PLEASE NOTE: This summary of the ALS assessment rule is provided for informational purposes and should not be relied on as a definitive statement of the law and regulations.
The regulation, at 42 CFR §414.605, tells us that Advanced Life Support, Level 1 (ALS1) is defined as:
“Transportation by ground ambulance vehicle, medically necessary supplies and services and either an ALS assessment by ALS personnel or the provision of at least one ALS intervention.”
It is important to note that either an ALS assessment or an ALS intervention, as defined in this same section, makes billing at the ALS1 level appropriate, where all other coverage requirements are met (such as medical necessity, transport to a covered destination, etc.). While the definition of an ALS intervention is typically well understood, there is often some confusion or apprehension with regard to the ALS assessment rule. The ALS assessment rule is clearly defined in the same section of the regulation as follows:
“An ALS assessment is an assessment performed by an ALS crew as part of an emergency response that was necessary because the patient’s reported condition at the time of dispatch was such that only an ALS crew was qualified to perform the assessment. An ALS assessment does not necessarily result in a determination that the patient requires an ALS level of service.”
It is important to note that CMS clearly states that to meet the definition of an “ALS Assessment”, the assessment by ALS personnel must not only be performed, but must be “necessary because the patient’s reported condition at the time of dispatch was such that only an ALS crew was qualified to perform the assessment.” In other words, there must be clearly understood dispatch protocols in place that, based on the “patient’s reported condition at the time of dispatch” make it clear to dispatch personnel, EMS crews, and billing personnel whether an ALS response is “necessary” as opposed to simply provided because that was the crew that was available. Each dispatch determinant must clearly establish two elements of the necessary response. The first is whether an ALS response is necessary, or a BLS response would have been acceptable; and the second is whether an “emergency response” is necessary. We will discuss the second in more detail in a moment.
To put defensible, and clearly understood, dispatch protocols in place an EMS agency should have their Medical Director closely involved in the development process. It is important (and especially so in the case of an agency that responds with an ALS crew to all requests for service) that the individuals tasked with developing the dispatch protocols work with an assumption that a qualified BLS crew, and a qualified ALS crew are equally available for each call for service. With that in mind, the Medical Director should indicate for each “reported condition” (dispatch determinant), whether a BLS response would be appropriate, or if an ALS response is necessary. Again, not simply “preferred”, but “necessary.” Once this has been accomplished it will be clear which of the dispatch determinants are eligible to result in a finding that a “necessary ALS assessment” was performed.
The Medicare Benefit Policy Manual, Chapter 10 §30.1.1 further clarifies as follows:
“In the case of an appropriately dispatched ALS Emergency service, as defined below, if the ALS crew completes an ALS Assessment, the services provided by the ambulance transportation service provider or supplier shall be covered at the ALS emergency level, regardless of whether the patient required ALS intervention services during the transport, provided that ambulance transportation itself was medically reasonable and necessary, as defined in section 10.2, above and all other coverage requirements are met.”
Now we will shift our focus to the second element of the response that, per CMS, must be clearly established by each dispatch determinant – whether an “emergency response” is reasonable. We sometimes see some confusion, or misunderstanding surrounding these two aspects of the response. We will hear, for example, that “an Emergency Response is an ALS response” or “a BLS response is a Non‐emergent response.” It is important to keep in mind that these two aspects, ALS vs. BLS and Emergency vs. Non‐emergency, are totally separate and unrelated. When developing the dispatch protocols, the Medical Director should clearly indicate which of the “reported conditions” (dispatch determinants) require an “immediate response,” regardless of whether that immediate response is to be with or without “lights & sirens,” and which of the reported conditions do not require an immediate response. For example, a discharge from a hospital, to return a patient to the patient’s place of residence, would clearly not require an immediate response.
It is important, if not critical, to make a distinction between the meaning of the words “emergency response” to a dispatcher or crewmember, as opposed to someone in the billing office. Often, to a dispatcher or crewmember, the phrase “emergency response” means to respond with lights and sirens. Similarly, then, the term “non‐emergency response” means to respond without lights and sirens. This could occur even if the call came through 911, and the patient had some reported condition that warranted an immediate response. A misunderstanding might arise when a dispatcher uses the phrase “non‐emergency” (to mean no lights and sirens), and the biller interprets this to mean that there was no basis to issue a request for an immediate response. This is why it becomes so important to recognize the difference between the response “priority” (immediate response required, or not required), and the response “mode” (with or without lights and sirens). In fact, some agencies use the term “mode” (designated with a letter or number) to indicate the way in which an ambulance is supposed to respond (i.e., lights and sirens). Unfortunately, because the same words (emergency and non‐emergency) are used by different departments of the same agency in different ways, this all gets very confusing (especially when the dispatched condition plays such an integral role in the billing decision‐making process). Therefore, it is critical to carefully take into consideration exactly what the dispatcher means when an “emergency” or “non‐emergency” dispatch is issued. Is the dispatcher dictating the mode of response (use of lights and sirens), or truly speaking to the gravity of the patient’s reported condition?
Remember that to Medicare, an “emergency response” means that there was an immediate response that, based on the reported condition of the patient at the time of dispatch, warrants an immediate response. It has absolutely nothing to do with the use of lights and sirens. So, a biller or coder should be careful not to take the word choice of the dispatcher out of context (especially when that word choice may mean something completely different to the individuals actually involved in the communication). A patient’s reported condition can be something that necessitates an immediate response, but also be one that local protocols indicate might not warrant use of lights and sirens. In those cases, the dispatcher may classify the call as “non‐emergency” intending to say, “you need to go now, but don’t use lights and sirens.” A biller who then sees that the call was dispatched as a “non‐emergency” may be tempted to bill the call at the non‐emergency response level. This is why it is so important for the ambulance service to have clearly defined, and sufficiently detailed dispatch protocols, which define exactly when an immediate response is necessary, and when it is not. Then, it is important for all of the various departments to understand the meaning of the dispatch determinants in the same way.
As discussed somewhat above, to properly apply the ALS assessment rule, it is important to understand the definitions of some terms used within the definition of an ALS assessment. Those include, “ALS crew” and “emergency response.” Those terms are also defined at 42 CFR §414.605 as follows:
“ALS personnel are individuals trained to the level of the emergency medical technician‐ intermediate (EMT‐Intermediate) or paramedic.”
“EMT‐Intermediate is an individual who is qualified, in accordance with state and local laws, as an EMT‐Basic and who is also certified in accordance with state and local laws to perform essential advanced techniques and to administer a limited number of medications.”
“The EMT‐Paramedic is defined as possessing the qualifications of the EMT‐Intermediate and also, in accordance with state and local laws, as having enhanced skills that include being able to administer additional interventions and medications.”
“Emergency response is a BLS or ALS1 level of service that has been provided in immediate response to a 911 call or the equivalent. An immediate response is one in which the ambulance provider/supplier begins as quickly as possible to take the steps necessary to respond to the call.”
The Medicare Benefit Policy Manual, Chapter 10 §30.1.1, further explains:
“The nature of an ambulance’s response (whether emergency or not) does not independently establish or support medical necessity for an ambulance transport. Rather, Medicare coverage always depends on, among other things, whether the service(s) furnished is actually medically reasonable and necessary based on the patient’s condition at the time of transport.”
CMS further goes on, in this manual section, to explain the application of the “emergency response” definition as follows:
“The phrase “911 call or the equivalent” is intended to establish the standard that the nature of the call at the time of dispatch is the determining factor. Regardless of the medium by which the call is made (e.g., a radio call could be appropriate) the call is of an emergent nature when, based on the information available to the dispatcher at the time of the call, it is reasonable for the dispatcher to issue an emergency dispatch in light of accepted, standard dispatch protocol. An emergency call need not come through 911 even in areas where a 911 call system exists. However, the determination to respond emergently with a BLS or ALS ambulance must be in accord with the local 911 or equivalent service dispatch protocol. If the call came in directly to the ambulance provider/supplier, then the provider’s/supplier’s dispatch protocol and the dispatcher’s actions must meet, at a minimum, the standards of the dispatch protocol of the local 911 or equivalent service. In areas that do not have a local 911 or equivalent service, the protocol and the dispatcher’s actions must meet, at a minimum, the standards of the dispatch protocol in another similar jurisdiction within the state, or if there is no similar jurisdiction, then the standards of any other dispatch protocol within the state. Where the dispatch was inconsistent with this standard of protocol, including where no protocol was used, the beneficiary’s condition (for example, symptoms) at the scene determines the appropriate level of payment.”
The last two sentences of the “emergency response” definition in the manual answer an important question that frequently comes up. “Does the fact that a call comes in 911, and therefore the ambulance service is required to respond emergently based on their protocols, mean that the resulting transport is always a Medicare covered service?” Clearly the answer to that question is “No”, as CMS states that the nature of an ambulance’s response does not independently establish or even support medical necessity for an ambulance transport. It is the patient’s condition at the time of transport that determines whether ambulance transport is medically necessary.
Once it has been determined that ambulance transport is medically necessary, based on a properly documented assessment of the patient at the scene, in order to determine the level of service at which the transport is to be billed one looks back to the patient’s reported condition at the time of dispatch. Therefore, the patient’s reported condition at the time of dispatch, in effect, establishes a “floor” for the level of service at which the claim will be payable, IF ambulance transport is medically necessary and all other coverage criteria are met.
It is important to clearly understand the emphasis placed on local dispatch protocols to define when an emergency response is reasonable, as well as when an ALS response is necessary, based on the local 911 or equivalent service dispatch protocol. We point out the last sentence of the “application” of the rule which states, “where no protocol was used, the beneficiary’s condition (for example, symptoms) at the scene determines the appropriate level of payment.” In other words, absent good clear dispatch protocols the ALS assessment rule would not apply, and an ALS intervention would be required for the claim to be payable at the ALS1 level of service.
It is also important to recognize that the ALS assessment rule applies only in cases where the “emergency response” definition is met. In the case of a non‐emergency ambulance response to the point of origin, a medically necessary ALS intervention is required to make a claim payable at the ALS level.
To help further explain this, consider the following 3 examples:
Example 1: An ALS crew is dispatched by 911 for Chest Pain, and responds immediately.
Upon arrival the crew finds a patient complaining of chest pain. The ALS crew assesses the patient and makes a determination as to the level of care and any interventions this patient requires.
In this case, assuming all other coverage criteria are met, the appropriate level of service would be ALS1‐emergency (A0427). This would be true even if no ALS interventions were provided to the patient.
Example 2: An ALS crew is dispatched by 911 for Chest Pain, and responds immediately.
Upon arrival the crew finds a patient stating that he has run out of his meds. He is not experiencing any chest pain now, and did not experience chest pain or any other complaints prior to calling 911. He has no complaints now, is in no distress, vital signs are within normal limits. He states that he is afraid he will have chest pain if he does not get his prescriptions refilled, and says he simply needs a ride to the pharmacy.
While the patient’s reported condition at the time of dispatch is the same as an example 1, “chest pain,” here in example 2 it does not appear that once the patient has been assessed there is any medical necessity for ambulance transport. Therefore, this claim is not payable by Medicare at any level of service.
Example 3: An ALS crew is dispatched by 911 for Chest Pain, and responds immediately.
Upon arrival the crew finds a patient who states he has not had chest pain, but rather is suffering from indigestion. After completing their assessment, the ALS crew determines that based on the patient’s medical history and current symptoms, which are all well documented in the PCR, ambulance transport is medically necessary, but the patient requires no ALS interventions.
Because the documentation of the patient’s condition at the time of transport supports medical necessity for an ambulance transport, one now looks back to the patient’s reported condition at the time of dispatch, and the reasonable response to that reported condition, to determine the appropriate level of service when coding the claim. In this case, as in example 1, the dispatch protocol indicates that an ALS emergency response was required based on the nature of the call at time of dispatch – chest pain. Therefore, A0427 (ALS1‐E) is the appropriate level of service for this claim, assuming all other coverage criteria are met, due to the qualifying ALS assessment that was performed.
We note that this would be true, even if the ALS crew, after their assessment, released the patient to a BLS crew, and did not accompany the patient to the hospital. This was made clear by CMS when they published the Ambulance Fee Schedule Final Rule in the Federal Register, dated February 27, 2002. In response to a question, CMS stated, “According to the definition of ‘‘ALS assessment’’ that we are promulgating in this final rule, an assessment may result in the determination that no ALS level service is required and, in that instance, an ALS1–Emergency level payment may be made to the transporting BLS ambulance supplier even if no ALS paramedic rides onboard.”
And as described above, CMS further clarified it’s interpretation of the “ALS assessment rule” with a 2017 amendment to the MBPM, Chapter 10 §30.1.1 emphasizing that ALS1‐E is the proper level of service that “shall” be paid in these situations: “In the case of an appropriately dispatched ALS Emergency service, as defined below, if the ALS crew completes an ALS Assessment, the services provided by the ambulance transportation service provider or supplier shall be covered at the ALS emergency level, regardless of whether the patient required ALS intervention services during the transport, provided that ambulance transportation itself was medically reasonable and necessary, as defined in section 10.2, above and all other coverage requirements are met.”
In summary, we point out once again the important role that clear dispatch protocols, as established by the EMS agency’s Medical Director, play in proper application of the ALS assessment rule. In the absence of clear dispatch protocols, most EMS agencies will be unable to be fairly reimbursed for their cost of providing many emergency ALS responses. As pointed out previously, where no dispatch protocol is used, the patient’s condition on scene determines the level of payment. In many cases this will result in the agency being required to submit a claim at the BLS level when, had clearly understood dispatch protocols been in place, an emergency ALS response and ALS assessment would have been indicated by the protocols, and therefore the EMS agency could have been reimbursed at the ALS1‐E level of service.
**The above summary was prepared by Page, Wolfberg & Wirth, LLC. This information is for educational purposes only – it is not to be relied on as legal advice. The summary is provided for informational purposes and should not be relied on as a definitive statement of the law and regulations.