Our service is having difficulties with whether our EMT B's are taking enough calls and if when they take the calls it is appropriate for them to attend.  We also struggle with transfers when hospitals seemingly randomly check the ALS/BLS box.

I think in both cases part of the problem is nobody actually knows what ALS or BLS means.  To some its billing, to others level of care, some see it as ACLS/BLS which covers cardiac but not trauma and finally some see it as just a unit designation.

So, I am asking you to help a brother out and provide your definition of ALS and BLS.

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Our guidelines state (paraphrased) that if it is highly unlikely that an ALS intervention will be required than the call should be triaged ALS. It goes on to define specifics. I think this breaks it down pretty well. If the pt will not require an ALS level intervention than its probably a BLS call. This is kind of a grey area sometimes. Its based on triage. If your pt requires cardiac monitoring than thats obviously going to be an ALS call. (even that may change based on your state EMS board) We are starting back into a teired response system here and this subject is coming up pretty often. Many EMTs are concerned about a paramedic releasing care of a pt to an EMT. If I dont see any reason that pt needs a prehospital ALS intervention and I dont perform any than that pt can be released to an EMT.

If you are going to be doing a long transport then you need to consider the likelihood that pt will need ALS level care during the hour or two you have care of the pt. Go beyond the current state of the pt and anticipate changes.

Bottom line. "BLS" vs "ALS" unfortunately tends to vary widely among states.
Thanks for the reply. Looks like you assess and then determine based as intervetion possibility. We run all parameic/basic crews so even if we determine it is BLS and it turns ALS help is just a shout away in the drivers seat.




Nathan said:
Our guidelines state that if it is highly unlikely that an ALS intervention will be required than the call should be triaged ALS. I think this breaks it down pretty well. If the pt will not require an ALS level intervention than its probably a BLS call. This is kind of a grey area sometimes based on triage. If your pt requires cardiac monitoring than thats obviously going to be an ALS call. (even that may change based on your state EMS board) We are starting back into a teired response system here and this subject is coming up pretty often. Many EMTs are concerned about a paramedic releasing care of a pt to an EMT. If I dont see any reason that pt needs a prehospital ALS intervention and I dont perform any than that pt can be released to an EMT.

If you are going to be doing a long transport then you need to consider the likelihood that pt will need any ALS level care during the hour or two you have care of the pt. Go beyond the current state of the pt and anticipate changes.

Bottom line. "BLS" vs "ALS" unfortunately tends to vary widely among states.
Historically, "ALS" meant drugs or invasive procedures, and "BLS" meant non-invasive assessment and treatment. Those definitions have become very muddy over the years, as technology changes (defibrillation used to be limited to ALS providers) and many states started monkeying with "scope of practice." Now, EMTs in various states use various invasive airways, administer various drugs, etc.

For technical purposes, you need to look at the definitions in YOUR state's laws. For billing purposes, you have to follow CMS guidelines.

If your service bills itself as "ALS" or "paramedic" then every patient should have an assessment at the ALS or paramedic level. If the patient doesn't require interventions that only the ALS provider can provide, or monitoring beyond the scope of the lower level provider, then it is appropriate for the BLS provider to attend the patient. In many all-paramedic 911-only services, it is possible for EMTs to attend >50% of patients.
Skip: Thanks for responding. Further definition question. What constitutes an ALS assessment? Is it just a initial patient survey by the medic or one that uses say a monitor? For instance how would a sprained ankle while playing football be assessed at ALS level?





Skip Kirkwood said:
Historically, "ALS" meant drugs or invasive procedures, and "BLS" meant non-invasive assessment and treatment. Those definitions have become very muddy over the years, as technology changes (defibrillation used to be limited to ALS providers) and many states started monkeying with "scope of practice." Now, EMTs in various states use various invasive airways, administer various drugs, etc.

For technical purposes, you need to look at the definitions in YOUR state's laws. For billing purposes, you have to follow CMS guidelines.

If your service bills itself as "ALS" or "paramedic" then every patient should have an assessment at the ALS or paramedic level. If the patient doesn't require interventions that only the ALS provider can provide, or monitoring beyond the scope of the lower level provider, then it is appropriate for the BLS provider to attend the patient. In many all-paramedic 911-only services, it is possible for EMTs to attend >50% of patients.
The term "ALS assessment" is another one with multiple meanings. I meant an assessment by the paramedic - period. For CMS (Medicare billing) purposes, an ALS assessment is an assessment by a paramedic in circumstances where it is warranted - usually based on dispatch data showing that the call is CHARLIE or above in MPDS terms (requiring a paramedic response). You can do an "ALS assessment" on ALPHA calls, but you can't bill an ALS rate for it.

An ALS assessment would include assessment skills not taught in BLS classes, like ECG interpretation, perhaps lung sounds, abdominal assessment, percussion of lungs, etc. I'm not sure what assessment techniques are included in EMT courses these days.

If it was supposed to make sense, the feds wouldn't be involved in it.

 

 

 

 

 

 

 

Nathan:

 

The most effective way to "connect the dots" between patient care and billing is the patient care report.

While there is liability associated with patient care, a service is equally vulnerable with billing practices. Aggressive assessment and care protocols do not necessarily support ALS billing. Whatever you do, document....document....document. "If it isn't written down, it didn't happen." Your billing staff MUST know how to read and interpret a PCR and should  not act in reliance upon a checkbox marked by the crew. Ultimately, the biller that pushes the button to send claims is responsible for accuracy and compliance. The issue is one of translation. The crew may follow protocols and do excellent patient care, but sloppy billing practices can be costly.

 

A couple tips:

 

If you make an immediate response to a 9-1-1 call, document it. This, and not red lights

and siren, puts the call in the emergency category. Medicare does not know your service

from 1000's of others.....you live and die by the PCR!

 

Document the "condition reported at time of dispatch." If the reported condition falls

within the ALS criteria and the only procedure done is an ALS Assessment, the call can

be billed at the ALS level. It must be a condition that only a paramedic is qualified to

assess. Skip is right on target.....you cannot bill ALS for the "sprained ankle" scenario.

 

 

 

(Skip, that's a great theme for a bumper sticker!)


Skip Kirkwood said:

"If it was supposed to make sense, the feds wouldn't be involved in it."

Whats wrong with AMPDS or similar? For transfers the facility makes the request and the service interprets reality.

AMPDS is a good start - our decision scheme about what to bill begins with the dispatch determinant.  But you don't want it to end there, because there are plenty of ALPHA and BRAVO calls (which are BLS by AMPDS definition) that a paramedic assessment and/or ALS treatment are appropriate.  You want to be able to bill ALS for them also.

 

An "ALS assessment" is an assessment that requires skills that only ALS providers (however your state defines them - usually EMT-I/AEMT or paramedic) have - evaluating lung sounds and bowel sounds, interpretation of ECG including 12-lead, etc.  You have to be reasonable - you can't bill for ALS based on a paramedic assessment lung sounds and 12-lead ECG on a patient whose only complaint is of a simple ankle injury that is clearly within the skills and scope of a BLS medic.  But if that patient also has pain 9 on a scale of 10 that requires narcotics, then voila - back to the ALS level.

 

It's hard to imagine that a 911 service can't have an EMT attend on maybe 40-50% of patients, unless the service has pushed to hard to start lifesaving KVO lines and do 12 leads on too many patients to push their billing differential way towards ALS from BLS.  If you add interfacility transports to that, the number could go even higher.

Do police services/ forces cahrge by the number of rounds let off or magazines emptied or the degree of handcuff used -nickle or zip tie? ; )

 

I find itemised prehospital care billing uncomfortable. Level of care though could be useable. Then again, we are all too scared to say everyone deserves an ambulance: no matter what.

 

Once could assume that the ALs providers is more than an interventionist and just as much a sustainer or stabilise. The old Chain of Survival blurb mentioned Early ALS to "stabilise".

Medicare and most state Medicaid programs don't allow for itemized billing.  Since that's often +/- 50% of the billing load, many services don't even bother trying to itemize any more (lots of work for crews, with little return).

 

Much of the health care industry DOES at least account for every item used, even if they are paid on a prospective payment system like Medicare DRGs (one lump sum for a diagnosis, not matter what it takes).  Check out someone's inpatient itemized hospital bill some time, for the $25 aspirin 325 mg tablets and such.

 

Police services (at least until now) have been entirely funded by local tax dollars.  However, I saw yesterday where NYPD is going to start charging for MVC response.  Wonder if that will stop people from calling 911 when they crash, and what the ramifications of THAT will be.  We can't even get most EMS folks to advocate for PARTIAL public funding of what EMS provides - too afraid that if they do, someone will suggest another provider.  After all, half of the world thinks that EMS should be free and that EMS people should work for free!  http://www.telegram.com/article/20101209/NEWS/12090834/1003/NEWS03  Following in the footsteps of my friend John Becknell, I'd suggest that they do snow-plowing using volunteers and pay for EMS for a while, and see how it works out!

I think in some cases it all depends on the provider. Some BLS or "Basic providers" feel comfortable taking patients that may be a little more severe, while others may want to have a medic for every call. The way things were explained to us is that if the patient is having a problem that drugs or invasive procedures such as an airway or IV wouldn’t change on the way to the hospital then a Medic is not needed, but if you patient need something done now or soon then you need a medic. Isaac to answer your question, BLS means strictly basic care. BLS providers can handle most of the calls that come out. ALS means advanced care. ALS providers need to handle the calls where the patients need a little more in order to have the best outcome. When it comes to who should be running the calls, well that all depends on the company. In my area we have one paid department and they are now requiring everyone to get their medic and all new employees to have their medic or be in the class. Medics should not always get stuck on calls because almost 70% of the calls do not require the advanced level of care. For most of our volunteer companies in the area they have many levels of providers ranging from a driver with CPR training only, first responders, EMT-B’s, Medics and Paramedics. Neither option is better than the other, it just depends on company preference.



Nicole said:

 The way things were explained to us is that if the patient is having a problem that drugs or invasive procedures such as an airway or IV wouldn’t change on the way to the hospital then a Medic is not needed, but if you patient need something done now or soon then you need a medic.

...

Medics should not always get stuck on calls because almost 70% of the calls do not require the advanced level of care.


1. How familiar are your EMTs with all of the indications for both the interventions and diagnostic tools that the paramedics carry? How good are they at identifying things such as atypical MI presentations? If they are at a nursing home for an "abnormal labs" patient, do they know which lab values could benefit from paramedic level care? Would it be unreasonable, for example, for an EMT to fail to recognize that hyperkalemia can be acutely treated by paramedics? At what level does pain become a "ALS" problem since paramedics possess more pain management interventions than EMTs? Alternatively, is the EMS culture a, "Let the patient tough it out so the paramedics can watch TV while waiting for the fabled bus of hemophiliac nuns that will crash into the bus of college cheerleaders"?

2. However 100% of those calls are going to be seen by providers with significantly more education, training, and scope of practice than paramedics. You will commonly be see emergency physicians argue that a specific patient doesn't need the emergency department, but how common do you see emergency physicians say that the patient doesn't need a physician?

Is it possible that one of the roots of the political and reimbursement issues that paramedics face is that paramedics constantly sell themselves short?

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