Specialty Care Transports (SCT): CMS Medical Necessity and Documentation Audits


Centers for Medicare & Medicaid Services (CMS) recently approved Recovery Audit Contractors (RACs) to audit Specialty Care Transports.  The codes impact in this audit are HCPCS A0434 (SCT) and A0425 (Mileage).

Specialty Care Transports

CMS defines SCT as interfacility transports of a critically injured or ill beneficiary by a ground ambulance vehicle which requires medically necessary supplies and services beyond the scope of the EMT-Paramedic.  SCT is necessary when the beneficiary’s condition requires ongoing care that must be furnished by one or more health professional in an appropriate specialty area, for example, an emergency or critical care nurse, emergency medicine, respiratory care, cardiovascular care, or an EMT-T Paramedic with additional training.

CMS clarifies “additional training” to mean specific additional training that a state requires a paramedic to complete in order to qualify to furnish specialty care to a critical ill or injured patient during an SCT.

Additional Training

Emergency Medical Service (EMS) providers must clearly document in protocols what classifies as an SCT.  Simply because an EMT-P is in the vehicle of a critically ill or injured patient does not mean nor would qualify, without additional training, as an SCT.

Additionally, transporting a patient from a general hospital to a specialty hospital would not be an SCT without meeting CMS or the appropriate payor requirement for SCT.

Coding and Billing for SCT

Often, EMS providers rely on third-party billing companies to bill their services.  If an SCT is billed the billing company must be certain the EMT-P who is providing services meets “additional training.”

As best practice for a billing company, a list of crew member who have additional training should be provided.  The training should be well documented by the EMS provider to prove, if ever needed, the EMT-P received additional training, what it was, when it was, and any refresher course training.  Buzz words like “intensive monitoring” is not enough to qualify as SCT.

SCT it based on two elements: 1) definition of the payors SCT of a beneficiary and 2) the scope of practice (or training) of the staff or crew member with the patient during transport.  If either one of these requirements are not met as defined by the payor or state law, there is no SCT.

Scope of Practice

Generally, each state will have requirements for EMT-P and what is considered scope of practice.  Training received beyond the specific qualification requirements to be an EMT-P could be additionally training to support an SCT provided the payor definitions of the beneficiary are clearly met.

Mileage (A0425)

CMS pays for loaded mileage only between pickup and destination.  CMS requires trips up to 100 miles must be rounded up to the nearest tenth (1/10) of a mile.  For example, loaded mileage was 4.67 miles.  The claim should report 4.7.  Mileage of less than 1 mile should be reported with a preceding zero before the decimal (e.g., 0.9).

Documentation of Mileage

The ePCR must clearly document the pickup address and the destination address.  Documenting an address by name only will not suffice a RAC or other payor audits.  The physical address must be documented on the ePCR.

Providing Documentation for an Audit

Read the letter carefully and pay close attention to the dates.  Failure to comply with the dates in the letter will result in audit findings and trigger an overpayment.

Most ePCRs have an electronic signature block.  If the ePCR when printed to a PDF does not have the crew member’s name printed below their signature provide a signature page of the crew members as part of the audit.  Illegible signatures are a common audit finding.  Avoid the headache of having to appeal simply due to a signature issue.

What to do with a Demand Letter

RACs, like most audits, are an administrative process.  Audit findings must be provided to the audited entity including an explanation of the findings and what rules, regulations or laws were relied on to support their findings.

Do not take the overpayment lightly.  EMS runs on razor thin margins and having to repay money can impact operations.  It is not unusual for auditors to make mistakes.  Have the audit results looked at by someone well qualified in EMS to determine if there is a valid appeal.

Writing the Appeal

Don’t just let anyone write an appeal letter.  It takes time, extreme attention to detail, and well laid out framework to have a well pleaded appeal.  Typically, appeals are best drafted by attorney’s often with the support of a subject matter expert.

A well drafted appeal letter can often have positive outcome to any audits.  The best place to be is to conduct internal audits on risk areas known to be audited and try to avoid being subject to a payor audit.