay the BLS entity at the ALS1 rate. The BLS
entity and the ALS entity should settle payment for the ALS
assessment.
In the above situation, the EMT— Intermediate or Paramedic
must actually ride on the BLS transport for the BLS
ambulance provider to bill an ALS service.
Service Provided
Medicare pays only for the category of service provided and
then only when the service is medically necessary, even if a
local government requires an ALS response for all calls.
December 3,2000
Chapter II Intermediary Coverage and Related Issues 8
However, until further notice, when an ALS ambulance
provider furnishes BLS or BLS emergency services to a
patient, the provider can submit and may be paid for ALS1 or
ALS1 emergency services.
December 3,2000
Chapter II Intermediary Coverage and Related Issues 9
MEDICAL REVIEW OF AMBULANCE SERVICES
Claims will be reviewed in accordance with instructions in
the Program Integrity Manual, Section 83-6-12. However,
additional factors must also be taken into consideration
based on the Ambulance Fee Schedule and Program
Memorandum AB-99-83.
Ambulance services are reviewed to determine if they met
Medical Review the ambulance coverage criteria. A determination is made as
to whether the patient's condition was such that another
Other methods method of transportation was contraindicated. Medically
contraindicated necessary transport by ambulance may include:
1. Emergency situations, e.g., accidents, injury; acute
illness
2. Need for restraints
3. Unconsciousness or shock
4. Requiring emergency treatment during the trip
5. Requiring immobilization, i.e., fracture or the possibility of
a fracture
9 6. Sustained acute stroke or myocardial infarction
7. Experiencing severe hemorrhage
Please note this list is not all-inclusive.
REVIEW CONSIDERATIONS RELATED TO THE
AMBULANCE FEE SCHEDULE
Because of the ambulance fee schedule billing
requirements, additional factors must be taken into
Review Under Fee consideration during the medical review process.
Schedule
1. Category of Category of Service
Service The documentation will be reviewed to determine if the
2. Medical category of service billed to Medicare is the category of
Conditions List service that was provided, and that it was the category of
3. Non-emergency service that was medically necessary. Until further notice,
Transport however, when an ALS ambulance provider furnishes BLS
or BLS emergency services to a patient, a claim for ALS1 or
ALS1 emergency services can be submitted.
December 3,2000
Chapter II Intermediary Coverage and Related Issues 10
Medical Conditions List
Addendum A (Medical Conditions List)was provided in the
NPRM to solicit comments on the need for such a list in the
support of the claims process. The conditions list was not a
part of the negotiated rule committee agreement. We did
not integrate this into the automated claims process but will
consider doing so based,on comments on the NPRM.
Therefore, the condition list could be a future adjustment to
the claims process but will not be discussed in detail at this
time.
Addendum A can be used as a guide in determining medical
necessity. This list identifies medical conditions, not
diagnoses, which generally require ambulance services and
the appropriate level of care. It includes non-emergency
conditions; emergency medical conditions, traumatic and
non-traumatic; and emergency and non-emergency
conditions that warrant inter-facility transport services.
Non-Emergency Transports
9 Ambulance transportation is covered when it meets medical
Bed confinement necessity requirements described above. One of the primary
criteria is met when determining factors of medical necessity for non-emergency
the beneficiary is: transport is the status of whether the patient is "bed
confined." For bed confinement, the following criteria must
1. Unable to get up be met:
from bed without
assistance 1. The beneficiary is unable to get up from bed without
2. Unable to ambulate assistance;
3. Unable to sit in a 2. The beneficiary is unable to ambulate; and
chair or wheelchair 3. The beneficiary is unable to sit in a chair or wheelchair.
All three of the above-listed components must be met in
order for the patient to meet the requirements of the
definition of"bed confined." The term applies to individuals
who are unable to tolerate any activity out of bed. This term
is not synonymous with "bed rest," "non-ambulatory," or
"stretcher-bound."
These criteria, as defined, are not meant to be the sole
criteria in determining medical necessity. They are factors to
be considered when making medical necessity
determinations.
December 3,2000
Chapter II Intermediary Coverage and Related Issues 11
Some non-emergency response services are actually
Non-emergency scheduled. Scheduled services are generally regularly
services may be: scheduled transportation for the diagnosis or treatment of a.
patient's medical condition (e.g., transportation for dialysis.)
1. Scheduled, or
2. Unscheduled Unscheduled services generally pertain to non-emergency
transportation for medically necessary services, e.g., from
one facility to another.
December 3,2000
Chapter IV Intermediary Payment and Reimbursement 1
•
CHAPTER IV - INTERMEDIARY PAYMENT AND REIMBURSEMENT
PAYMENT OF AMBULANCE SERVICES 1
OBJECTIVE 1
AMBULANCE FEE SCHEDULE 2
NEW PROVIDERS 4
GROUND AMBULANCE 4
AIR AMBULANCE 4
EMERGENCY RESPONSE ADJUSTMENT FACTOR.... 4
MULTIPLE PATIENTS 5
PRONOUNCEMENT OF DEATH 6
1111 MULTIPLE ARRIVALS 6
COMPONENTS OF THE FEE SCHEDULE 6
SERVICE LEVEL RVU 7
SERVICES FURNISHED IN RURAL AREAS ._ 8
MILEAGE 9
USING THE FEE SCHEDULE 10
DETERMINING FEE SCHEDULE AMOUNTS 11
PAYMENT EXAMPLE 13
December 2000
Chapter IV Intermediary Payment and Reimbursement 1
p
PAYMENT OF AMBULANCE SERVICES
OBJECTIVE
The objective of this chapter is to provide the
information that is needed to compute the payment
due to Medicare providers for ambulance services.
Participants will learn the following in the course of
this chapter.
1. The Ambulance Fee Schedule will be phased in
over a four-year transition beginning with the
implementation of the fee schedule.
2. Payment rates will be made based on seven
RVUs (Relative Value Units)with an additional
payment for mileage.
3. Services provided in a rural area qualify for an
increased adjustment.
• December 2000
Chapter IV Intermediary Payment and Reimbursement 2
NOVERVIEW
AMBULANCE FEE SCHEDULE
Ambulance Fee Schedule Section 4531 (b) (2) of the Balanced Budget Act
(BBA)of 1997 added a new section 1834 (I)to the
• Mechanisms to control Social Security Act which mandates implementation
increases in of a national fee schedule for ambulance services
expenditures furnished as a benefit under Medicare Part B. This
Payments made based section requires that in establishing the ambulance
• on service provided fee schedule, HCFA will:
• Payments adjusted for • Establish mechanisms to control increases in
inflation expenditures for ambulance services under Part B
• Four-year phase-in of of the Medicare program;
fee schedule
(calendar) • Establish definitions for ambulance services that
• Services made on link payments to the type of service furnished and
assignment basis are appropriate for the beneficiary's condition;
• Consider appropriate regional and operational
differences;
• Consider adjustments to payment rates to account
for inflation and other relevant factors;
Ambulance fee schedule
applies to: • Phase in the fee schedule in an efficient and fair
manner; and,
• All public or private
• For profit or not-for- • Require payment for ambulance services be made
profit only on an assignment-related basis.
• Volunteer
• Government-affiliated In addition, the BBA requires that ambulance services
• Institutionally affiliated covered under Medicare be paid based on the lower
• Wholly independent of the actual billed charge or the Ambulance Fee
suppliers Schedule amount.
The Ambulance Fee Schedule applies to all entities
that furnish ambulance services, regardless of type.
All public or private, for profit or not-for-profit,
volunteer, government-affiliated, institutionally
affiliated or owned, or wholly independent supplier
ambulance companies, however organized, would be
paid according to this ambulance fee schedule.
December 2000
Chapter IV Intermediary Payment and Reimbursement 3
IMPLEMENTATION METHODOLOGY
Ambulance claims from providers are currently paid
based on the provider's interim rate (which is a
percentage based on the provider's historical cost-to-
charge ratio multiplied by the submitted charge) and
then cost-settled at the end of the provider's fiscal
year.
The proposed ambulance fee schedule is to be
phased in over a four-year period. Therefore, for
dates of service (DOS) in the first year of transition,
• Paid based on the providers will be paid based on 80 percent of the
provider's interim current payment allowance (as described in Program
rate Memorandum AB-99-73) plus 20 percent of the
• Cost-settled at end ambulance fee schedule amount.
of the provider's
fiscal year via The ambulance fee schedule will be implemented as
Medicare cost follows:
report.
Transition Former Fee
Year Payment % Schedule %
leak 1 80 20
2 50 50 _
3 20 80
4 0 100
Currently, provider claims are paid based on the
provider's interim rate and are cost settled at the end
of the provider's fiscal year. Payments are made by
the statutory ambulance inflation factor applied to the
provider's cost per ambulance trip.
The fee schedule transition will be phased in on a
calendar year basis. Therefore, for providers that file
cost reports on other than a CY basis, two different
blended rates would apply.
Effective for services furnished during the first year of
transition, the proposed blended amount for provider
claims would equal the sum of 80 percent of the
current payment system amount and 20 percent of
the ambulance fee schedule amount. The intent of
implementing payment under the fee schedule at only
20 percent in the first year is to give ambulance
providers a period of time to adjust to the new
December 2000
Chapter IV Intermediary Payment and Reimbursement 4
110 payment amounts, since some providers may receive
substantially lower payments than they do now.
The Program's payment in all cases would be subject
to the Part B coinsurance and deductible
requirements.
NEW PROVIDERS
Since new providers would not have a cost per trip
limit from the prior year, there would not be a cost per
trip inflation limit applied to new providers in their first
year of furnishing ambulance services.
Seven Categories of Ground NINE CATEGORIES OF AMBULANCE SERVICES
Service
1. Basic Life Support (BLS) Nine categories of ambulance services are
2. Basic Life Support— reimbursable under the new fee schedule. There are
Emergency(BLS-ER) seven ground and two air:
3. Advanced Life Support, Level GROUND AMBULANCE
1 (ALS1)
4. Advanced Life Support Level 1 1. Basic Life Support (BLS)
-Emergency(ALS1 — ER) 2. BLS— Emergency
5. Advanced Life Support Level 2 3 Advanced Life Support, Level 1 (ALS1)
(ALS2) 4. ALS1 - Emergency
6. Specialty Care Transport 5. Advanced Life Support, Level 2 (ALS2)
(SCT) 6. Specialty Care Transport (SCT)
7. Paramedic Intercept (P1) 7. Paramedic Intercept (PI) (carrier only)
(carrier only)
AIR AMBULANCE
There are two categories of air ambulance services to
Two Categories of Air distinguish fixed wing from rotary wing (helicopter)
Ambulance aircraft.
1. Fixed Wing Air Mileage is expressed in statute (ground miles) not
Ambulance (FW) nautical miles. The mileage rate will be calculated
per actual loaded (patient onboard) miles flown.
2. Rotary Wing Air
Ambulance (RW) 1. Fixed Wing Air Ambulance (FW)
2. Rotary Wing Air Ambulance (RW)
EMERGENCY RESPONSE ADJUSTMENT FACTOR
NDecember 2000
Chapter IV Intermediary Payment and Reimbursement 5
• An ambulance service that qualifies as an emergency
response service will be assigned higher RVUs to
Emergency Response recognize the additional costs incurred in responding
Adjustment Factor immediately to an emergency medical condition.
• Assignment of higher An immediate response is defined as one in which
RVUs the ambulance provider begins as quickly as possible
to take the steps necessary to respond to the call.
• Only applicable to BLS The emergency response adjustment factor does not
and ALS1 services apply to PI, ALS2, SCT, FW, or RW.
Multiple Patients MULTIPLE PATIENTS
• If both patients were If an ambulance transports more than one patient at a
Medicare beneficiaries, time, payment will be prorated based on the
payment would be one- ambulance fee schedule by the number of the
half of the fee schedule patients in the ambulance.
amount for each patient If two patients were transported at one time, and one
• If only one of two was a Medicare beneficiary and the other was not,
patients were Medicare Medicare will make payment based on one-half of the
beneficiaries, payment ambulance fee schedule amount for the level of
would be one-half of the medically appropriate service furnished to the
Medicare patient.
fee schedule amount
The Medicare Part B assignment rules apply to this
prorated payment.
If both patients were Medicare beneficiaries, payment
for each beneficiary will be made based on half of the
ambulance fee schedule amount for the level of
medically appropriate services furnished to each
patient.
The Medicare Part B coinsurance, deductible, and
assignment rules apply to these prorated amounts.
December 2000
Chapter IV Intermediary Payment and Reimbursement 6
PRONOUNCEMENT OF DEATH
There are three scenarios that apply to ambulance
Pronouncement of Death services and the pronouncement of death.
• 3 scenarios apply The beneficiary is pronounced dead prior to the time
that the ambulance is called, no payment would be
• Payment is contingent made.
upon when the beneficiary
is pronounced dead in The beneficiary is pronounced dead after the
relationship to when the ambulance is called but before the ambulance arrives
ambulance is called at the scene, payment for an ambulance trip will be
made at the BLS rate, but no mileage will be paid.
If the beneficiary was pronounced dead after being
loaded into the ambulance, full payment will be made.
Multiple Arrivals
MULTIPLE ARRIVALS
• Medicare will make
payment to the entity When multiple units respond to a call, Medicare will
that provides pay the entity that provides the transportation for the
transportation for the beneficiary. The transporting entity will bill Medicare.
beneficiary
For example: If BLS and ALS entities respond to a
• ''If more than one call and the BLS entity furnishes the transportation
entity provides after an ALS assessment is furnished, the BLS entity
services, negotiation would bill Medicare using the ALS1 rate. The ALS
of payment must be unit would not be entitled to bill Medicare since they
made between did not provide the transport.
providers
Medicare would pay the BLS entity at the ALS1 rate.
The BLS entity and the ALS entity would have to
negotiate payment for the ALS assessment.
Ground Ambulance Fee COMPONENTS OF THE FEE SCHEDULE
Components
GROUND AMBULANCE SERVICES
1. Conversion Factor
2. Relative Value Unit Conversion Factor (CF)
3. Geographic Practice
Cost Index The CF is a money amount used to develop a base
4. National uniform rate for each category of ground ambulance service.
mileage rate The CF will be updated by HCFA as necessary.
5. Additional amount for
mileage in a rural area December 2000
Chapter IV Intermediary Payment and Reimbursement 7
• Relative Value Units (RVUs)
RVUs set a numeric value for ambulance services
relative to the value of a base level ambulance
service. Since there are marked differences in
resources necessary to furnish the various levels of
ground ambulance services, different levels of
payment are appropriate for the various levels of
service.
The different payment amounts are based on levels
of service. An RVU expresses the constant multiplier
for a particular type of service (including, where
appropriate, an emergency response). An RVU of
1.00 is assigned to the BLS of ground service, i.e.,
BLS has an RVU of 1; higher RVU values are
assigned to the other types of ground ambulance
services, which require more services than BLS.
The service levels and their associated RVUs are
listed below.
Service Level RVU
BLS 1.00
BLS— Emergency 1.60
ALS1 1.20
ALS — Emergency 1.90
ALS2 2.75
SCT 3.25
PI 1.75
Geographic Adjustment Factor (GAF)
The GAF is one of two factors intended to address
The location where the regional differences in the cost of furnishing
beneficiary was put in the ambulance services.
ambulance ("point of
pickup") establishes which The GAF for the ambulance schedule uses the non-
GPCI applies. facility practice expense (PE) of the geographic
practice cost index (GPCI) of the Medicare physician
fee schedule to adjust payment to account for
regional differences. Thus, the geographic areas
applicable to the ambulance fee schedule are the
same for those used for the physician fee schedule.
December 2000
Chapter IV Intermediary Payment and Reimbursement 8
1111
The location where the beneficiary was put in the
ambulance ("point of pickup")establishes which GPCI
applies. For multiple vehicle transports, each leg of
the transport is separately evaluated for the
applicable GPCI. Thus, for second (or any
subsequent) leg of a transport, the point of pickup
establishes the applicable GPCI for that portion of the
ambulance transport.
For ground ambulance services, the applicable GPCI
is multiplied by 70% of the base rate. The base rate
for each category of ground ambulance service is the
CF multiplied by the applicable RVU. The GPCI is
not applied to the mileage factor.
The physician fee schedule law requires that the
GPCI be updated every 3 years. The next revision
will be effective January 1, 2001. These have been
published in the July 17, 2000 Proposed Rule (65 FR
44176).
SERVICES FURNISHED IN RURAL AREAS
Services furnished in Rural
Areas: Payment is increased for ambulance services that are
furnished in rural areas. This adjustment is made to
• Increased adjustment cover the additional cost per ambulance trip of
applies isolated, essential ambulance providers, for which
there are not many trips furnished over the course of
• Rural designation is a typical month because of a small rural population.
made at the time the
beneficiary is placed on The definition of a rural area is an area outside a
the ambulance Metropolitan Statistical Area (MSA)or a New England
County Metropolitan Area, or an area within an MSA
identified as rural using the Goldsmith modification.
The application of the rural adjustment will be
determined by the geographic location at which the
beneficiary is placed on board the ambulance. The
rural adjustment would be made using the following
methodology:
11111 December 2000
Chapter IV Intermediary Payment and Reimbursement 9
III Rural Adjustment Methodology • Ground —A 50 percent add-on ($7.50) is applied
to the mileage payment rate for the first 17 loaded
miles only.
• Ground — 50% add-on to
mileage for the first 17 • Air—A 50 percent add-on is applied to the base
miles only rate and all of the loaded mileage.
• Air—50% add-on to the
base rate and all loaded
miles
MILEAGE
Mileage
Mileage will be paid separately from the base rate.
• Paid in addition to •
base payment rate The mileage rate with the implementation of the fee
schedule is as follows:
• For 2001
• $5 ground
➢ $5 ground • $6 fixed wing
➢ $6 fixed wing • $16 rotary wing
➢ $16 rotary wing
USING THE FEE SCHEDULE
HCFA will provide each intermediary with two files: a
national zip code file and a national Ambulance Fee
Schedule file. Each intermediary will program a link
between the zip code file to determine the locality and
the fee schedule file to obtain the fee schedule
amount.
The fee schedule locality is based on the point of
pickup as identified by the zip code that is coded on
the claim form. The intermediary will use the zip code
as the point Of pickup to crosswalk to the appropriate
fee schedule.
December 2000
Chapter IV Intermediary Payment and Reimbursement 10
Determining Fee Schedule Amounts
When an urban zip code is reported with a ground or
air ambulance code, determine the amount for the
service by using the fee schedule amount for the
urban base rate. The mileage amount will be
determined by multiplying the number of reported
miles by the urban mileage rate.
When a rural zip code is reported with a ground
HCPCS code the amount for the service will be
determined by using the fee schedule amount for the
urban base rate. The mileage amount will be
determined by multiplying the first 17 loaded miles by
the urban mileage rate and then multiplying this by
1.5, multiplying the number of loaded miles in excess
of 17 miles by the urban mileage rate, and adding the
two mileage amounts.
If a rural zip code is reported with an air HCPCS
code, determine the amount for the service by using
the fee schedule amount for rural base rate. To
determine the amount allowable for the mileage,
multiply the number of loaded miles by the rural
mileage rate.
December 2000
Chapter IV Intermediary Payment and Reimbursement 11
110
Amount
Service Level RVUs CF Unadjusted adjusted Amount Loaded Rural
Base by GCPI not mileage ground
adjusted
rate(UBR)t (70%of (30%of UBR) mileage*
UBR)
BLS 1.00 157.52 $157.52 $110.26 $47.26 $5.00 $7.50
BLS Emergency. 1.60 157.52 252.03 176.42 75.61 5.00 7.50
ALS1 1.20 157.52 189.02 132.31 56.71 5.00 7.50
ALS1-Emergency 1.90 157.52 299.29 209.50 89.79 5.00 7.50
ALS2 2.75 157.52 433.18 303.23 129.95 5.00 7.50
SCT 3.25 157.52 511.94 358.36 153.58 5.00 7.50
PI 1.75 157.52 275.66 192.96 82.70 (1)No Mileage Rate
Amount
Service Level Unadjusted Adjusted Amount oaded Rural air Rural air
base rate by GPCI not mileage mileage** base rate***
adjusted
(UBR)t (50%of (50%of UBR)
UBR)
FW $2,213.00 $1,106.50 $1,106.50 $6.00 $9.00 $3,319.50
RW 2,573.00 1,286.50 1,286.50_ 16.00 24.00 3,859.50
* A 50 percent add-on to the mileage rate(that is,a rate of$7.50 per mile)for each of the first 17 miles identified
as rural. -
The regular mileage allowance applies for every mile over 17 miles.
** A 50 percent add on to the air mileage rate is applied to every mile identified as rural.
*** A 50 percent add-on to the air base is applied to air trips identified as rural.
The payment rate for rural air ambulance(rural air mileage rate and rural air base rate)is 50 percent more than
the corresponding
payment rate for urban services(that is,the sum of the base rate adjusted by the geographic adjustment factor
and the mileage).
t This column illustrates the payment rates without adjustment by the GPCI. The conversion factor(CF)has
been inflated for 2001.
Legend Legend for Formulas
ALS1 --Advanced Life Support,Level 1 CF conversion factor(ground=$157.52;air=
1.0).
ALS2--Advanced Life Support, Level 2 GPCI practice expense portion of the
BLS- Basic Life Support geographic practice cost index from the
CF--Conversion Factor physician fee schedule. (The GPCI is
determined by
FW-Fixed Wing the address of the point of pickup.)
GPCI--Practice Expense Portion of the MGR mileage ground rate(5.0).
Geographic Practice Cost index from MAR mileage air rate(fixed wing rate=6.0,
the Physician Fee Schedule helicopter rate=16.0).
PI--Paramedic ALS intercept RA rural air adjustment factor(0.50 on
RVUs-Relative Value Units entire claim).
RW--Rotary Wing RG rural ground adjustment factor amount
SCT--Specialty Care Transport (0.50 on first 17 miles).
UBR--Unadjusted Base Rate RVUs relative value units(from chart).
• December 2000
Chapter IV Fiscal Intermediary Payment and Reimbursement 15
•
PAYMENT EXAMPLE
Ground Ambulance, Rural (Hospital Based
Provider)
A Medicare beneficiary residing in a rural area in the
state of Iowa was transported via ground ambulance
from her home located in a rural area (non-MSA)to
the nearest appropriate facility (Hospital A). Because
the point of pick-up is in a rural area, under our
proposal, a rural payment rate would apply. The total
distance from the beneficiary's home to Hospital A is
14 miles. A BLS non-emergency transport was
furnished. The level of service would be BLS (non-
emergency).
For Iowa, the GPCI = 0.882. The ambulance fee
schedule amount would be calculated as follows—
14 mile trip = 14 miles at the rural payment rate plus 0
mile at the regular rate.
Payment Rate (per the 2001 fee schedule for Payment of
Ambulance Service) =
[(RVU*(.3+(.7*GPCI)))*CF]+[(((1+RG)*MGR)*#MI LE17)
+(MGR*#MILES>#17)]
2001 Fee Schedule for Payment of Ambulance Service for BLS non-Emergency
Service Level RVUs CF Unadj.Base Amt.adj.by Amt.not Loaded Rural
rate GCPI adjusted mileage ground
mileage
BLS 1.00 157.52 $157.52 $110.26 $47.26 $5.00 $7.50
STEP 1: DETERMINE THE PAYMENT RATE
Payment Rate =
[(1.00*(.3+(.7*.882)))*157.521+[(((1+.5)*5)*14)+(5*0)]
$249.51
The payment of$249.51 is subject to Part B
deductible and coinsurance requirements.
•
December 2000
Chapter IV Fiscal Intermediary Payment and Reimbursement 15
Since 2001 is the first year of a proposed 4-year
transition period, the ambulance fee schedule
payment rate would be multiplied by 20 percent. The
total payment under the proposed fee schedule for
2001 is:
Payment Rate = Fee Schedule * Transition
Percentage
Payment Rate = 249.51*0.2
Payment Rate = $49.90
STEP 2: DETERMINE THE TOTAL CHARGE
UNDER THE CURRENT SYSTEM
The remaining 80 percent of the payment rate is
determined by the current payment system. For Fls,
the current payment calculation is as follows:
Assume that Hospital A's charge (HCB)for a BLS
non-emergency service is $220.00, its charge for
mileage (HCM) is $4.00 per mile, and its past year's
cost-to-charge ratio (CCR) is 0.9.
Also assuming that the beneficiary's Medicare Part B
deductible has been met, the beneficiary's
coinsurance liability for 2001 would be:
Total Charge = HCB+(HCM*#MILES)
Total Charge = 220+(4*14)
Total Charge =$276.00 (Current system)
COINSURANCE CALCULATION
For 2001, the coinsurance is equal to 20 percent of:
Total Rate = (0.80*Current System)+(0.20*FS)
Total Rate = (0.80*276)+(49.90)
Total Rate = (220.80+(49.90)
Total Rate = $270.70
Coinsurance = 0.20*270.70 = $54.14
STEP 3: DETERMINE THE BLENDED PAYMENT
For 2001, the transition payment rate is equal to:
December 2000
Chapter IV Fiscal Intermediary Payment and Reimbursement 15
Transition Payment Rate = [0.80*((HCB)+(HCM*
#MILES))*CCR]+[0.20*FS]
Transition Payment Rate =
[0.80*((220)+(4*14))*0.9]+[49.90]=$248.62
Assuming the Part B deductible is met:
Medicare Program payment = (transition payment
rate)— (coinsurance)
Medicare Program payment = 248.62—54.14
Medicare Program payment = $194.48
' j
December 2000