(Medicare Claims Processing Manual)

The MAC does not consider in its determination such factors involving selection of a hospital which reflect the personal preferences of the individual or physician, (e.g., physician does not have staff privileges at the participating hospital) nearness to beneficiary's residence, presence of previous medical records at the nonparticipating hospital, cost, or type of accommodations available.   The following sections discuss documentation of the accessibility requirement and provide guidelines for making a determination where the participating hospital is:   Closer to the site of the emergency than is the admitting nonparticipating hospital;    Fifteen or fewer miles farther from the site of the emergency than is the nonparticipating hospital; or    Sixteen or more miles farther from the site of the emergency than is the admitting nonparticipating hospital.   In urban and suburban areas, where both participating and nonparticipating hospitals are similarly available, it is presumed, in the absence of clear and convincing evidence to the contrary, that the services could have been provided in the participating h ospital.   1.  Participating Hospital Closer to Site of Emergency   If there is an adequately equipped participating hospital with available beds closer to the site of the emergency than the nonparticipating hospital, accessibility is not met.  Claim is denied unless extenuating circumstances were present that necessitated  admission to the nonparticipating hospital, e.g., because of road or traffic conditions additional travel time would have been needed.   2.  Participating Hospital 15 or Fewer Miles Farther From the Location of the Emergency Than the Admitting Nonparticipating Hospital   In this situation the accessibility is provisionally not met.  The claim is reviewed to determine if the nature of the emergency required the immediate transportation to the nonparticipating hospital.  If the review indicates that the nature of the emergen cy would have allowed the additional transportation time needed to take the patient to the participating hospital without undue hazard, the accessibility requirement is not met.  The claim is denied.   3.  Participating Hospital More than 15 Miles Farther From the Location of the Emergency Than the Admitting Nonparticipating Hospital   The accessibility requirement is deemed met.   B.  Foreign Nonemergency Claims   The following presumptions are applied to the relative accessibility of the nearest participating U.S. and foreign hospitals.  1.  Admitting Foreign Hospital is Closer to the Beneficiary's Residence Than the Nearest Participating U.S. Hospital   The accessibility requirement is met.   2.  Admitting Foreign Hospital is Farther From the Beneficiary's Residence Than the Nearest Participating U.S. Hospital   The accessibility requirement is not met unless evidence establishes the practical necessity for the beneficiary's admission.  This requirement is met if the use of a closer participating U.S. hospital was impractical, e.g., non-availability of beds, neede d equipment or personnel, or transportation not available.   In determining whether a foreign hospital is more accessible than a participating hospital, the MAC does not consider the personal preference of the beneficiary, physician, or others in the selection of a hospital, the type of accommodations available, or the nonavailability of staff privileges to the attending physician.  350.11.5 - Medical Necessity (Rev. 3287, Issued: 06- 30-15, Effective: 04 -21-15, Implementation: 04- 21-15)  A.  Emergency Services   Reimbursement for emergency inpatient hospital services is permitted only for those periods during which the patient's state of injury or disease is such that a health or life -endangering emergency existed and continued to exist, requiring immediate care t hat could be provided only in a hospital.  The allegation that an emergency existed must be substantiated by sufficient medical information from the physician or hospital.  If the physician's statement does not provide it, or is not supplemented by adequat e clinical corroboration of this allegation, it does not constitute sufficient evidence.   Death of the patient does not necessarily establish the existence of a medical emergency, since in some chronic, terminal illnesses, time is available to plan admission to a participating hospital.  The lack of adequate care at home or lack of transportation to a participating hospital does not constitute a reason for emergency hospital admission, without an immediate threat to the life and health of the patient.  Since the existence of medical necessity for emergency services is based upon the physician's assessment of the patient prior to admission, serious medical conditions developing after a non-emergency admission are not "emergencies" under the emergency services provisions of the Act.  The emergency ceases when it becomes safe, from a medical standpoint, to move the individual to a participating hospital, another institution, or to discharge the individual.  B.  Criteria   Since the decision that a medical emergency existed can be a matter of subjective medical judgment involving the entire gamut of disease and accident situations, it is impossible to provide arbitrary guidelines.  1.  Diagnosis is Considered "Usually an Emergency"   An emergency condition is an unanticipated deterioration of a beneficiary's health which requires the immediate provision of inpatient hospital services because the patient's chances of survival, or regaining prior health status, depends  upon the speed wit h which medical or surgical procedures are, or can be, applied.  While many diagnoses (e.g., myocardial infarction, acute appendicitis) are normally considered emergencies, the hospital must check medical documentation for internal consistencies (e.g., signs and symptoms upon admission, notations concerning changes in a preexisting condition, results of diagnostic tests).  EXAMPLE:  If the diagnosis is given as "coronary," the physician's statement is "coronary," without further explanatory remarks, and the statement of services rendered gives no indication that an electrocardiogram was taken, or that the patient required intensive care, etc., further information is required.  On the other hand, if the diagnosis is one that ordinarily indicates a medical and/or surgical emergency, and the treatment, diagnostic procedures, and period of hospitalization are consistent with the diagnosis, further documentation may be unnecessary.  An example is: admitting diagnosis -  appendicitis; discharge diagnosis -  appendicitis; surgical procedures -  appendectomy; period of inpatient stay - 7 days.   2.  Patient Dies During Hospitalization   If an emergency existed at the time of admission and the patient subsequently expires, the claim is allowed for emergency services if the period of coverage is reasonable.  However, death of the patient is not prima facie evidence that an emergency existed ; e.g., death can occur as a result of elective surgery or in the case of a chronically ill patient who has a long terminal hospitalization.  Such claims are denied.   3.  Patient's Physician Does Not Have Staff Privileges at a Participating Hospital  The fact that the beneficiary's attending physician does not have staff privileges at a participating hospital has no bearing on the emergency services determination.  If the lack of staff privileges in an accessible participating hospital is the governing factor in the decision to admit the beneficiary to an "emergency hospital," the claim is denied irrespective of the seriousness of the medical situation.  4.  Beneficiary Chooses to be Admitted to a Nonparticipating Hospital   The claim is denied if the beneficiary chooses to be admitted to a non- participating hospital as a personal preference (e.g., participating hospital is on the other side of town) when a bed for the required service is available in an accessible , participat ing hospital.  5.  Beneficiary Cannot be Cared for Adequately at Home   The patient who cannot be cared for adequately at home does not necessarily require emergency services.  The claim is denied in the absence of an injury, the appearance of a disease or disorder, or an acute change in a pre -existing disease state which pose s an immediate threat to the life or health of the individual and which necessitates the use of the most accessible hospital equipped to furnish emergency services.   6.  Lack of Suitable Transportation to a Participating Hospital   Lack of transportation to a participating hospital does not, in and of itself, constitute a reason for emergency services.  The availability of suitable transportation can be considered only when the beneficiary's medical condition contraindicates taking the time to arrange transportation to a participating hospital.  The cla im is denied if there is no immediate threat to the life or health of the individual, and time could have been taken to arrange transportation to a participating hospital.   7.  "Emergency Condition" Develops Subsequent to a Non- emergency Admission to a Nonparticipating Hospital   Program payment cannot be made for emergency services furnished by a nonparticipating hospital when the emergency condition arises after a non- emergency admission.  An example: treatment of postoperative complications following an elective surgical procedu re or treatment of a myocardial infarction that occurred during a hospitalization for an elective surgical procedure.  The existence of medical necessity for emergency services is based upon the physician's initial assessment of the apparent condition of t he patient at the time of the patient's arrival at the hospital, i.e., prior to admission.  8.  Additional "Emergency Condition" Develops Subsequent to an Emergency Admission to a Nonparticipating Hospital   If the patient enters a nonparticipating hospital under an emergency situation and subsequently has other injuries, diseases or disorders, or acute changes in preexisting disease conditions, related or unrelated to the condition for which the patient enter ed, which pose an immediate threat to life or health, emergency services coverage continues.  Emergency services coverage ends when it becomes safe from a medical standpoint to move the patient to an available bed in a participating institution or to discharge the patient, whichever occurs first.   C.  Documenting Medical Necessity   1.  Physician's Supporting Statement   Claims for emergency services by a non -participating hospital should be accompanied by an Attending Physician's Statement and Documentation of Medicare Emergency, Form CMS -1771 or its equivalent.  This form describes the nature of the emergency, furnishing relevant clinical information about the patient, and certifying that the services rendered were required as emergency services.  However, a copy of the patient's hospital records may be submitted instead.  It should include history, physical, and admission notes, the medical record admission sheet, nurses' notes, doctors' orders, discharge summary, and all progress notes.  A statement that an emergency existed, or the listing of diagnoses, without supporting information, is not sufficient.  In addition, the statement must include the date, in the physician's judgment, the emergency ceased.  The physician who attended the patient at the hospital makes the statement concerning emergency services.  Only in exceptional situations, with appropriate justification, may another physician having full knowledge of the case, make the certification.  2.  Beneficiary's Statement in Canadian Travel Claims   In Canadian travel claims, the beneficiary's statement is considered in making a determination regarding medical necessity for emergency services; i.e., whether an emergency occurred while a beneficiary was traveling between Alaska and another State by the  most direct route without unreasonable delay.  (See 350.4.)   350.11.6 - Time Limitation on Emergency and Foreign Claims  (Rev. 3287, Issued: 06- 30-15, Effective: 04 -21-15, Implementation: 04- 21-15)  The regular time limits apply to requests and claims for payment for emergency hospital services and hospital services outside the U.S., for physician and ambulance services furnished in connection with foreign hospitalization, and for nonemergency service s furnished by a domestic nonparticipating hospital.  See chapter 1 for a description of these requirements.   A.  Beneficiary Denial Notices   MACs shall send denial letters for non- covered foreign related claims.   Part B MACs will send an MSN for covered foreign emergency and shipboard claims related to a covered Part A foreign claim.  An MSN is also sent for shipboard services provided within US territories.  B.  Termination of Emergency Services   No payment will be made for inpatient or outpatient emergency services rendered after a reasonable period of medical care in relation to the emergency condition in question.  Some services may be covered in a domestic nonparticipating hospital as Part B Me dical and Other Health Services.  (See the Medicare Benefit Policy Manual, chapter 6.)  If, based upon all information, the total period claimed for emergency services coverage does not exceed the time required for a reasonable period of emergency medical care, the entire inpatient stay is covered.  The fact that a medical record or other information states that the patient showed definite improvement several days prior to discharge is not necessarily an indication that the need for emergency services ceased as of that date.  The concept of a reasonable period of emergency medical care is most easily applied when relatively short -term medical care is followed by the patients progressive improvement.  There are situations or conditions in which the determina tion of the end of covered emergency services may be more difficult because the patients impairment is prolonged, there is no progressive improvement, or the patients course may be progressively downhill, even though the condition is not critical.  The s troke patient may be in this category.  In such cases the need for emergency medical care usually ceases before the need for medical care in an institutional setting (i.e., hospital or SNF) ceases.  Thus, the reasonable period of emergency care does not include the entire hospital stay if the stay was prolonged beyond the point when major diagnostic evaluation and treatment were carried out.