The URL can be used to link to this page

Home My WebLink AboutDocumentation_Regular_Tab 07A_02/08/2001 `�'�' � RESOLUTION NO. 18-00-01 A RESOLUTION OF THE VILLAGE COUNCIL OF THE VILLAGE OF TEQUESTA, PALM BEACH COiTNTY, �'LORIDA, PROVIDING AN AMENDMENT TO CHAPTER 9 OF THE VILLAGE CODE OF ORDINANCES, ARTICLE IV, PRE-HOSPITAL EMERGENCY MEDICAL SERVICES, SPECIFICALLY AMENDING SECTION 9- 55 SCHEDULE OF USER FEES, TO PROVIDE FOR THE 2001 SCHEDULE OF USER FEES; REPEALNG THE EXISTING SAID USER FEES; PROVIDING FOR SEVERABILITY; PROVIDING FOR CODIFICATION; PROVIDING FOR AN EFFECTIVE DATE. WHEREAS The Village of Tequesta, Florida, has adopted Ordinance No. 523 providing for pre-hospital transport service and care and establishing a schedule for user fees to oftset the cost of this service; and, WHEREAS, Ordinance No. 523 provides for adjustments to the user fees by means of changing conditions, inflation, or other cost factors associated with providing such service; and WHEREAS the Village Council of the Village of Tequesta, Florida, deems it necessary to amend its user fees rates as set forth herein, NOTnI, THEREFORE, BE IT RESOLVED BY THE VILLAGE COUNCIL OF THE VILLAGE OF TEQUESTA, PALM BEACH COUNTY, FLORIDA, AS FOLLOWS: Section 1. Chapter 9 of the Code of Ordinances, Article IV, Pre-Hospital Emergency Medical Services, Section 9-55, Schedule of user fees, shall be amended to increase the medical transportation charge from $315.00 to $320.00 for ALS service and to $465.00 for ALS Level 2 service; and to increase the per mile charge, from $6.25 per mile to $6.50 per mile, therefore, establishing a 2001 user fee rate schedule as follows: Emergency Medical Treatment $ 0.00 Emergency Medical Transportation ALS $320.00 Emergency Medical Transportation ALS Level 2 $465.00 Plus, per mile charge, pickup to hospital $ 6.50 Section 2. Repeal of user fees and conflict. All other user fees of the �Tillage of Tequesta, Florida, are parts hereof which are in conflict with this resolution or part of any , other ordinance associated with user fee rates for ambulance transport service are hereby repealed. Section 3. Severability. If any portion of this resolution or the application thereof is held invalid, such invalidity shall not effect the other provisions or applications of the existing ordinance, which can be given effect without the invalid provisions or applications, or to this end, the provisions of this resolution are hereby declared severable. Section 4. Codification. This resolution shall be codified and make part of the official Code of Ordinances of the Village of Tequesta. Section 5. Effective date. These user fees shall take effect 60 days after resolution is adopted. THE FOREGOING RESOLUTION WAS OFFERED by Council member who moved its adoption. The motion was seconded by Council member 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 day of , A.D., 2001. MAYOR OF TEQUESTA Joseph N. Capretta ATTEST: Joann Manganiello Village Clerk Word/Resolutions/Transport Fees a Me�o-r�a��`a��Z TO: MICHAEL R. COUZZO, VILLAGE M R FROM: JAMES M. WEINAND, FIRE CHI SUBJECT: REVIEW OF EMS TRANSPOR F S DATE: 1 /16/01 In accordance with Ordinance No. 523, Section 9-54, Determination of Fee Amounts, and the directions given by the Public Safety Committee to review the EMS transport charges annually, I have attached a spreadsheet denoting the surrounding advanced life support providers and their current fee schedule for ALS transports. For comparison purposes, I have included a column titled Four Mile Transport. This column was added to denote the total fee associated with a four- mile transport, which represents approximately 95% of our transports in the Tequesta area. As you can see from this spreadsheet, the average advance life support transport rate, with the other associated charges is $323.75 and the average mileage rate is $6.52 per mile, making the average four-mile ALS transport $349.83. Therefore, I am recommending that our EMS transport rate be adjusted to $320.00 per transport, and the mileage rate be adjusted to $6.50 per mile. These new rates would denote a$346 transport charge from Tequesta to Jupiter Medical Center, which is just under the average of the survey. This also equates to a 1.76% rate increase over this years ambulance rates. When this service was adopted by Ordinance, the Ordinance gave the ability to adjust the rates on an annual basis by resolution. Therefore, I have attached a resolution for the Village Council's consideration. If you see it fit, please forward this to the February 2001 Village Council agenda for their consideration, action or comments. ( would also like the Village Council to consider adding an ALS Level 2 user fee. This level 2 charge is important to maximize the revenues aliotted under the Medicare Reform Act and helps offset the cost of additional medications given in critically injured patients. For example, we are in the process of revising our medical protocols to include the new medication called Amiodarone (see attached article). Tequesta Pharmacy has quoted us a price of $90.00 per 3mg. A 3mg dose is what is administered to patients requiring this type of treatment. This medicine is primarily used in critically injured patients (usually Cardiac Arrests} and studies have shown that this drug has increased the survival rate by 27 percent, when utilized. To the best of knowledge, � no other EMS provider in this area is using this medication; Tequesta will again be the leader in pre-hospital emergency care. During the negotiated rule-making cession of the Medicare Reform Act, ambulance providers and the International Association of Fire ChieYs were successful in demonstrating to the Medicare Officials that critically injured patients cost more to treat than what is currently being reim6ursed under the existing fee schedule. Medicare agreed to an ALS Levei 2 rate structure and would reimburse at a higher rate if the agency had a higher rate charge, if not they will reimburse at the ALS level 1 rate. #; � I recommend that we establish an ALS Level 2 treatment rate of $465.00 and $6.50 per mile. This will help offset the cost of this new treatment and maximize the insurance reimbursement revenues available. An ALS level 2 charge is determined by the following Medicare definition; Advanced Life Support, Level 2: Where medically necessary, the administration of at least three different medications and/or the provision of one of the following ALS procedures: Manual defibrillation/cardioversion, Endotracheal intubation, Central venous line, Cardiac pacing, Chest decompression, Surgical airway, or Intraosseous line. Another factor to keep in mind is that it is always prudent to keep our transport and mileage rates above the current Medicare allowable, to maximize future revenues. If you have any questions or concerns, please do not hesitate to contact me. JMW/sd Attachment 2 « . 2001 AMBULANCE & FIRE RESCUE FEE SCHEDULE BLS ALS Other Mileage Four mile ALS Agency Rate Rate Fees Rate Rate Transport AMR Atlantic Ambulance $317.70 $317.70 Oxygen $28.10 $6.80 $373.00 Boca Raton Fire Dept. $195.00 $297.00 Oxygen $25.00 $7.00 $350.00 Boynton Beach Fi�e Dept. $289.00 $289.00 $6.50 $315.00 Delray Beach Fire Dept. $218.00 $300.00 $6.08 $324.32 Greenacres Public Safety $197.00 $280.00 $5.70 $302.80 Lake Park N/A $400.00 $7.00 $428.00 Lake Worth Fire Dept. $310.00 $310.00 $6.00 $334.00 North Palm Beach Public Safety $310.00 $310.00 $6.00 $334.00 Palm Beach County Fire Rescue $225.00 $325.00 $7.50 $355.00 Palm Beach Gardens Fire Dept. $297.50 $297.50 $5.50 $319.50 Riviera Beach Fire Dept. $340.00 $340.00 Immobilization $16.00 $7.00 $384.00 West Palm Beach Fire Dept. $340.00 $340.00 $7.25 $369.00 Tequesta Fire Rescue $315.00 $315.00 $6.25 $340.00 Martin County Fire-Rescue 342.10 342.10 6.71 $368.94 Average $264.02 $318.81 $6.52 $349.83 Current Medicare Allowable BLS 198.81 $5.00 $218.81 BLS Emergency 230.95 $5.00 $250.95 ALS 314.09 $5.00 $334.09 ALS Emergency 330.16 $5.00 $350.16 ALS Level 2 367.67 $5.00 $387.67 ..- -• . 11 � � �� . � �. •• � �• � • � �• �i * ;, <:;�"� ,q�� ' ' ""�"� . ;:�� . ,-. • ** , � t,` �:: =� :.�,:.. •&�.. _ ,�;,:�. f��:� _ = t °�` ;; : ;, n �_E -'t ��r , ;�.. , �.`�' .,��:. , . .,a:��. ��. �� a, -,��i;> `";�"t:: r.-� .ip .;AS;�,: I � ' ' � 1 I��II��il��l��t�lf��l�l��iili��ll��„I,�III��1 �XNCPMX **•'*"*'�'*" 3-OIGIT 334 T�EQUESTA UEM O1JAN 1 4 PO BOX 3273 JUPITER FL 33469-1004 . . >�--. - � . �. , ,r.'_�..� � '� � �f . � �, i "� � » �i:. � ��' : �. ' '�,�.. . �:; a ; ;,� R � � � , � . �.+ .�� y . . �'. { . . � , � .'� ' t ,� . , � . `; �,. •:... . x`,-_".;; : � � �. . �. :.�R �; � � �,,: � °* �' r: " ',$S'�' i'�n: '�'' . s 9`. a,' .i` • ;t.- . �� . ' � ., �v: i „ ' '� ._ .�.f,. .:.�,� q fi.i,� ¢ � �h ; .�' � F-� Y�, '~ � y 2 , . .ai 7E" ii# ,� � '. �•'y ' ' n� ' � , "�;� .,. '-,; 3i�'� �;' . 'c'� . , •sm.#'�' .,.,�'�,a`.3r� , . , 4 �, . .4" �," : , . �a;r� . ' ;t;x, r � k° .; r • .�ks ' �` �..2 �� ,• ;F ,��.. ' . . ,`. , - � � . �, . ; � Ay : � .�. � . . �� '� ,'.,}� -'�' �� < .F^,.p,.'�f ' " W��. ' . '�'� " a . . : r '; - �;i' ,� �'S , ., t w $ ; r .��>�F : . ' F - r.. ' ' i� �'r:,,.,�'�' •"� � VERY 90 SECONDS A PERSON SUFFERS SUDDEN '��" �� ` cardiac arrest in the United States, with 60-85% $ ° k °' f � ' . * .:;.': ; �. 3� experiencing ventricular fibrillation (VF) or ,.�"�,,� ' ° �: pulseless ventricular tachycardia (VT) as the initial '-: •�'' _ `.�� arresc rhythm.� Current advanced cardiac li[e support �"��,. ,.� :k'.:- :`"`'� i, ' i M _ � (ACL's`j gttidedt� adveft�ate ¢IecRical shock as the pri- _. ;.: r : ,�;�°, �,,_� !�;�; . mary treatrnent for VFM to simultaneously depolarize • '' <�,>. .-�,�;as:;. . .,; �' �•.._ ��;" ;�.., .' cardiac cetls and allrnx the natural caxd'sac electrical sys- " ";�"�=;' .. . , . _ '~�� tem co inidate pacing.2 -•._r . �. -}�' �. . ,; .: 3, • .,. A criacai appraisal oE prehospital literamre r�veals . -',:, ,` � litde on the pharmarnthetapy af cardiac arrest. Indeed, ,�, �'_� a tht ma'orit of dru s used in cardiac arrest have ; d � j a i �� ,�.., J Y g �: . .?.'� :. :� i rema a part of the EMS azsenal based on tradiaon, �` ' artecd te or inference.}S In 1997, eter Kudenchuk �` o- "` �"'� ° # ' and h�3 collea gues, evaluating the _ cacy of an exist- �. >f. ing att�iarrhythtnic Eor out-of-hos�ital cardiac arrest, - ..�.��,...._, . . n[11i�ted a omized stu�y known as the ARRES? �', - • .'� , ,. � f ' on -H�411 R c� 'on of�, . , ' - Refrac�ry Sustained Ven[ricular Tac�►►yarrhythmias),13 + _� .. � The study compared standard ACLS protocok for '' '. VFfpulseless vf with standard ACtS protocols plus N °` '"�° �` .<. V� . a amiodarone for 504 out-ot hospital arrest padents,� The �. �.a. . ° dara demonstrated a 27% increase in the overall sur- A 4>»,.� :,-. ,�, � vival-to-hospital admission of patients who received i ,�; '; amiodarone when compared with standard ACLS, but j . ..,:... . "? t10 significant change in the overall survival rate of ' � ,�..`;� ` patirnts discharged alive (rom the hospital. � ',<:;. ',�, �°. S . w - :Y , '�.� � ., •. , . f6: . � ' ' '"Y 'y'!P:.� i " � � ;x} , :'.'�.�„%: h S' : ar., . ' ' ' +. • sB''..��. � . h. i'Fate�s �]1j�A�F'a�f.. .-1 . � ��d+'.L� ,.4 1. �:. '. ' . � M � � y�.} Y{ �� ..&„ . '��:_: �_ � _; E^ 1&Y[ 1�' .�'� a. ... "� E � �: f� �. «; - �: f' AN OLD DRUG W1TH NEW IRICKS � ' _.___.._...._...__._._..__.._..–.--.—_._� _.�..__.._T.---._.__ _.._.._...�.__._.........._. __. _...__._ � The ARREST tcial has significantly affecced �he culture and M science of prehospital arrest management A significant number � � - "" • of EMS systems have now incorporated amiodarone into their protocols (see p. 72), and the new American Heart AssociaRon ` (AHA) ACLS guidelincs will likely include anuodatone as a key � component in rhe management of shocic refractory VFM. So what is this drag? How does it work—and why? To understand how amiodarone works (or Eor that matter any I antiarrhythmic drug), you must first understand how arrhythtnias occvr. �� iS �Of YHIh'ICII� �I�IIIIIaS VF/V7 occur for many reasons, but they have one ultimate cause--e critical alteration in the elec�iral activity of myocar- dial celk. Research indicates that three unique mechanisms commonly rnntribute to the forn�adon of venuicular arrhytii_ mias: a6nornial automeuicity, triggered activity and re-entry.s • Abnormal automatirity occurs when spontaneously gener_ ated impuLses occur in depressed cardiac tissue. These ur►puLses can appear in any locaaon of rhe heart, even in fibers that would not possess the pmperty of automaticiry under normal conditions. Accelerated idioventricular rhytluns and ventricular tachycardias that occur several '� days post-myocardial �fanction (MI) are common anhyth- mias related to abnormal automaacity.b � • Triggered eutivity is commonly initiated by fluctuaaons in Maximum Durability Maximum Value �� o . i'I. �i �� -;, The Nonin 5500 � Hand-Held Pulse Oxi meter has proven its durability and versatility in hospitals, clinics, and EMS agencies worldwide . • : , d piatiSetS Shock and Vibration Tested wt+o receh�ed amiodarone incr�ased 279G wl�en USAF Approved for Aeromedical Use eampared with standaM ACLS l00 Hours Battery Life—Memory & Printer Options Weather-prooF Carrying Case—Operates Below Freezing �. • When ypa want tne Very best: Sele� NQnin! �' �d��i� !�'�a�ib�i a�l ar �� tc�_r#� ' i 1, ,y r� s 4�r' F� to rl , p {a . �.x � � j ' t � ' V' � 9 �'�M � ' �;� k,� n�u � ,f ��i ,�;�� d s a ,,� �, ';. °" � �@� '�" y �''��9�+�'. ' �"rI ;'c �,�$ �'� 5 yk9 P� �ni � : �. � � ��4� �,�" D y f� .� J ��. n � � i '' i�;:� O Z � � y w 0 i ,o -_. _� o z • a Upon successful IV ac�ess, the amiadarone a(gor�m calls fur 1he rapid administration of 1 mg af IV epmephrine foQowed 6y 300 mg of IV amiodarnne, For More Information Circle A56 On Reader Service Card �hen a rapid 10 ml Aush of nonnal saline (NS1 to iaci4ifabe drug delivery. 62 JEMS MA1 2D00 �i9ore �: Richmond Ambulance Authority _____ _ _ afterdepolarizations include catecholamine dependent � an� Cardiac Arrest Treatment Algorithm �, VF/VI associated with ischemia and reperfusion mber and VT associated with digitalis toxicity (due to their hypercalcemia) 6 aaon = • 12e-entry is the generation of an impuLse through assue a k already acavated by the same impulse and is thought � to be a cause of VFM du " the ear P�Y � �Y P� � Z. ,. _ __.._. ,_ .: ,. . of myocardial ischemia. When a patient in VF/VT • any ` ARfiiytttt�a �5isis ��urs �Y Ux'ee ShueR3 .,. experiences a sudden loss of puLse, several major body how Continlfe£�Rs reactions occur. Sudden dramadc loss of blood pres- (nt�te at unc� �nd .. - -... sure causes a massive dump of epinephrine, norepi- -; Qb�tai�1 {YaEC�35. <.�,_ nephrine and acerylcholine, creaung an unstable elec- �m�� T �� trical state within the heart, Iowering ventricular mate R �� depolarizarion thresholds and promoting influx of cal- ocar- ��'� �� cium ions into the cells. Acetylcholine promotes the isms depolarizaaon of potassium-dependent membranes. 1 �_ These significant changes in reftactoriness are the _ , _ . _ -: common basis For re-entry arrhythmias, such as >ner- MityfhmW pets�s�s 1� r�GUrs kP.ta'e arrival at hospilaC e��,y depa�trne�t .� ��T- hese Admi�►��r �d tt �i4Ci� 4J pt�Ld�1e b�hefit in it[e fitltowing se� n,n :• li�or.�;�►� �.��, t.5m�1� n� consid�t'r��l rlt i�e ta1N� lp.�� a m�d�um lhe histay of amiodarone dose a� 3 , ticity �� <" Amiodarone, fust synthesized from compounds lmown as :u lar •�1'P�ytiuttt S Iit�tkt} tI�P: t'e�e�E iR � 1t�� tQ mglic4 benzofurans in 1961, was originally marketed in 1967 as veral •�� '�� g �� g � P � $ �� an oral ana-anginal agent because of its potettt va�odilatory � S�te af reit;li:tot}r 1� 11 � efiects. !n late 1985, amiodarone received FDA approval - Prowv►��de �mgtmi� ��► ta� t7 m � ��'"� ' for use as an oral antiarrhyihmic a,gent in 1995, the FDA u � +�� approved IV azniodarone for the treacment of otherwise � �� ' uncontrollable, life-threatening vena arrhythmias. i z , � �2CtrDpf1yS10{Q91C Cf1�I"dC�l'IS11fS Of 8tI110I�'ORB Amiodarone may best be described as a broad-spectrum a . antiarrhythmic agent with mul�ple and complex elec�o- AFrh�nid pp#'sisLQ or recuts afEer arrivat at bospital emerg�nq� �Ep�r6qe�f ,_ physiologic effecrs_ Using the tra�uonal Vaughn-�llimru lY kmid�l°4n�. ; - Antianhythmic Class fication for drugs, amiodarone is cate- $uppldnE�at 154 mq itrfnsians adittini�Cerad oVer 1Ik�3U iitlqute9. gorized as a class III antiarrhythmic drug similar to ' Nt4 tnn1E t11ap SiX to eight supp�Ementat iniusigits pe�' 24 f�ot�(s, bretylium (see www.jems.com). However, amiodarone .> ....._ ,. .. . ° possesses electrophysiologic propetties oE n1� rhe Vaughn- ; �, Williams classes. • Class I properties include significant inhibition of ,_._. .... .. _.� . sodium channels, with impaired recovery of the krrtiythmiapersistsnriizcursaEhuspitaE myocardium due to its membrane stabilizing �` Cpnsider emetgen�,y abtation a+'surget}E. properties. - - • A noncompetitive anu-adrenergic blockade is attrib- uted to amiodarone's Class II eHects, contribu�ng to a negative conducrion chrough the AV node and pro- lon��on of che ERP oFall carcliac tissues. • Class III effects cause a delay in repolari�a�ion and an �ncrease in action potential duradon, resulting in the � �a a� n� �d� �r a��d nr ��n P. or� No. ��.r �na d��► �t m� �a,m,eM � � lengthening of the eEfective reFracro riod ERP in ' � emergenq medicuro. Yrginia Commonweala Il�uvers�ly. Medicat Cdlege of Ympnia. Ricfimond, yi TY Pe � ) � atrial, ventricular, atrioventricular (AV) nodal and w • His-Purkinje tissues. -� the cell membrane voltage that cause afterdepolarizatiotts. These • The Class N effect is primarily in}u6ition oE pota5siwn channek, - o afterdepolarizations are membrane oscillations that rely on the which prolongs repolarization in atrial and ventricular tissue a upstroke of the cell action potential and may be Eurther defined as (prolonging repolarizauon ame reduces venti ectopy). The 'apid early or delayed. Torsades de pointes (an unusual form oE ventricu- occuirrence oF venu 6bri]Ia6on is reduced after amiodarone rone, lar tachycardia with changes in electrical axis) is thought to be administration and thought to he due to these C►ass IV effects caused by early afterdepolarizations Arrhythmias due to delayed and improved intracellular calcium stability.�,�z.i3 M6Y �nnn i,-�� L9 , ANOLDDRUGWITHNEWTRiCKS WEAR YOUR TRAINING AIDS! _._........_.......�_..._..._......__....._... �._..._._.._....._._........_._._....__...._....__. _...._..._..__._._...._.. Padcaging Wyeth-Ayerst Laboratories manufactures N amiodarone under the trade name Cordarone and packages it in a single-use 3 mt cleaz glass ampule, which contains 150 mg (SO mg/mL) of amio- darone hydrochloride I'his packaging limitation requires the ALS provider to with- � cUaw medication using a needle attached to a syringe. The man- ufacturer is in the process oE evaluating packaging more con- ducive to use in acute-care simadons. • Nwl S�i In�ic�ons 8 dosing • �•e�.r s� • KMle N amiodarone is indicated For both the �eatrnent and prophy- • EK6'� . iaaris of frequendy recurring ventricular fibrillaaon and hemody- �� namically unstable ventricular tachycardia in patients refractory �� • HuwN Pluw�e to other therapy.0 Because of recommendations based on the `� • Pn�e T�il� ARREST trial, Joseph P. Omato, MD Richmond (va.) Ambu- EK6 CHEAT�SFIIRT • SbIR C��ts ]ance Authority, developed a modified ACLS algorithm. it rec- � F.A.E. ommends a prehospital dose of 300 mg (6.0 mL) of N anuo- "G7►eat Shi►ts' are printed upside-down p� �e (�t (� �e wearer, � dazone for the patient in pulseless refractory VF/VT when three 'Wafch-my-Back Shi►fs' are right�ide-up on ihe badt for your parU�er. initial attempts (2ooJ, zoo-3o0) 360J) at defibrilladon fai1. Check out our cool T shirts filled with invaluab/e If VFM persists or recurs following the third defibrillation information fior nescue and emengency personnel. attempt, the protol dictates that the provider immediately conanue CPR, intubate the patient and establish rapid IV �'��' �� access (if not already accomplished). Upon successful N access, the algorithm c�lls for the rapid � S'' ��.t(y,`�•�� `�� administration of 1 mg of N epinephrine followed by 300 mg of IV amiodarone, then a rapid 10 mL flush of normal saline (r►g) F°r M°re IM°rma�°^ �� g �� Reader 5etvice CartJ Sfay Safe & Warm � From Head fo T el G . PulseOx �v � CO in one! � ceroa a,� W � • ? � � � _ - � `�--�_ �. ; �. � Allia.nce � Medicalry Find Great Deals! , , s Sell Items Free!� G� • s� � allmed.net l`��' a med.nef ar»� � : �='-��;�'• Diamond-LineT"'' �' -'� :`�=::�.__.._. Brass Regulator N amiodarone is indicated for buth the �- �',`�=`_ y ". ��. o with built in gauge! treatment and '� �';=`:=��==' � � �� proplryfa�usoffrequenti�rrecurringventricufarfibrilfation Oniine Auction ��''��"'`�� artd hemodynamically unstable ventricutar tachycanlia ia �t'i'C1::1� RF.G(,[.. tTOR.S petiertts reffdCbury tp other thera{1�. Ph(888)633-6908 • Fax (800�ALLMED • Onfine www,a�imed.net For More Information Circle /60 On Reader Service Card u a v , . . ., r_- -- .� . ", : !� ,� _ = . i f� ,a � �� .�, i�,:, �, � AN OLD DRUG WITH NEW 7RICKS ` ' � _...- ' to Facilitate drug delivery.► If VFM persists after CPR circuladon of drugs (3a(p ��_ onds), the algorithm calk for immediate deEibrillation (Eounh `� shock) at 360 joules. IF VFM still persists despite a fourth �f shock, the algorithm follows standard ACLS protoco]s. les important to note that amiodarone is given immediateiy Discover the following the bolvs of epinephrine—there is no waiting period between drug dosings (see Figure 1, p. 63). V anner Advantage! �plf�j�djC�011S • 1,050 Watt Power Inverter • 55 Amp Bottery Chorger/Conditioner �' ' There are several distinct contraindications for the use of amio- • UL Certified ta Federo! 5pe�ifi�afion darone in the patient with a pulse in ventricular tachycardia. KKK-A-1@22D -" ; �; . . Amiodarone is con[raindicated in patients with cardiogenic . • Underwriters laborabries Usted '� shock, marked sinus bradycardia and second- or third-degree (UL and C-UL) r>,, AV block, unless a functioning pacemaker is available. However, '�moh Monitar Con►rol S�Slem `„" in the presence of life-threatening arrhythmias, such as '�nverter Lockout Control imerlack k " u A � VF/pulseless VC, the only true contraindication to the adtninis- ' tradon of amiodarone is a known drug hypersensftivity,v.►o,is Designed specifically For EMS vehicles, the 20 OSOCUI combines a Amiodarone is administered via an IV and cannot be adminis- powerful DC to AC power inverter with an auromatic 6attery cered via an endouacheal cube. charger/conditiuner and a 30 Amp AC lrunsfer switch. :ded` 800—qC PQwFR �sit our newly updoted we6 site at: �ad Po E �,�� wwwvanner.com e-moil: pwrscles@vonner.com For More Information Cir�cle #r82 On Reader Service C� M . r �� QF� U� S�r-ur�s � � _ .�::n` � " : "� - KKK and NFPA : .. : � ,� ` ',::`. � packages available. .. �;:,,,- ,, ► � � ;:< , � a, , � - .� ;, ;_` `� We can su I atl our lighting ;,��. . pP Y y ' f.- ' and electrical needs: ' ` � � ' ��` rnarket-exclusive combination Z `�:,�'' . ha/ogen/strobe, strobe or halogen only, W incandescent lighting and V-MUXT"+ � fhe leading multiplex electrica! sysfem. 0 W 0 • �� The comentional method of circular swirling of an ampule to ensure �om- Z'ec�arnolo�ie ][,� plete medi�ation transfer to the ampule's main body is not advised when using amiadarone. Amiodarane s soap-Gke consistency causes excessive Tot{ free: 800-989-2718 foaming �o occur when agi4ted which can m�Ce �� re website: www.weldoninc.com • e-rnaf�; wtisales@weldoninc.com moval di(6cu� and reduce 1he overall amount of drug yv�hin ihe amp�le m�n 6ody. Light Bars • Emergency Lighting • General Lighting • Multiplexing For Mora Information Circle R63 On Reader Service Card AN OLD DRUG WITH NEW TR(CKS ._.__....__.......____----......_.._._....---------......_� ..............._...__......._........_..... ........_. __._ . _. __ __ WHERE ARE THEY � • �� When You R[eed Them? Nypotension and bcadycardia are side effects that can and do I BE 169 occur aCter IV amiodarone administration in patients with a E Nyion coated 12" stainless steel palpable pulse. Postresuscitation care of the patient who E� security wire with steel [� receives iV amiaiarone should Eollow accepted ACLS princi- � � oxygen wrench. , ples of care. :. �' • Bradycardia is likely a side ellect of amiodarone's mulaple electrophysiological characteristia (and the reason epinep�- � I rine is rnncunendy administered with amiodarone). When ! associated with serious signs or symptotns re]ated to the slow ' • Keeps Ilowmeter or oxygen w�e�eh rate (chest pain, shortness oE breath, decreased level of con � fmmediately available wfien needed sciousness, hypotension, shock, pulmonary congestion, acute �' • Durable ateei conatructlon MI), heart rate acceleration is best accomplished using conven- i � Elimirtates misplaeed flowmeter or oxygen wrench CtOi18I ACLS gllld2llri25 induding transcutaneous pacing, � i • eas�ry tnsaned a�opine, epinephrine or dopamine_ Transcutaneous pacing is I ; BE 169 3 ' Steel Oxygen Wrench � - ._. � ��' : �, � ,��•.r'r:.. . _ .��' . . I BE 167 �, � Nylon coated 8" stainless steet , � �� . ' > > ... l flowmeter security wire. ..`; rii ., For more infortt�ation on au ,� _, .� � , . , � oort�plete fr�e of aluminum and . � �.';�s .': �� .� z n. - ' rK ,, . , ., . IasticmeAfcal nenlscontadw: e'�'"� ;�.,�'. ��"�'. . ,,�.��, �,.�" ��s"�."'` " � .� . ' �;�..,.,,_ P �P� '.: -,�:. -�r i , - y . ti:. , •. "' "i,�,l�;d;�';'�s�" 't'�''� �.t..:�'��i::".�.�!c2 '4iy;. f� ..,��.: 4,hN',e`-�r:!',.`: � Instrumentation Industries, Inc, - ��` „�"�"� `' �� '''�' ��., ��' .,. 1-800-633-8577 ae�';'P'°:�'`P ,5�° �� F'��'.�.� www.iiirespiratory.com sar5�ia.respw.t«v.wm For More Information Circle M8�4 On Reader Servioe CaM � • � . � � i . . � I � . I . . . 1 �� ` p O :,i ,. ' ' .. , .?LSri'"r,,:»�•:Y;i.. . i '"�,:, I t�Q '�`t� G��4�G3Lt��4(�O�iI : f' � �� ,�:� �� ' � ;aiY ��5 ti�'�c� ��Ck '� w��-�� '" r $ ,��- � T .. '! �� '��fi �� ,.� :.... . _ � : >. , ,..�� ,.,.. , ; � o . ��,�a� e r � t�� , e��„ . :�: �: - �� . ,.. -� p�st few wee1�S: , a,. , x .<.: ;, -. ,; : .4 � .. ,'.�'��. "I.eYs se¢: Tw�t u��ti��s i�+� �� t}'tult�'e� . ,. ,` un�t, .;: That's a tvtct�: of t�Fee �rirnar�+ r��e� tw�r b�p�; ` �„ �;� �,, t�. ;� drug 1�ags ►vith tl�re�.aii1�1�� each, an� w�'ll need urr- six �rh�u(es ,��r a�t�' stc�ti�t� 31ack_ 3'{tat's 21 ampc�les :� • amiodarone. t�bw much w�il. thdt cos.t?" � �I e�tecke�! with t3i� pha�n�y; that �Gii! be $Z , ump��es }z�cause we cc�n only order them in �0 �c�x�` ' '�` " Wf�at2 Th� mwciin.urri F tan biti the ��3n€��t;4 $230. Ij �e use two 1�0-mg amps of amiodurc�rte nt u e. of Sf 82, then add in other medications, di�posRbtes �� „ � cds� o� the tne iiE uri�d r�s�qnss vehi,�l�, Yll be losing :i�i4 '` Qn my Curdiac arrest tc�11�. ° ,; ,� . It se�riis li�el�+ klt�t apniodarott� (Coxd�rone ��',, Wyeth-A��rst) �� "soo�i j� added Eo parameiii�'- "' boxes a�edss th� �ountry. The drug represe�hts the �i;� � ``""'" ex ensive medication to ever be widel p _ y introdueed, j � � �w the prehospital environment. Many EMS owt►ers a,�� . � � - . . , � � � � � �� •�- -• managers are having trouble coming to terms w� I; i; ' �' ' stocking this new drug with its related cost, while ti� n �. For More Information Circle N65 On Reader Serviee Card " �' �r.; t !� 6R iG�uc w�v �nnn _ often considered the preferred me[hod of heart-rate acceleration while attempting 1V access or waiting for atropine to take effect. w � do Bradycardia unresponsive to fluid boluses or with proFound th a hypotension may require further support with vasopressors.z �vho Hypotension may present as mild or profound after IV � inci- amiodarone administration and is possibly due to the �` �� ' polysorbate 80 additive. Mild hypotension may respond to �•� • +� � � .. � � tiple fluid boluses (150-500 mt of normal saline) in the �ph- absence of overt heart failure, whereas pro[ound hypocen- `hen sion may require Eurtrer support with vasopressor agents slow (e.g., dopamine, norepinephrine, etc.). ' ' � � . � ! con- Persistent ventricular arrhythmias may necessitate initiation cute oE a postresuscitative infusion of an antiarrhythmic. A main- ven- tenance inEusion of amiodarone following a 300 mg bolus �ing, isn't usually required because blood levels remain etevated tg is continued on p. 73 , ;�- � face an uncertafn Ai.� reimbu�s�^m;�nt futui Althq�xgh amiodarone is expensive it mag well repre- ; sent an impa�tant tuming point in the eveluriqn of out- of-hospiEal care-.-placing expensive, cutting-edge �ned- ications into drug boxes that have changed little in the past two: dec�des. 1� the cohtext tzf card➢ac at-rest patients, such n�w in.terventions ate sqreiy. needed beeaus� the survipal rate of ar�est patients has al�o r • � . • . changed �itt{e during the same period. The upcfmistic view is �at by placing p� �edicit�� i� thg loop � • . o�' newly evotving intei'ven.tiqns we may �dv�tce tf� �_ qua�ity of eara w.e bring to out �ta.tierit�--at an • i�tcYeased, but t�ECessary, cost. �' For yFars, EM.S 1�as e�joyed relative insvlatio� J�ram � the world of expeasive p�tented drugs. T)te rcason: I�(ost � drngs rve've used are i�expensive, simple, eas�r to �anu_ o facture, generic ro�npounds. t1 pre-filled syringe of � � �. � 1:10,000 epinephrine costs ab.out $3. In the early t990s .� * ' . � we added adenosi�e (Adenoeard) co our dnrg boxes. At • •' •• • •- • •. �erat �30 for a 6 cng bottle, that seemed expensive back then, ; the but its impact o.�' providing a much safer anc� effecdve � � • treatmettt for SVTs than previous inedications has been �-�, • �onse unquestionable. � ' k-up A decade later, enter amiodarone—at about $180 per � '• - �ther (300 mg1 dose. A hefty price as prehospital drugs go; bi�k „ , es of to f�lly appreciate the drug's price tag you need to con- � � �� s�der the components of modern drug devetopment, mar- • •. •- � rr 30 ketiag and the associated casfs that dnig companies iricur, � • -• • � - • • . pt �s Factors that inftuence t�e egs�s of newty released drugs cosi � Reseatch and development costs; � � d the • Drug development in the laboratory; oney • Legal and administtative costs to obta'in patent(s); � Costs of federal FDA.mandated studies Call (800) 434 to order or rom • Costs oE clinical trials visit our website at http :��Wyyyy ,vortran .001'Y1 dn�g � Advertising; most • Mailings to indivicival providers; - ' � .• :d to • Print advertising in medical journals; �. , :,, � tr and � Detailit�g,by regional drug representatiyes; N'��h • On-site displays at major medical meetings; �' they • Miscellaneous educationaI materials (videotapes); ' ' � ' � :i� ., cont'rnued on p. 70 ,�,, � . . .. _ . ..� Amiodarone: The Cost oJDoing Business continuedJrom p. 69 • ProEit margin; and :� • Need to maximize profits while drug is patent- .> protecced. First approved for use in the United States in its oral � Eorm in 1985, an IV fonn of amiodarone was subse- quently deve�oped by Wyeth-Ayerst (at the FDA's request) and released a decade later in 1995. That � process, as wel] as the funding oE ongoing drug studies, �' educational programs and marketing, has represented an expenditure oE "hundreds of millions oE dollars," according to Philip de Vane, MD, vice president of clini- � I cal affairs for Wyeth-Ayerst. Despite a need to recoup these expenditures, Wyeth-Aqerst has pledged to �� dampen associated costs of stocking amiodarone by exchanging dr�g vials as they expire. [t would be naive to ignore the Eact that tHtte pharma- „: : ce�itiral industry is big busi�ess. The companies have an � obligation to their stockholders to xnake profiks from the � � drugs they develop and �nanufacture. When a new drug ;;: , is rele�se� onto the prescription market, it almost '� always arrives with a heEty grice tag. Newly develoPed d�e`ugs are protected by patents to ensure that only the pharmaceutical eampa�y that devrl- fi� ^ ope�t thtm can produce them. During this period, which ?� - typically 1ast� five to seven years, drug casts te�d to be high because co�p�nies maximiza profits wtule having the Iuxury oE no m�rket competition. When the drug lASes its pac�txt. prote�tion, other drug manufacturers can �' groduce gei�eric ee�uiwalet�ts, whic� results in a sig�if'i- K cant priee decre�,se. T�Jyeth-Ayezst's atnindarone patent., �+nder th+� hrand narrce Cordamtte, eaEp�res in 200�. So wh$t challenges doe� amiddarone pose co EM�? First, setvices must conskder the ecott�ornic irFtpact_ Clearly, when an extta $ t�60 is added to every v-fib cardiac '� arrest proGt margins t►arrow ar can become non-ex'tstent. °°� � �;r, 'a r ': �-� ,, ; , ., , .. � : . . ;? .�'�p, '�d�' +r�s`� "'i,i A f � r�� . 5 '�1� , �� k i I ; ..r � �ba� �`''��.� � . . ; ,;: � , Y �; ° .�'�1..,.�II� I .:ie �'�:,:�V�V:Y�� ,��A��:r r'i:.a. ,. ., ::,;r�i,; 'J � i �';+i1t - 6( „ % � �, , + y ., y F � � � P kj NA�""' ' ,�. �.r: � .�"�1 ,y. Y.�,lat',�. �� „�h, '� { q ;�F , a : ':��.';,��., .:'(, �. .9�: ��yQ Jy„ � _ ' � 1 � I� �1 � �O lEMS MAY 2000 _ �� '. Sj1 ' . _ � �.� 6b99 �x� `L��S°99Z IOQ��} if�a as�a�d :� . r `a�e� �oi�d�a��qns l�o�a�npoa�u� - :,; , � ,. � .. % , �W� �� qia�sqns ��., .: � ,; �� Fs � : � _ �� - - �. °� •�e�.�a� p�aa-o�-ICs�a - ` E:_ iry � u� �a� �di� �uawaCeu�ua ��ad :� , � Y �,� u�inn a��a�snr►au l�fa�i��w e �f��.�;� , �; �;,�� ..��a��n,iadns pue �aa��ueW SW3 ao� . `�� . , - _ � F:; � � v`'.{ 1 ; F,� 3, v^� " �� h`'` � t,�h �,n� r Z�y ` �� ry I ; � .. ,�"E» Y i a�t�i�t��» t ��fi'�"�.{ �'i��'1. �� "'� . _ , b fi "�.. : W� v 4� 7^" ..'. �r . � . .. ��^v"� { u> ,��. � .., � � x 9i "�' ��. T �` 4 �3' s3� 1 S �, _ . . "r� ��. ��%�� S � �t ° � � s�� 3 �ax�" �� 6 '� �y�l�'� - s�, n ti '� a �` �'. r 5� 6 �. �: 4 f :. � . . . �. `f �ir"� n, .7 �i f 1 .,'�,r?s �' i � � � :: ! ' � (s v � _ �;.. . ,.. _,..l.L. .,i.�.,��vh... . � ,,..s;,.: g . ..�t:, ; d ' S 1; s ,: A t �� +4 s 1 t �� i � s s... 4r' '.e � � � � � � ,��; � t ^�fi� � � r , � �� , ; �2 � 4'�. ��."^ _, ��' ,:v�ec ''d _� �k.'..V ��''`� e 7 . Q Y ' i& -. �,.�� ;�� , .'� �'�� " 9 �F � � � � : C v iC ! � ��{! 1' S.,- V " ^� �':: 'M y 's .x....a .,� At :a � e'`!' � � 'En ' } .. . w' WY .# ,��, 'r , � k d � d.5 Y� A ( �: i� -: p Sp ' 4 . 5 j ?� `,�� _ � � � + �� . n � t'�. kc?�k �1>� Se� a� �.�i , .`ee s1 � :� r 2 � � �� - w y � 1 a s r`� �.� �s °�'�� ' " � �� > " s, �� v � - � i �� l � k ,j ��'� �, �:,r t �,� �e � . ;, ,{ . . , SS ,P��,� n, .��1�'"�r, �''': e ��. �1 � Q s . ' . P - FG 6 �� j ��.'4 5 i3 � � t � � �1 . '�� k�ey : . 'k r �� .�� s � � v r k � a i � � , � s c;. .- i 4 :�"�+ e i n rt�� e' �gy �:��.��,e, r a� a ': e� i� r R , � ` � ,c-� � : .� �� `:.. , ,,... . ��. � _. ' �. .: ' . . ': �.�.: �'� q„5�.:: �+ `J S E C ✓�:. Y � • N •.. . ti � .., . �o . ... . ,: 4 ,- �:..,: . ° f� _ �. ° : '' �a, , � 4 t`;� 8 „�t .: ti i �, afc .,��@ i � � °�'. ��'e . .� g �`� n :a ' ��`L �. • �� . . ,�� t. �.i , .+a e �t ..t p . i a. . �� , e . "_„ £ . , ' ,� �� 75 . . � . .�, ; :, ,. . �"� �X:,. ,r � . "..;. s..�. . . . .. . fi . . �q n u n .e�¢* a;. o t . - -. ,._ . " .^_ . .,Y . :�. . .. _ ' ' . , `_ . [ '��( B ` L� . ii: {� �I � : i ;, � aD 1C ' �' 0 � �"b14� `�� ! i'S' r � . ..i . � . -. � . � .. � " �• ... �. :. . ,. ., . . . C 4'. Yi � k 1' .0 t,�i:t S n .�3 zY� .F � T. - � _ � f '.k b�,`- • q ; 'it =� i h � .. -� . . . _ � E.:�.; a 1��. :5h� 4: �x , ,.... .. f � ; ,� d'�:: ,x E�, e 'le c � :"• t e :.x� .:;as" e s i s'T.. .�,�aaE , " �c .' . . . . .. . . . .. �. , . .... .. ..� . . �';,: ; � �� : �> . . , . . W�:.:. �� 5 . , 6 , i �~ � ��-. � .. . , fi' . -rf.. . (6� :t � {' • d . C . . f I � � � 1 ., � i � �.. _�� r :�1 �5�,�,1. �� L a s k S� �f�i� ��,�� e e 4 � �'� � � .�e'�r � .. .F,. > �'� kp �'y�s V.� R��4� "` i�� o � ,�i '. .::� `'� : 7 � � 8s�� i k� k ir �s y�� F i' ? 3� . '� �„� ,�'�" � '�,�fiv� � H1 4 ,� . . . ,�� }x £� € � �:� �� '"� �� G�-�,*�a , e 5 ', . � _ ._ .. m 'G3 1'^Fa 4 �� li x� �N .� q Y � . ."� . . .. . . � . . � . . . 1 � ` 4 k. : k 3 .§. � � �f F � �Y f �. � i S a�9 �! � � �: : � � � � '%�: � i�• i e 7 t r d r ,z a. �" ° �� ` • � ��, �. �i E v� �� rv 0. i . � t 7 � � "` y �.a6*,� �?ny n. y4� R � �.r '�� ?Ska.�. " r ��,��b �.� R �z ��s� � i xi�c��f� y ,e` a �e� � � is q 7 � g.�°d'� s �r .r� � � + �rs R � . � 3 s� '�. r� � �'�` Y�`j�`��"��`e� �� '�YC�k,r�� 'aP %� "� c .� } `y� � €�,� � .s' � e �y .'� ..:' . . . . d. '� d 1�' .��`, �° �� fi Ts,� �z `�' �' ��q��+�^� �' jr � � �f 3 � n �'' � � �� :� � -� �E;�r} � � Z � �, �a� � �; ..: . f r .� n �"'. � r ye.��r S�at7 i�`»�� i. �." T F3 S� �� Fr��F��'�` ' � 4� '?;� � � tA r� � t .�: � � P r� w�, , : �.q . , �..� ,� i'.A�F`:W��?",� t�.{3��n �t'.�'� . . � _ 'r, _eA e 's a . � e �a.. .. ' '. . . �: �... �.� 1.' Gcw 1'� - " 4 ! �ic6 '�y i .xY tl ��1" , � y � , ��(��'� . " . . ` � r c �;:.. ...... in ': ,?��F!,��.�,�ia��R'fl.-.. . �`+... .�� , ... .r. � ::. ' .arv o� nxuc w[rri tvEw rruacs ', ; w ,' � : t ' p,j' . , � . ( t .�', ��'' §! f F �� R �> ' ) i; � ; � Earn Your Masters Degree � Advance Your Profesaional DerefopmeM Through The - Non-Credit Option ,�; � ��; 7 ; ,��;; Get Cor�nected -_ �� :�. �� : .. : ��.�...:4. k .. o �, -�; `: ." ;•�,; _ � with UMBC� � .� ��w r �=�.i„�,�. t,.�'�:r ..��,>�-:, �� . � o • • a.�''-a�,;�a, , �' , � � ' r �� C 3 K� �' �, "" � r � �" , {, �, � � ��(Y ih f r( � � COI�IT'ACT IlS NOW FOR � � � '` � ` � ��'- �.�`�� : A A � MORE IlVFORMATION i � �� ` � y U1 V LL�� ` �.��t� ��:,,.a,: , ; ,. e ��, Call (410) 4SS-2797, .=,�r ,.., . _ ��_� ;:'� s E-mail connect@umbc.edu �. � �_ ��:�' A N H O N O N ��?:; � �'„'•, / �:,i•'�,'^,'Fti �r�. U N 1 Y E R S 1 T Y OT �'Lf1[1 1IS 011 tDC Wef! Qt i , i t °'c _"�, '7��!�?� , ;,.r`e. . s- " 1 N M A R Y l A N D wtow.ehs.umbc.edulde ' �'�'�� -�.v�`'��,=:r; � ;:�,.�� E: .;��,,. -; ��.< For Mo►e Information Cir�le S67 On Reader Service Card - <. ..,.,, �� ;� ,� .- ,:�'?�. " ' " "�er�� "��rY Y . > � ;�..�: ,^ �t , �� ; � ��'�. �, Need to stay in touch? No Problem� ;�� `� A��; �� -. � � ° � ' � �„�w.. � a �� _ , �� B,� r� �;�r�� z. 9� �� ,� , '' � ` • , ..3 c '�R��'p tS t,?�'+� �� ;k� �� '� pv I i '�, a �� + � a i , ��.' �� J �,� , ` �� ° t2 s�,•� �� h � � " � t � �� , � � �. . . � at x M1 � ,� r � a ��' � ��, y 4 ,: q s � �, � ��+% �t� � � g � • Two-Way Radios � h �� s�.��; � -� �.4 ��n ,� _ , � ° � �'. • Nextel Phones '�' `� .�. � � "� ' ; y a" s� � �" �� n z � t��, +. y' ' ; t � � � r.m � , �' f �' 9x� z e:� a� � :. • Offices Worldwide � fi s � 4 � �; � �: � � 4$ � ,� y ' Y 8 �+ �' L F� '4`,�`f. 9iq �E,'�. ,.�, • Largest Inventory :.'�; t c . � � � ryk ` 1 ` , r s �`� t r� ; , r r i , r�w• F 4�, �, , :Y 4 ? Y f a � + z: Ca!l Nationwide Toll-Fi�ee �, F ., , ~ �` � � � M1 � � �� 4 ' �� : . { � t � K 's 1 , „ C 1-500-5'27-1670 �`� � ,. ,', �' �� : .�� ' � �� . � 8�� . ' x � ' _ ��t��' Wireless Worldwide � _ �� www.bearcom.co►n 1+�1(�#�� . � ��4�fl.� .. �+��+��y` For More Informat7on Circle 1f68 On Reader Service Card �� [1Vq(�� t d4m39� �� NA(o�lib,1 '' 7�I TFMG G► Y 7 11 0 11 r _ — -- —�— — .. AN OLD DRUG W►TH NEW TRlCKS CONTINUED FROM P. 69 ......._..__ _.___......._�...__._.......__......__._...__�_.. _ . � for 20-30 minutes, which in most cases provides adequate time to reach a hospital in most urban rystems. Systems with longer transport times may consider a maintenance infusion oE amiodarone during transport. � �. Eariy hospital natification Early hospital notiRcation is extremely important to allow �� emergency deparl7t►ent (ED) staEf to mobilize additional �� resources co properl}► handle a patient who has received prehospital IV amiodarone. Hospitals may not routinely 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 phartnacy. • : �v. : fi �� CompGcations in drawing up amiodarone - Because amiodarone comes packaged in 3 mL glass 1 �'0° , ampules, the EMS provider must break the ampule and `;;' " carefully withdraw the drug using a needle and syringe_ . This is a dilFicult task when attempring to rapidly adminis- ai'? ,. ,;, , ter a medication to a patient in cardiac arrest. , In addition, the conventional method of circular k . .; swirting of an ampule to ensure complete medication , transfer to the ampule's main body is not advised when _'3�. using amiodarone. Amiodarone's soap-like consistency ..,:. _ .i�•., causes excessive foaming [o occur when agitated, which can make medication removal diCEicult and reduce the `� •.:,; overall amount of drug within the ampule's main body. Y ��' Iap the ampule neck lightiy to ensure medication transfer :� =' to the ampule's body and avoid excessive shaking prior to ,;>„ '' use to reduce Eoaming. ,, The slow, but steady adoption of amiodarane � 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 EMS systems have jumped on the bandwagon and now stock amiodarone. Also, several states have added amio- ` s darone to their lists of approved prehospital medications_ See Figure 2 for a sampling oF EMS systems currently stocking amiodarone for use in modiFied VF/VI protocols. A local e�erience: The Austinliravis County EMS System ' '''' ' ' The addition of 1V amiodarone (single 300 mg bolos) for � • shock resistant VF/pulseless VT was imptemented in the •' � • Austin(Iravis 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 Erom defib- rillation alone. The remaining 12 patients remained in VF despite initial � countershocks and received 300 mg of [V 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 Eor both patient groups was 27% compared with a previously docu- mented (1999 Austinll'rmRS County Cardiac Arrest StatisNcs) VF survival rate of 20%. This equates to an overall increase of 7°h in the VF survival rate and a 5% increase in the group receiving u . v , . . . r_.� _.. �� ,� -- I � �' AN OLD DBUG WIiH NEW TRICKS � ...--�-°-----......__........_.._._�_.......____�.....__._.__..__.._..---__ _..._....__._�..._..__..__.._._. �;, , � ..__......__ � ; amiodarone. Although these data are promising, the over- � 1 I � all VF patient population is small and continued data col- I ! I. � lection is needed to reach a definitive conclusion about � amiodarone's effectiveness. � � ' ' ' � ' � COIIC�USIOh � � Although IV amiodarone is not included in the current I � ;, .� ►� �. �, ACLS guidelines Eor the treatment of VINF, the American College of Cardiology/AHA committee on management of ` acute myocardial infarction has recommended the drug's i use. The committee has identified amiodarone as a bene�- ` cial, useful and effective agent for the treatment of sus- f � tained monomorphic VI in patients with AMI when VT is � � not accompanied by chest pain, pulmonary congestion or ` � hypotension. I Data Erom the ARRES? trial and other studies suggest � that N amiodarone should become an option for manage- � ment of the patient in refractory VFNT. Although the ' � 2000 ACLS guidelines are yet to be published, many sys- l � tems have already opted on the basis of availabie data to � s � � add IV amiodarone to their guidelines for shock refractory 11 VFNT. � Ronny Taylor, Lic-P, is dinical deve[opmertt wid special projeUS coordi- nator for thc City o`Austin (Tows) EMS clinica! pracNce division and ` `� Austinlltavis County EMS System. "�^"°�"`�� Edward Racht, MD, is thc medical dircctor for the City of `, •�,� �� Atutinllravis County (Texns) E[�{S Clinicai Practicc. �,�y �,:� .=.; ;.i, '`' � References `<� �� ,,� 1. Cummins RO, Omato JP, et al: "Improving snrvival [rom suddea � cardiac arrest: rhe `chain of survival' concept." Circulation. � ' 22(1):86-91, 1991. 2. Cummins R�, ed: Advanced Cardiac LiJc SupPort. American Heart Associatioa Dallas, 1997.. � � i a' ti� 3. Harrison EE: "Lidocaine in prehospital counrershoc& re&actory a r . ,� w' ventricular fibrillation." Annals of Emergtncy Medicine. �'�. � l �� 3� � M `� $ 9 , , � 10:420-423, 1981. �"?� ,�'� �, ' b� i ��' 4. Nowak RM, Bodnar TJ, et al: "Bretylium tosylate as initial treat- g� :"r ,> i ,, ment for cardiopulmonary anesr. Randomized comparison with � i �'�'�� .� placebo." Anna[s of Emtrgency Medicinc. 10:404-q07, 1981. "� �� _��`��`�� , � �' G s ' - 5. Haynes RE, C6inn TL, et al: "Comparison of bretylium tos late �. y � QU��f�'��►� �SC1refS �QVI�1, F&�10IIa�CS,� ��OW �{�e'�,SPS� and lidocaine in tnanagement of out of hospital ventricular fibril- iYfll Sl��eil#53G}iaHC�tD.3 lation: A randomized clinical trial." Amcrican Journal oJ B_ ,� _. _:... pjity .��i' knowledge as i�' {�t�y Cardiology. 48:353-356, 1981. 1Vete at tLe Scene. 6. Marriott HJL, Conover MB: Advanced Concepts in Arrhythmias, ■ A eross reference for scenarios dealing vs�fh trauma third edition. Mosby. St. Louis, 1998. pediatrics, geriatrics, chief camplaint, and specific. diagnosis 7- Kudenchuk PJ, Cobb LA, et al: "Amiodarone for resuscitation 15 IqC�U'dea. after out-of-hospital cazdiac anest due to ventriculaz fibrillation." � Hot topics inelude: pediatric trauma, endocrine e►t�ergencies New EnglandJourna! oJ114edicine. 341:871-87g, 1999. B. Gonzalez E: "Pharmacologic interventions for rehactory ventricu- (other than diabetes), neonatal emergencies, and patients� lar tibrillation." Pharmacist Reporter. 4(5):49-52, 1999. W1L}I tUbCS aRa S11UDf5. 9. Physiciqn's Desk Reference, 54�h ed. "Cordarone lntravenous." May 1999. �O�* Montvale, NJ. 3,229-3,231, 2000. Approx. 286 pp./Approx. 50 illus. �� v 10. Gonzalez E, KannewurE B, Omato J: "Intravenous amiodarone for ISBN: D (30352) v ventricular aRhythmias: overview and dinical use." Resuscitallon_ 3933-42, 1998. � 11. Bauman ]L: "Introduction: Amiodarone from last to first-line antiarrhythmic therapy." Wyeth-Ayerst Laboratories educational '" � publication. 7-8, 1999. °� � � � � � 12. Hoyt BT: `intravenous amiodarone: Advances in treating ventricu- lat taehycardia/fibrillation." Resident Reporter. 4(2):23-2g, 1999. 13. Peter J. Kudenchuk, MD: Report given at the 70�h Scientific Ses- � � ; ! sions of the American Heart Association. Oriando. Nov. 12, 1997. 14. Ryan TJ, Anderson JL, et al: "ACCIAHA guidelines for the man- � �� agement of patients with acute myocardial in[atction." Circu(ation. . 9 Fo� More Infomtatlon CireFe #69 On I�eader 5erviee Ca►d 15. Package insert. Cordarone (amiodarone HCI). Wyeth Labotato- ries, Revised May 7, 1999. �4 ,JEMS MAY zooe � Y� . ,, f Chapter I Overview of Ambulance Fee Schedule 1 CHAPTER I: OVERVIEW OF AMBULANCE FEE SCHEDULE OBJECTIVE ......................................................................................................... 2 BACKGROUND .................................................................................................... 2 CurrentPayment System ................................................................................... 2 BBA.....:................................................................................................................ 3 Negotiated Rulemaking Process .......................................................................4 PROPOSED ...............................................................................................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 .........................................................................................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). 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 m�ans 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. CAWs), 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. 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 i � 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 y 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 Registeron 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 5 December 2000 � Chapter t 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 schedu{e 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 4 X Chapter I Overview of Ambulance Fee Schedule 7 This manual provides payment and billing concepts to implement the fee scheduie 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 estabfishment ofi a peripheral intravenous line. b. Basic Life Support (BLS) - Emergency - When medicalfy 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 service. Medicare pays for the appropnate 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, Leve12 (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 ber►eficiary, 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 (PI) - 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 two categories of air ambulance services: fixed wing (airplane) and rotary wing (helicopter) aircraft. The higher operational costs of the finro 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 inaccessibte 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. 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: Fee Schedule Cost/Charge Percentaqe Percentaae Year 1 20% 80% Year 2 50 50 Year 3 80 20 Year 4 100 p 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 • Laaded 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 nationaliy 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 • Uniform Base Rate • A nationally uniform base rate for fixed wing and a for fixed wing and nationally uniform base rate for rotary wing. 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- Err�ergency 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 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. Fbr 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 (5) Adjustment for Mileage for Services Furnished in Intercept has no mileage 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 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 8-00-01 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 to air ambulance 15 services December 2000 Chapter I Overview of Ambulance Fee Schedule 16 (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 �mbulance 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 r 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 fl intermediarv Coveraqe 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 BasicLife 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 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 Service ..............................................................................................9 MedicalConditions List ......................................................................................10 Non-Emergency Transports ...............................................................................10 December 3, 2000 • 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 scheduie has seven categories of Service ground (land or water) ambulance services and finro 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(ALS.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 s 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 Bfueprint. 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 t �' Chapter II Intermediary Coverage and Related Issues 6 SPECIAL CIRCUMSTANCES In the regulation for the Ambu�ance 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 usua! r�les 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 inedically appropriate services furnished to each patient. Muttiple 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 — lntermediate 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 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 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 inedical necessity for non-emergency the benpficiary is: transport is the status of whether the patient is "bed confined." For bed confinement, the following criteria must 1. Unabl� 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 �hair 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 actuaily Non-emergency scheduled. Scheduled services are generally regularly services may be: scheduled transportation for the diagnosis or treatment of a patienYs 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 � CHAPTER IV - INTERMEDIARY PAYMENT AND REIMBURSEMENT PAYMENT OF AMBULANCE SERVICES ............................................................1 OBJECTIVE .........................................................................................................1 AMBULANCE FEE SCHEDULE ........................................................................... 2 NEWPROVIDERS ...............................................................................................4 GROUNDAMBULANCE ...................................................................................... 4 AIR AMBU�,4NCE ............................................................................................... 4 EMERGENCY RESPONSE ADJUSTMENT FACTOR ......................................... 4 MULTIPLEPATIENTS ......................................................................................... 5 PRONOUNCEMENT OF DEATH ......................................................................... 6 MULTIPLEARRIVALS ......................................................................................... 6 COMPONENTS OF THE FEE SCHEDULE ......................................................... 6 SERVICE 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 {V Intermediary Payment and Reimbursement 1 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 OVERVIEW 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 P � 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 multip{ied 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 wil{ 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 Pa ment % Schedule % 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 schedufe transition wifl 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 n �� Chapter IV Intermediary Payment and Reimbursement 4 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. Baslc Life Support — reimbursable under the new fee schedule. There are Emergency (BLS-ER) seven ground and two air: 3. Advanced Life Support, Level 1 (ALS1) GROUND AMBULANCE 4. Advanced Life Support Level 1 � gasic Life Support (BLS) — Emergency (ALS1 — ER) 5. Advanced Life Support Leve12 2• BLS — Emergency (ALS2) 3. Advanced Life Support, Level 1(ALS1) 6. Specialty Care Transport 4 • ALS1 - Emergency (SCT) 5. Advanced Life Support, Level 2(ALS2) 7. Paramedic Intercept (PI) 6 • Specialty Care Transport (SCT) (carrier only) 7. Paramedic Intercept (PI) (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 December 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 and ALS1 services The emergency response adjustment factor does not 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 fee schedule amount Medicare patient. 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 app{y 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. 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 ALS 1 1.20 ALS — Emergency 1.90 ALS2 2,75 SCT 3.25 P I 1.75 Geographic Adjustment Factor (GAF) The GAF is one of two factors intended to address 7he loaation where the regional differences in the cost of furnishing beneficiary wa� put in the ambulance services. ambulance ("point of p9ckup") estabiishes which The GAF for the ambulance schedule uses the non- ��'�� Pp�1e�• 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 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 �R 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 fumished 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: December 2000 r Chapter IV Intermediary Payment and Reimbursement 9 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 �ip code as the point of pickup to crosswalk to the appropriate fee schedule. December 2000 r • 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 mifeage 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 r r Chapter IV Intermediary Payment and Reimbursement 11 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 a157.52 �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 Milea e Rate Amount Service Level Unadjusted djusted mount oaded ural air ural air base rate by GPCI ot mileage mileage'"" ase rate *** adjusted (UBR)t (50% of (50% of UBR) UBR �N......•......• ................... $2,213.00 �1,106.50 �1,106.50 �6.00 a9.00 $3,379.50 RW..•......•.• ....................... 2,573.00 1,286.50 1,286.50 16.00 24.0� 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 r v Chaoter IV Fiscal Intermediarv Pavment and Reimbursement 15 PAYMENT EXAMPLE Ground Ambulance, Rural (Hospital Based Provider) A Medicare beneficiary residing in a rural area in the state of lowa 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, unde� 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 lowa, 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]+[(((� +RG}*MGR)*#MILE�17) +(MGR*#MILES>#17)] 2001 Fee Schedule for Pa ment of Ambulance Service for BLS non-Emer enc Service Level RVUs CF Unadj. Base Amt, adj. by Amt. not Loaded Rural rate GCPI adjusted miteage ground milea e 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 . 52 1+I�� + • 5 )''S) *14 )+� 5* �)l =$249.51 The payment of $249.51 is subject to Part B deductible and coinsurance requirements. December 2000 � . Chaqter IV Fiscal Intermediarv Pavment 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 I , ,.�. ... , Cha�ter IV Fiscal Intermediarv Pavment 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 December 2000