CMS has addressed the definition of specialty care transport (SCT) yet again in the recent final rule mostly devoted to the 2007 Medicare physician fee schedule (on display November 1, 2006, to be published December 1, 2006, effective January 1, 2007).  (See pp. 501-510 of the display copy of the rule, which includes a history of many of the definitions and guidance documents relating to SCT.)  SCT is the highest level of service provided by ground ambulance, as defined by CMS — it includes interfacility ambulance services which may be provided only by a paramedic with additional training or a more highly-trained professional (e.g., nurse or physician).

The defintion of SCT in the regs (42 CFR 414.605) reads as follows:

Specialty care transport (SCT) means interfacility transportation of a critically injured or ill beneficiary by a ground ambulance vehicle, including medically necessary supplies and services, at a level of service beyond the scope of the EMT–Paramedic. SCT is necessary when a beneficiary’s condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area, for example, nursing, emergency medicine, respiratory care, cardiovascular care, or a paramedic with additional training.

CMS and its public have struggled with the definition of interfacility (hospital-to-hospital? hospital-to-acute care hospital?) for over five years, and CMS included another stab at it in the draft version of the 2007 physician fee schedule rule.

Based on the comments received (including a suggestion to reconvene the negotiated rulemaking workgroup to decide what "critical care" means), CMS, in a measured tone that — to my reading — thinly veiled its exasperation, decided to withdraw its proposed clarification at the regulatory level, and to expand its "guidance" on the issue. 

The current CMS view goes beyond prior guidance: the word "interfacility" for SCT purposes now explicitly includes Medicare-certified SNF-to-hospital (AND hospital-to-SNF) ambulance runs (assuming clinical appropriateness/need for SCT-level service); this has already been permitted by liberal carriers, and CMS expects this will remain a small fraction of the total SCT volume.  "Hospital" is defined broadly to include anything that would be considered a "hospital-based facility" under CMS "provider-based" rules, 42 CFR 413.65.

Here’s to a definition that should stick.

— David Harlow