Hidden costs of behavioral health transports
EMS documentation must support both medical necessity and reasonableness for the transport
By Matthew Konya, Esq, EMT-B
Calls involving patients experiencing a behavioral health crisis are common in EMS, but EMS providers encounter patients at different stages and conditions during such a crisis. For example, a patient having a behavioral health emergency may call 911 directly, or a hospital may call an EMS agency to transport a patient from their hospital to a behavioral health facility specially equipped to treat the patient’s medical condition. In some cases, a third-party caller or the police may contact an EMS agency requesting a person be transported for a behavioral health assessment at a psychiatric hospital, or even for a medical assessment that must often occur before receiving mental health care at a specialty hospital. Patients may seek treatment voluntarily or can be subject to an involuntary behavioral health commitment – such as a 302 commitment, 5150 hold, or Baker Act hold.
It is important to recognize that patients who require behavioral health treatment (either voluntarily or under an involuntary behavioral health commitment) do not automatically require ambulance transportation. Documentation matters in all patient encounters and it is even more critical in behavioral health patient encounters.
Why documentation matters
Medicare represents the most frequently billed insurance payer for ambulance services nationwide, and Medicare will only pay for ambulance transport if the transport meets very stringent coverage criteria – namely, medical necessity and reasonableness. While Medicaid and third-party insurers also have rules about payment requirements, this article focuses on documentation’s impact on determining medical necessity and reasonableness under Medicare’s rules.
First, for ambulance transport to be “medically necessary” under Medicare guidelines, a patient’s medical condition is such that other means of transportation are contraindicated. If a patient could safely be transported by means other than an ambulance, the transport does not qualify for Medicare reimbursement.
Second, Medicare considers a transport “reasonable” when a patient is transported for services or procedures unavailable at the point of origin. A patient would not meet the reasonableness requirement if they could receive the required services at the point of origin. The classic example when a transport is not reasonable is a nursing home patient being transported to a hospital to receive services that could be provided by nursing home staff – such as simple suture removal.
Therefore, EMS documentation must support both medical necessity and reasonableness for the transport. Medical necessity answers the question, “why did the patient need to be transported by ambulance?” Reasonableness answers the question, “why did the patient need to be moved from point A to point B in the first place?” It is possible to have a transport that meets the medical necessity requirement but fails to meet the reasonableness requirement, and vice versa. Or, a transport may fail to meet both requirements. Only when both criteria are satisfied can the transport be eligible for Medicare reimbursement (assuming all other coverage criteria are also met, such as signature, and vehicle requirements).
Quick documentation tips for behavioral health trips
While medical necessity and reasonableness requirements apply to all ambulance transports, documentation of these things can be especially tricky for behavioral health transports. This difficulty is partly because, unlike many other medical conditions, behavioral health emergency signs and symptoms are often not visible or easily quantifiable. Additionally, patients may not be forthcoming with information due to the nature of the complaint and the stigma surrounding such behavioral health complaints.
1. Documenting medical necessity
Depending on when EMS encounters the patient, documentation regarding medical necessity can be tricky. It is likely easy to document medical necessity for a patient in the middle of a behavioral crisis, actively trying to hurt themselves or others. By contrast, documenting medical necessity may be more difficult for a patient at a hospital waiting for transport to another facility who has been medically evaluated and has been calm and cooperative with hospital staff since coming to the hospital a few days prior. Notwithstanding, in both situations, the patient may require monitoring in the back of an ambulance.
No matter the situation, the PCR should document a thorough assessment of the patient, including the patient’s need for observation and potential harm to themselves and others. The PCR should include detailed information about the events prior to the EMS provider’s interaction with the patient – such as medications, evaluations and interventions received, behaviors manifested, and hospital provider impressions of the patient. When documenting an interfacility transport, there should be documentation on how the patient arrived at the hospital, why the patient came to the hospital in the first place, and what the patient’s physical and mental condition was during the hospital stay.
Documentation must include information about the patient’s demeanor and behavior during transport. Finally, there must be documentation if the patient required any restraints beyond normal cot straps during transport – either physical or chemical – including the reasons why EMS providers used such restraints. Providers should specifically cite any protocols adhered to during the transport.
2. Documenting reasonableness
For emergencies, reasonableness is typically more easily established. It is impossible to bring the hospital to the patient, so the patient needs to go to the hospital. However, reasonableness can be more difficult to establish for interfacility transports, especially patients experiencing a behavioral health crisis.
Typically, when dealing with interfacility transports of behavioral health patients, the reason for transport is that the hospital where a patient is currently located cannot provide inpatient behavioral health treatment therefore necessitating transport to a facility that can treat the patient. In these cases, the PCR must specifically document the services or procedures available at the destination facility that were unavailable at the sending facility. Simply noting “higher level of care” or “services unavailable” as the reason for the transport is not good enough. For example, providers should document as specifically as possible, such as noting: “patient transported to mental health facility to receive cognitive behavioral therapy not available at ABC hospital.” It should be clear that the patient requires ongoing care that could not be provided at the originating facility.
Documenting behavioral health transports: The bottom line
Weak documentation can have many unintended consequences. It can lead to the patient being financially responsible for a transport that should have been covered by insurance, because the provider failed to document medical necessity or reasonableness with enough detail. Weak documentation could also lead to an overpayment demand or penalties for an agency that billed for transports based upon what reviewers and auditors deem to be inadequate documentation.
While weak documentation affects all types of EMS transports, it can be especially pronounced when dealing with patients experiencing a behavioral health crisis. EMS providers should be extra careful to document interactions with patients experiencing a behavioral health crisis thoroughly. With that in mind, remember, the job of an EMS provider is not to document every transport in such a way as to ensure it is reimbursable by insurance.
The goal is to provide enough detailed documentation for billers and coders to make the correct billing and coding determination. When medical necessity and reasonableness are clearly met, that should be reflected in the documentation. Where the documentation is complete and thorough but fails to meet Medicare medical necessity or reasonableness requirements, then the billers and coders must decide how (and to whom) to bill the transport. Not all ambulance transports will be billable to Medicare (or any insurance for that matter). It is critical for the documentation to be complete so that proper billing decisions can be made.
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