Ground to Air Transports and hospice patient transport billing

November 23, 2010, 6:24 am

Ground to Air Transports

When a beneficiary is transported by ground ambulance and transferred to an air ambulance, the ground ambulance supplier may bill Medicare for the level of service provided and mileage from the point of pickup to the point of transfer to the air ambulance. The air ambulance supplier also bills for its respective services and mileage from the point of pick-up to the destination.

Gurney or Wheelchair Vans Transports
Gurney and wheelchair vans do not meet the staff, vehicle and equipment requirements to meet the Medicare coverage guidelines, therefore transportation provided in a gurney or wheelchair van is not covered by Medicare.

Note: If the beneficiary requires a denial, a claim can be submitted using HCPCS A0999 (unlisted ambulance service) and a “GY” modifier. Include in the narrative field that this service is for a gurney or wheelchair van and submitted for denial.

Hospice Patient Transports
Ambulance transports unrelated to the beneficiary’s terminal illness or on the same day as either the start or end date of hospice care is allowed. Submit the claim with the origin and destination modifiers and the GW modifier which indicates the services are unrelated. All other criteria for ambulance transports must be met. Ambulance transports related to the beneficiary’s terminal illness should be billed to Medicare Part A.

Example:
02022006 0202200641 A0428 RHGW1 1
02022006 0202200641 A0425 RHGW1 25

Hospital Discharge Transports
Patients discharged from inpatient hospital care must meet medical necessity for non-emergency transportation to the patient’s residence, skilled nursing facility, or rehabilitation hospital. Non-emergency ambulance services require a physician certification statement.

Multiple Arrivals
The general Medicare program rule is that the ambulance benefit is a transportation benefit and without a transport there is no payable service. When multiple ambulance suppliers respond, payment may be made only to the ambulance supplier that actually furnishes the transport. Ambulance suppliers that arrive on the scene but do not furnish a transport are not due payment from Medicare.

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ambulance billing - claim tips

November 25, 2010, 5:03 am

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Billing Information

• Submit the most updated industry-standard codes.

• Submit the appropriate modifier as indicated in the Origin and Destination Modifier Table on page 4.

• Submit non-emergency ambulance and/or scheduled ground transportation claims with a completed medical necessity form. Non-emergency ambulance and/or scheduled ground transportation electronic or paper claims submitted without a medical necessity form will deny as provider responsibility.

• Electronic submitters must fax a copy of the completed medical necessity form to the Precertification Department at (617) 972-9409 for non-emergency ambulance and/or scheduled ground transportation the same day the claim is submitted.

• Non-emergency ambulance and/or scheduled ground transportation claims submitted on paper must have the completed medical necessity form accompanying the claim.

• Tufts Health Plan will accept medical necessity forms that are used by the ambulance provider for non-emergency and/or scheduled ground transportation claims.

In the event that an ambulance provider must submit a claim for a service where the member has acknowledged liability, submit a medical necessity form indicating the service is not a covered service with a valid waiver indicating that the member has been notified that the service is not covered and the member has assumed liability. This will ensure accurate claim adjudication.

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ambulance billing modifier

November 26, 2010, 2:00 am

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Modifier Listing for Ambulance Billing

The following list includes the current modifiers that are recognized by Medicare for billing purposes. Please consult your current HCPCS and CPT manuals for more detailed information regarding each modifier. Modifiers used for ambulance billing have been separated out and can be found towards the end of this article. For ambulance destination modifiers the first modifier indicates the pick-up point and the second indicates the point of destination. DME modifiers are omitted.

Ambulance modifiers

GM Multiple patient transport
QL Patient pronounced dead after ambulance called
QM Ambulance services provided under arrangement by a hospital
QN Ambulance services furnished directly by a hospital

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CERT - Certificate of Medical necessity for ambulance transfers

November 27, 2010, 12:23 am

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Certificate of Medical Necessity for Ambulance Transfers

Recent CERT findings have identified concerns regarding the improper use of Certificates of Medical Necessity (CMN)/ Physician Certification Statement (PCS) and the Advanced Beneficiary Notice (ABN) to justify ambulance transport of Medicare beneficiaries. This issue has resulted in the denial of four ambulance claims processed by Highmark Medicare Services and recoupment of the associated payments. Furthermore, when extrapolated, these four errors alone will add approximately $30 million to this year’s national Medicare “fraud, waste, and abuse” figure to be reported in
November 2010.

To address this problem, ambulance companies and physicians must be sure that the patient’s medical record clearly supports the need for ambulance transport and includes the specific information that render the ambulance transport medically necessary. Medical necessity is established when the patient’s condition is such that use of any other method of transportation is contraindicated. If another means of transportation could be used without endangering the individual’s health, whether or not such other transportation is actually available, no payment can be made for ambulance services.

Please note that the supporting documentation needs to describe the patient’s condition at the time of transport, not what occurred years ago (as an outdated CMN/PCS may do). In addition, inclusion of a signed CMN/PCS in the medical record does not, by itself, establish the medical necessity of the transport; all other program criteria must be met in order for payment to be rendered.
Medicare will not pay for transports that are not clearly medically necessary and reasonable.

Emergency Medical Services providers should also be cognizant that the patient’s condition has not changed such that a CMN/PCS would no longer be valid. As a reminder, the physician’s order must
be dated no earlier than 60 days before the date the service is furnished.
• A patient who is able to walk from the porch to the ambulance is likely not eligible for ambulance transfer in routine non-emergent settings.

Medicare Report: September 2010

• A patient whose CMN/PCS states that continuous oxygen is necessary, but whose trip sheet documents that no oxygen was needed or used, is likely not eligible for ambulance transfer in routine non-emergent settings.

As noted earlier, even if a physician writes an order for a patient to go by ambulance, that alone does not prove medical necessity. All other program criteria must be met in order for payment to be made.
Transports that are not medically necessary should be brought to the attention of the provider signing the CMN/PCS and the billing company so the claim can be submitted to Medicare with the appropriate modifier for denial. The claim should be reported with the GA modifier if the patient signed an ABN which acknowledges that the patient was informed the transport would not be paid by Medicare. ABNs are rarely appropriate for ambulance services and are only appropriate for
use in non-emergency situations. The GZ modifier should be reported on the claim if the beneficiary did not sign an ABN and is unaware that Medicare will not pay for the transport.

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Modifier usage in ambulance billing and tips

November 28, 2010, 12:28 am

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Additional Modifiers for Use With Ambulance Transports

-GM Multiple patients on one ambulance trip
When more than one patient is transported in an ambulance, the Medicare allowed charge for
each beneficiary is a percentage of the allowed charge for a single beneficiary transport. The
applicable percentage is based on the total number of patients transported, including both
Medicare beneficiaries and non-Medicare patients.

Billing Tips

• Use the “GM” modifier to identify a multiple transport.
• Submit documentation to specify the particulars of a multiple transport. The
documentation must include the total number of patients transported in the vehicle at the
same time and the health insurance claim numbers for each Medicare beneficiary.
• Submit the charges applicable to the appropriate service rendered to each beneficiary and
the total mileage for the trip.
• Submit all associated Medicare claims for the multiple transports within a reasonable
number of days of submitting the first claim.
• If there is only one Medicare beneficiary in the multiple patient transports, the supplier
must document this.

-QL Patient pronounced dead after ambulance called
Time of Death Pronouncement - Ground or Water

Medicare ambulance benefits are a transport benefit If no transport of a Medicare beneficiary
occurs, then there is no Medicare covered service. In general, if the beneficiary dies before being
transported, then no Medicare payment may be made. In a situation where the beneficiary dies,
whether any payment under the Medicare ambulance benefits may be made depends on the time
at which the beneficiary is pronounced dead by an individual authorized by the State to make
such pronouncements. The chart below shows the Medicare payment determination for various
ground ambulance scenarios in which the beneficiary dies. In each case, the assumption is that
the ambulance transport would have otherwise been medically necessary.

Time of Death Pronouncement Medicare Payment Determination

Before dispatch No payment
After dispatch, before beneficiary is loaded onboard the ambulance (before or after arrival at the point of pickup).
After pickup, prior to or upon arrival at
the receiving facility.

Medicare Payment Determination

No payment
The ambulance BLS base rate is paid. No mileage or rural adjustment. Use the QL modifier when submitting the claim.
Medically necessary level of service furnished is allowed.

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when Medicare allow payment for air ambulance billing - tips

November 29, 2010, 3:29 am

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Air Ambulance

Medicare allows payment for an air ambulance service when the air ambulance takes off to pick
up a Medicare beneficiary, but the beneficiary is pronounced dead before being loaded onto the
ambulance for transport (either before or after the ambulance arrives on the scene). This is
provided the air ambulance service would otherwise have been medically necessary. The
allowed amount is the appropriate air base rate, i.e.; fixed or rotary wing. No amount is allowed
for mileage or rural adjustment.

No payment is allowed if the dispatcher received pronouncement of death and had a reasonable
opportunity to notify the pilot to abort the flight. The supplier must submit documentation with
the claim sufficient to show that:

• The air ambulance was dispatched to pick up a Medicare beneficiary;
• The aircraft actually took off to make the pickup;
• The beneficiary to whom the dispatch relates was pronounced dead before being loaded
onto the ambulance for transport;
• The pronouncement of death was made by an individual authorized by State law to make
such pronouncements; and
• The dispatcher did not receive notice of such pronouncement in sufficient time to permit
the flight to be aborted before take off.

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ambulance HCPCS CODE LIST A0225, S0208

December 3, 2010, 5:59 am

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HCPCS procedure codes are used for Ambulance service

The HCPCS procedure codes listed in the following table are the only reimbursable procedure codes, per the Ancillary Provider Agreement. Hospital-owned providers are subject to their respective contracts. Submit the most appropriate HCPCS procedure codes when billing for services.

Procedure Codes	Description

A0225	Ambulance service, neonatal transport, base rate, emergency transport, one way
A0384	Basic life support, specialized service - defibrillation (where permitted)
A0392	Advanced life support, specialized service, defibrillation (where not permitted by basic life support)
A0394	Advanced life support disposable supplies - IV drug therapy
A0396	Advanced life support disposable supplies - esophageal intubation
A0422	Oxygen and oxygen supplies
A0425	Ground Mileage-per mile
A0426	Advanced Life Support, non-emergency-base rate
A0427	Advanced Life Support, Level I - base rate
A0428	Basic Life Support, non-emergency-base rate
A0429	Basic Life Support, emergency-base rate
A0433	Advanced Life Support, Level II -base rate
A0434	Specialty Care Transport
S0208*	Paramedic intercept, hospital-based ALS service (non-voluntary), non-transport

* Applies to hospital-based ambulance services only.

Note: HCPCS procedure code A0998 (ambulance response and treatment; no transport), if billed, will deny as not covered, member responsibility.

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ambulance billing - Multiple Patients Transported Simultaneously

December 8, 2010, 5:44 am

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Multiple Patients Transported Simultaneously

When more than one patient is transported in an ambulance, the Medicare allowed charge for each beneficiary is a percentage of the allowed charge for a single beneficiary transport. The applicable percentage is based on the total number of patients transported, including both Medicare beneficiaries and non-Medicare patients.

If two patients are transported at the same time in one ambulance to the same destination, the adjusted payment allowance for each Medicare beneficiary would equal 75% of the single-patient allowed amount applicable to the level of service furnished a beneficiary, plus 50% of the total mileage payment allowance for the entire trip.
If three or more patients are transported at the same time in one ambulance to the same destination, the adjusted payment for each Medicare beneficiary would equal 60% of the single-patient allowed amount, plus a proportional mileage allowed amount, i.e., the total mileage allowed amount divided by the number of all the patients onboard.
The fact that the level of medically necessary service among the patients may be different is not relevant to this payment policy. The percentage is applied to the allowed amount applicable to the level of service that is medically necessary for each beneficiary.
If a multi-patient transport includes multiple destinations, then the Medicare allowed amount for mileage depends upon whether it is for an emergency versus non-emergency transport.
For example:
• For an emergency ground transport, which includes BLS-E, ALS1-E, ALS2 and SCT, the mileage payment shall be based on the number of miles to the nearest appropriate facility for each patient, divided by the number of patients on board when the vehicle arrives at the facility. This formula applies cumulatively for beneficiaries who are the 2nd and 3rd patients to be delivered.

• For a non-emergency ground transport, which includes BLS and ALS1, the mileage payment shall be based on the number of miles from the point of pick up to the nearest appropriate facility for each beneficiary, divided by the number of beneficiaries on board at the point of pick up. This formula applies cumulatively for beneficiaries for multiple points of pick up. Mileage other than the mileage that would be incurred by transporting the beneficiary directly from the point of pick up to the nearest appropriate facility is not covered. Thus, for non-emergency transports, the extra mileage that may be incurred by having multi-destinations shall not be taken into account.

• If a Medicare beneficiary is furnished medically necessary supplies and the supplier bills supplies separately, then the allowed amount of the supplies is not subject to an apportionment for multiple patients. The allowed amount for supplies should be determined in the same manner as if the beneficiary was the only patient onboard the vehicle.

• For air transports the policy is the same as for emergency ground transports.

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Ambulance claim billing guidelines

December 10, 2010, 3:19 am

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Billing Guidelines

• Use the “GM” modifier to identify a multiple transport.

• Submit documentation to specify the particulars of a multiple transport. The documentation must include the total number of patients transported in the vehicle at the same time and the health insurance claim numbers for each Medicare beneficiary.

• Submit the charges applicable to the appropriate service rendered to each beneficiary and the total mileage for the trip.

• Submit all associated Medicare claims for the multiple transports within a reasonable number of days of submitting the first claim.

• If there is only one Medicare beneficiary in the multiple patient transports, the supplier must document this.

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Will Medicare cover excess mileage ambulance transportation?

December 14, 2010, 10:03 pm

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Non Covered Mileage

Medicare only pays for medically necessary transportation to the closest facility. If a patient requests that they be transported to a more distant facility, the excess mileage will be the responsibility of the patient. A claim should be submitted to Medicare with one line for the “base rate,” one line for the “covered mileage” and one line for the “excess mileage”. The “excess mileage should be billed with HCPCS code A0888 and a “GY” modifier only.

Example: In this example the closest facility is 25 miles from the “place of pick-up.” The patient requests that they be transported to a facility 55 miles away from the “place of pick-up.” Line 2 represents the “covered” miles (25). Line 3 represents the “non-covered” miles (30) which would be the patient’s responsibility.

02022006 0202200641 A0428 RH 11
02022006 0202200641 A0425 RH 1 25
02022006 0202200641 A0888 GY 1 30

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Patient, Physician or Family Convenience Transports billing tips

December 18, 2010, 5:37 am

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Patient, Physician or Family Convenience Transports

Coverage is not available if transport is requested solely because the patient and/or family prefer a specific hospital or physician, or so the patient can be closer to home. A request from or on behalf of a Medicare beneficiary for transport by ambulance for the beneficiary's personal convenience or that of the doctor or beneficiary’s family is not a Medicare benefit under section 1861(s)(7) of the Social Security Act. If you furnish a service pursuant to such a request, then you may charge the individual your full fee and collect the fee at a time of your choosing. You should advise the beneficiary, in advance of furnishing the service, that such "convenience transportation" is not covered under Medicare. However, the use of an Advance Beneficiary Notice (ABN) is not indicated. You may use a “Notice of Exclusions from Medicare Benefits (NEMB)” to document the agreement for private payment of such services.

Patient Assistance
If the sole reason for ambulance transport was that the patient needed assistance into the home (e.g., patient resides on second floor), the services would not be considered for payment.

Patient Refuses Transport
In a situation where the patient refuses transport, Medicare does not cover the services. This also applies to any medical services provided. The beneficiary would be liable for the expenses. The Medicare ambulance benefit is a transportation benefit only.

Physician Office Transport
Coverage of transports to or from a physician’s office is allowed only in the following instance:
• The ambulance transport enroute to a Medicare covered destination, and
• When, during transport, the patient requires immediate professional attention and the ambulance stops at the physician’s office for stabilization and then, transports the patient to the hospital.

NOTE:
The SX PH modifiers for the origin and destination must be submitted to identify that the above circumstances existed.

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Speciality Care Transports billing

December 26, 2010, 10:16 pm

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Specialty Care Transports

SCT is a highly skilled level of care of a critically injured or ill patient during transfer from one hospital to another (Effective 1-1-07, coverage is provided for inter-facility transports*). Typically, this occurs when the patient, who is already receiving a high level of care in the transferring acute care hospital, requires a level of care that the transferring hospital is not able to provide. This includes the situation where a beneficiary is taken by ground ambulance to an air ambulance and then from the air ambulance to the final destination hospital. For services prior to 1-1-07, transfer to or from any other type of facility (e.g., skilled nursing facility, nursing home) is not SCT. When billing SCT transports, be sure to include the following information in the Comments field (NTE02) or on the paper claim:

• Information that the patient was discharged from the 1st facility and admitted to the 2nd facility.
• Information to show that is providing care beyond the scope of a paramedic.
• Information to indicate what ongoing care is being provided by a health care professional beyond the scope of a paramedic.

Example:

RN on board IV heparin D/C 1st
ADM 2ndheart cath not available @1st.

*For purposes of SCT payment, CMS considers a “facility” to include only a SNF or a hospital that participates in the Medicare program, or a hospital-based facility that meets CMS’ requirements for provider-based status. Medicare hospitals include, but are not limited to, rehabilitation hospitals, cancer hospitals, children’s hospitals, psychiatric hospitals, critical access hospitals (CAHs), inpatient acute-care hospitals, and sole community hospitals (SCHs). The following origin/destination modifier combinations will be considered for coverage; HH, HN, NH, NN. In addition, the following origin/destination modifier combinations will be considered for coverage when the final destination is hospital or SNF; NI, IN, HI or IH.

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Skilled Nursing Facility Transports ambulance biling

December 28, 2010, 12:58 am

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Skilled Nursing Facility Transports

The following ambulance services are included in consolidated billing. Claims should be submitted by the SNF to Medicare Part A.

• For beneficiaries in a Part A covered stay, a medically necessary ambulance transport from one SNF to another SNF.
• Ambulance transports for beneficiaries in a Part A covered stay, to or from a diagnostic or therapeutic site other than a physicians office or hospital (i.e. IDTF, cancer treatment center, radiation treatment center, wound care center) are to be part of SNF Consolidated billing.
• If the patient is traveling from the SNF to a doctor’s office the trip would be the responsibility of the SNF, as would the return trip.

• Medically necessary ambulance transports that are furnished during the course of a covered Part A stay are included in consolidated billing with the exception of specific excluded services.
Listed below are a number of specific circumstances under which a beneficiary may receive ambulance services when resident status has ended. These ambulance trips are excluded from consolidated billing, and claims should be submitted by the ambulance supplier to the carrier (Part B).

• The ambulance trip is to the SNF for admission
• A medically necessary round trip to a Medicare participating hospital or Critical Access Hospital for the specific purpose of receiving emergency or other excluded services.
• Medically necessary ambulance trips after a formal discharge or other departure from the SNF, unless the beneficiary is readmitted or returns to that or another SNF before midnight of the same day.

• An ambulance trip for the purpose of receiving dialysis and dialysis-related services that are excluded from consolidated billing.
• A trip for an inpatient admission to a Medicare participation hospital or Critical Access hospital.
• After discharge from the SNF, a medically necessary trip to the beneficiary’s home where the beneficiary will receive services from a Medicare participating home health agency under a plan of care.

Certain services are excluded from consolidated billing only when furnished on an outpatient basis by a hospital or a critical access hospital. Ambulance transportation for the following services is excluded and should be billed to Part B:

• Cardiac catheterization services;
• Computerized axial tomography scans;
• Magnetic resonance imaging;
• Ambulatory surgery involving the use of an operating room (the ambulatory surgical exclusion includes the insertion of percutaneous esophageal gastrostomy (PEG) tubes in a gastrointestinal or endoscopy suite);
• Emergency services;
• Angiography; and
• Lymphatic and venous procedures
• Radiology therapy
• Removal, replacement or insertion of a PEG tube

Services for those patients requiring an ambulance that have exhausted the Medicare Part A skilled nursing benefit, who are residents of a SNF, but no longer in a Part A stay, would be reported to the carrier for Part B reimbursement. All the standard coverage and billing requirements apply to these transports (medically necessary, closest facility etc).

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Air ambulance billing and Medicare coverage

January 17, 2011, 11:23 pm

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Air Ambulance

Medicare allows payment for an air ambulance service when the air ambulance takes off to pick up a Medicare beneficiary, but the beneficiary is pronounced dead before being loaded onto the ambulance for transport (either before or after the ambulance arrives on the scene). This is provided the air ambulance service would otherwise have been medically necessary. The allowed amount is the appropriate air base rate, i.e.; fixed or rotary wing. No amount is allowed for mileage or rural adjustment.

No payment is allowed if the dispatcher received pronouncement of death and had a reasonable opportunity to notify the pilot to abort the flight. The supplier must submit documentation with the claim sufficient to show that:

• The air ambulance was dispatched to pick up a Medicare beneficiary;
• The aircraft actually took off to make the pickup;
• The beneficiary to whom the dispatch relates was pronounced dead before being loaded onto the ambulance for transport;
• The pronouncement of death was made by an individual authorized by State law to make such pronouncements; and
• The dispatcher did not receive notice of such pronouncement in sufficient time to permit the flight to be aborted before take off.

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compliance program policy for ambulance suppliers

February 6, 2011, 8:27 am

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COMPLIANCE PROGRAM GUIDANCE FOR AMBULANCE SUPPLIERS

Compliance Program Guidance for Ambulance Suppliers had been developed by the Office of Inspector General (OIG). The OIG has previously developed and published voluntary compliance program guidance focused on several different areas of the health care industry. This voluntary compliance program guidance should assist ambulance suppliers and other health care providers in developing their own strategies for complying with federal health care program requirements.

The creation of compliance program guidance (CPGs) is a major initiative of the OIG in its effort to engage the private health care community in preventing the submission of erroneous claims and in combating fraudulent and abusive conduct. In the past several years, the OIG has developed and issued CPGs directed at a variety of segments in the health care industry. The development of these CPGs is based on our belief that a health care provider can use internal controls to more efficiently monitor adherence to applicable statutes, regulations, and program requirements.

The CPG for Ambulance Suppliers can be found at: http://oig.hhs.gov/fraud/docs/complianceguidance/032403ambulancecpgfr.pdf

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When we should ask ABN from patient in ambulance billing - non emergency transport

February 6, 2011, 8:27 am

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ABN Requirements for Non-Emergency Transports

The ABN is a written notice a physician or supplier gives to a Medicare beneficiary before items or services are furnished when the physician or supplier believes that Medicare probably or certainly will not pay for some or all of the items or services on the basis of certain Medicare statutory exclusions.
An ABN is rarely used for ambulance services, and may only be issued for non-emergency transports. An ABN may not be used when a beneficiary is under great duress. A beneficiary is considered to be under great duress when his or her medical condition requires emergency care.

An ABN may be needed and may be used for non-emergency transports in the following situations:

a) A transport by air ambulance when the transporting entity has a reasonable basis to believe that the transport can be done safely and effectively by ground ambulance transportation.
b) A level of care downgrade, e.g., from ALS-2 to ALS-1, or from ALS to Basic Life Support (BLS), when the transport at the lower level of care is a covered transport.
c) A transport from a residence to a hospital for a service that can be performed more economically in the beneficiary’s home, and
d) A transport of a skilled nursing facility patient to a hospital or to another SNF for a service that can be performed more economically in the first SNF.
An ABN is not needed, and should not be used in the following situations:
a) Any denial where the patient could be transported safely by other means.
b) Any denial that is based on not meeting an origin or destination requirement.
c) A denial for mileage that is beyond the nearest appropriate facility.
d) A denial where the PCS or accepted alternative (i.e. certified mail) is not obtained.
e) A convenience discharge, e.g., where the patient is an inpatient at one hospital that can care for their needs, but wants to be transferred to a second hospital to be closer to family.

The Notice of Exclusions from Medicare Benefits (NEMB) is an optional form that CMS developed to assist suppliers in informing beneficiaries that the services they are receiving are excluded from Medicare benefits. When an ABN is not appropriate to use because medical necessity is not the basis for the expected denial, an NEMB may be used. Ambulance suppliers may develop their own process to communicate to beneficiaries that they will be billed for excluded services.

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ABN form in ambulance billing - GA, GX, GY, GZ modifiers

February 11, 2011, 5:22 am

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LIMITATION OF LIABILITY (ADVANCE BENEFICIARY NOTICE)

Services denied as not reasonable and medically necessary, under section 1862(a)(1) of the Social Security Act, are subject to the Limitation of Liability (Advance Beneficiary Notice (ABN)) provision. The ABN is a notice given to beneficiaries to convey that Medicare is not likely to provide coverage in a specific case. Providers must complete the ABN and deliver the notice to affected beneficiaries or their representative before providing the items or services that are the subject of the notice.

The ABN must be verbally reviewed with the beneficiary or his/her representative and any questions raised during that review must be answered before it is signed. The ABN must be delivered far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice. ABNs are never required in emergency or urgent care situations. Once all blanks are completed and the form is signed, a copy is given to the beneficiary or representative. In all cases, the provider must retain the original notice on file.

Complete instructions and the ABN form (CMS-R-131) can be found on the CMS website at the following address: http://www.cms.gov/BNI/

ABN Modifiers
GA Waiver of liability statement issued, as required by payer policy
GX Notice of liability issued, voluntary under payer policy
GY Item or service statutorily excluded or does not meet the definition of any Medicare benefit
GZ Item or service expected to be denied as not reasonable and necessary (forgot to issue ABN to patient)

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Origin and Destination Modifier Table in ambulance billing

February 25, 2011, 9:04 am

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Origin and Destination Modifier Table

The modifiers listed in the following Origin and Destination Modifier table are required for billing, as applicable. The first letter should indicate the transport’s place of origin, and the second letter should indicate the destination.

Origin and Destination Modifier Table

Modifier	Description
D	Diagnostic or therapeutic site other than ‘P’ or ‘H’
E	Residential, domiciliary, custodial facility (nursing home, not skilled nursing facility)
G	Hospital-based dialysis facility (hospital or hospital-related)
H	Hospital
I	Site of transfer (for example, airport or helicopter pad) between types of ambulance)
J	Non-hospital based dialysis facility
N	Skilled Nursing Facility
P	Physician’s office (includes HMO non-hospital based facility, clinic, etc.)
R	Residence
S	Scene of accident or acute event
X	Intermediate stop at physician’s office en route to the hospital. Note: Modifier X can only be used as a designation code in the second position of a modifier.

Note: Modifiers contained in this table are accepted and converted by Tufts Health Plan to 00. The modifiers will reflect that no modifier was used to process the claim on the SOA and will populate the modifier field with 00.

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Medicare coverage of Ambulance service - conditions

September 14, 2011, 4:55 am

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Requirements for Coverage

For ambulance services to be covered by Medicare, the following requirements must be met:
 Actual transportation of the beneficiary occurs.
 Services must be medically necessary and reasonable for the condition of the patient.
 The condition of the patient would not allow transportation by other means.
 A diagnosis must be on the claim or a detailed description of the patient’s condition at the time of transfer must be submitted with the claim or provided upon request to determine medical necessity.
 Ambulance personnel should document their observations of the patient’s condition.
 Transportation to a hospital from another hospital when a patient’s needs cannot be met at the first hospital and the patient is admitted to the second hospital.
 Transportation is to an extended care facility or to the patient’s home.
 Transportation is to the closest appropriate facilities.
 Transportation is provided by an approved supplier/provider of ambulance services.
 The transportation is not part of a Part A (in patient) service.

Medical Necessity
The following conditions may establish that the patient had to be transported by ambulance:
 Patient is transported in an emergency situation; e.g., as a result of an accident or injury.
 Patient needs to be restrained.
 Patient is unconscious or in shock.
 Patient requires oxygen or other emergency treatment on the way to the destination.
 Patient must remain immobile because of a fracture or the possibility of a fracture that has not been set.
 Patient sustains an acute stroke or myocardial infarction.
 Patient is experiencing severe hemorrhaging.
 Patient has a condition that requires him to be moved only by stretcher.
 Patient has a condition that makes him bed-confined before and after the ambulance trip.

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When Medicare covers Ambulance service - Rules and regulation

January 6, 2012, 4:44 am

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Ambulance billing - COVERAGE REQUIREMENTS

Medicare coverage for ambulance transportation is limited by CMS national policy in accordance with federal law. Ambulance services involve the assessment and administration of emergency care by medically trained personnel and transportation of patients within an appropriate, safe and monitored environment.Ambulance transportation is a covered service under Medicare when the patient’s condition is such that the use of any other method of transportation would endanger the patient’s health.

A patient whose condition permits transport in any type of vehicle other than an ambulance would not qualify for services under Medicare.

Medicare payment for ambulance transportation depends on the patient’s condition at the actual time of the transport regardless of the patient’s diagnosis or any other reason for transport.

To be deemed medically necessary for payment, the patient must require both the transportation and the level of service provided.

For the purposes of this policy, the following definitions apply:

 Medically trained personnel refers to individuals who have fulfilled state training and educational requirements and are certified or licensed by their respective state to provide Basic Life Support (BLS) and/or Advanced Life Support (ALS) Emergency Medical Technician (EMT)-level services.

 The vehicle used as an ambulance must be specially designed or equipped to respond to medical emergencies and, in non-emergency situations, be capable of transporting beneficiaries with acute medical conditions. The vehicle must comply with state or local laws governing the licensing and certification of an emergency medical transportation vehicle. At a minimum, the ambulance must contain a stretcher, linens, emergency medical supplies, oxygen equipment and other lifesaving emergency medical equipment, and be equipped with emergency warning lights, sirens and telecommunications equipment as required by state or local law. This should include, at a minimum, one two-way voice radio or wireless telephone.

Medicare Part A and B - Requirements for Coverage

For ambulance services to be covered by Medicare, the following requirements must be met:

Actual transportation of the beneficiary occurs.

Services must be medically necessary and reasonable for the condition of the patient.

The condition of the patient would not allow transportation by other means.

A diagnosis must be on the claim or a detailed description of the patient’s condition at the time of transfer must be submitted with the claim or provided upon request to determine medical necessity.

Ambulance personnel should document their observations of the patient’s condition.

Transportation to a hospital from another hospital when a patient’s needs cannot be met at the first hospital and the patient is admitted to the second hospital.

Transportation is to an extended care facility or to the patient’s home.

Transportation is to the closest appropriate facilities.

Transportation is provided by an approved supplier/provider of ambulance services.

The transportation is not part of a Part A (in patient) service.

Medical Necessity

The following conditions may establish that the patient had to be transported by ambulance:

 Patient is transported in an emergency situation; e.g., as a result of an accident or injury.

 Patient needs to be restrained.

 Patient is unconscious or in shock.

 Patient requires oxygen or other emergency treatment on the way to the destination.

 Patient must remain immobile because of a fracture or the possibility of a fracture that has not been set.

 Patient sustains an acute stroke or myocardial infarction.

 Patient is experiencing severe hemorrhaging.

 Patient has a condition that requires him to be moved only by stretcher.

 Patient has a condition that makes him bed-confined before and after the ambulance trip.

Definition of Bed-Confined

There is now a national definition of the term “bed-confined.” The patient must meet all of the following criteria

 Unable to get up from bed without assistance.

 Unable to ambulate.

 Unable to sit in a chair or wheelchair.

Note: The term “bed-confined” is not synonymous with “bed rest” or “non-ambulatory.” In addition, “bed-confined” is not meant to be the sole criterion to be used in determining if the patient must be transported by ambulance. It is one factor to be considered when making coverage determinations.

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