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CMS Releases TIP Rules

Earlier this week, the Centers for Medicare and Medicaid Services (CMS) released the regulations to reimburse ground ambulance agencies for providing treatment-in-place (TIP) services to Medicare beneficiaries. This new payment flexibility, even though temporary, marks an important new chapter in the CMS’ reimbursement to EMS agencies. 

Historically, CMS reimbursed ground ambulance agencies only for patient transport or when a cardiac arrest is terminated on scene. However, the COVID-19 pandemic upended the healthcare system. Hospitals quickly became inundated with patients and many states adopted new flexibility for fire departments and other EMS agencies to provide TIP services to low acuity patients. 

In March, Congress passed the American Rescue Plan Act of 2021 (P.L. 117-2) which directed CMS to reimburse EMS agencies for treating patients on-scene without transportation. CMS TIP reimbursement will be retroactive to March 1, 2020 and remain in effect until the end of the COVID-19 Public Health Emergency (PHE). The following principles and requirements will guide the reimbursement of TIP services:

Agency Type: The agency providing the services must be a Medicare-enrolled supplier or provider of ground ambulance service. Non-transport fire departments are ineligible. 

Call Parameters: The TIP services must be provided to a patient in response to a 9-1-1 call for emergency service. Additionally, CMS is restricting reimbursement to cases where the patient would have been transported to a hospital but was not transported due to “community-wide EMS protocols” that either prohibited the transport or permitted the patient to receive TIP. CMS will not provide TIP reimbursement when patients refused transportation against medical advice or when there were no protocols in effect. 

Protocols Limiting Transportation: CMS only is permitting TIP payments to be made in limited circumstances. This is not a blanket reimbursement for patient refusals or cases that did not meet CMS’ medical necessity requirements. Any agency billing CMS for TIP services must maintain documentation (and provide it upon request) that protocols were in place which limited patient transports or permitted TIP interventions with patient consent. CMS recognizes that, in some limited cases, the authorization for non-transport or for providing TIP may have come from a verbal order. CMS is permitting TIP reimbursement in these cases; however, there must be documentation reflecting this verbal order. 

It is important to note that CMS requires protocols to be in place at the time of service and not when Congress passed the authorizing legislation in March or when CMS published these rules in May. Agencies could develop protocols now and begin providing TIP services. This reimbursement opportunity for TIP expires at the end of the COVID-19 PHE. 

Copayments or Deductibles: To protect patients from surprise bills, CMS is permitting ambulance agencies to waive the collection of patient deductible or copays when submitting a TIP reimbursement to CMS. If an agency already collected more from a patient in copays or other payments than Medicare allows for the service, then the agency must refund the patient any excess above the maximum cost sharing amount.

Payment Amount and Process: Agencies seeking to bill Medicare for TIP services must use either the A0429 (BLS Emergency) or A0427 (ALS Level 1) billing codes. Reimbursement will be made at either the BLS Emergent or ALS 1 rates respectively. CMS will not pay for TIP services as the ALS 2 rate since this level of service would likely have resulted in a transport. CMS also requests that TIP claims include a valid origin/destination modified combination that would have been appropriate if the patient were transported. CMS also is requesting that the “CR” modifier be used to distinguish these claims from those made through the ET3 Pilot Project current underway. Mileage code should not be included since TIP does not include transport. 

Timeline for Claims: CMS is permitting these reimbursements to be made retroactive to March 1, 2020. Billing claims for TIP services provided from March 1, 2020 through May 5, 2021 must be submitted by May 5, 2022. All TIP services provided to Medicare beneficiaries after May 5, 2021 must be submitted within one year of the service date.

Fire service leaders are strongly encouraged to review CMS’ fact sheet on this new reimbursement opportunity. It is critically important that fire departments follow CMS’ rules and policies when billing CMS for TIP services. This is a fantastic opportunity to build momentum in gaining permanent CMS reimbursement for TIP services. Fire departments must demonstrate to CMS that they will adhere to all CMS’ policies and that Medicare beneficiaries will benefit from these new flexibilities. 

Mike McEvoy, PhD, NRP, RN, CCRN, is the EMS chief for Saratoga County, N.Y., and chair of the EMS Section. 
Evan Davis is the IAFC's government relations strategic manager and liaison to the EMS Section.   

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