Ambulance billing Guide, Codes and services

Medicare requires the signature of the beneficiary or that of his representative for both the purpose of accepting assignment and submitting a claim to Medicare. If the beneficiary is unable to sign because of a mental or physical condition, the following individuals may sign the claim form on behalf of the beneficiary:

 The beneficiary’s legal guardian.

 A relative or other person who receives Social Security or other governmental benefits on behalf of the beneficiary.

 A relative or other person who arranges for the beneficiary’s treatment or exercises other responsibility for his affairs.

 A representative of an agency or institution that did not furnish the services for which payment is claimed, but furnished other care, services or assistance to the beneficiary.

· A representative of the provider or of the non-participating hospital claiming payment for services it has furnished if the provider or non-participating hospital is unable to have the claim signed in accordance with 42 CFR 424.36(b) (1–4).

 A representative of the ambulance provider or supplier who is present during an emergency and/or non-emergency transport, provided that the ambulance provider or supplier maintains certain documentation in its records for at least four years from the date of service.

A provider/supplier (or his employee) cannot request payment for services furnished except under circumstances fully documented to show that the beneficiary is unable to sign and that there is no other person who could sign.

Medicare does not require that the signature to authorize claim submission be obtained at the time of transport for the purpose of accepting assignment of Medicare payment for ambulance benefits. When a provider/supplier is unable to obtain the signature of the beneficiary or that of his representative at the time of transport, the provider/supplier may obtain this signature any time prior to submitting the claim to Medicare for payment.

If the beneficiary/representative refuses to authorize the submission of a claim, including a refusal to furnish an authorizing signature, the ambulance provider/supplier may not bill Medicare but may bill the beneficiary (or his estate) for the full charge of the ambulance items and services furnished. If, after seeing this bill, the beneficiary/ representative decides to have Medicare pay for these items and services, a beneficiary/representative signature is required and the ambulance provider/supplier must afford the beneficiary/representative this option within the claims filing period.

Medicare requires that services provided/ordered be authenticated by the author. The method used must be a handwritten or electronic signature. Stamped signatures are not acceptable. These guidelines impact the ambulance trip/run sheets and the Physician Certification Statements (PCSs).

Run sheets must have legible signatures, including credentials, from the provider(s) who renders the services documented.

The signature of the medical professional completing the PCS must also be legible (or accompanied by a typed or printed name) and include credentials. Furthermore, signatures on the PCS must be dated at the time they are completed.

Signature Authentication Process

If the signature is found to be illegible or missing from the medical documentation, a signature log or attestation statement to determine the identity of the author may be requested by the reviewer before the claim is processed.

Signature Log

A signature log includes the typed or printed name and usual signature of the author associated with initials or an illegible signature. The signature log may be submitted when records are requested. The signature log may be included on the actual page where the initials or illegible signatures are used or it may be a separate document.

Attestation Statement

An attestation statement is required when a signature is missing from the documentation; it must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary and date of service. An attestation is specific to the service documented.

Providers should not add late signatures to the medical record, but make use of the signature authentication process. When medical records are requested, you may notice changes within the request letter. To meet the requirements for signatures, additional documentation (attestation statement or signature log) may need to be submitted with your medical records.

Documentation Requirements for Ambulance Billing

The trip record documentation of each patient encounter should include the following:

 Complete and legible information.

 Reason for the transport.

 A concise explanation of symptoms reported by the patient and/or other observers and details of the patient’s physical assessments that explain why the patient requires ambulance transportation and cannot be safely transported by an alternate mode.

 Relevant history (when available).

 Observations and findings (patient’s condition at the time of transfer).

 A description of the patient’s physical condition in sufficient detail to demonstrate that the patient’s condition or functional status at the time of transport meets Medicare limitation of coverage for ambulance services.

 A detailed description of existing safety issues.

 A detailed description of special precautions taken (if any) and explanation of the need for such precautions.

 Assessment and clinical evaluations that should include:

oVital signs.

o Neurological assessment.

o Cardiac information.

 Documentation of procedures and supplies provided such as:

O IV therapy.

o Respiratory therapy.

o Intubation.

o Cardiopulmonary Resuscitation (CPR).

o Oxygen administered.

o Drug therapy.

o Restraints.

 A description of specific monitoring and treatments ordered and performed/ administered; that a treatment (such as oxygen) and/or monitoring (such as cardiac rhythm monitoring) was performed absent sufficient description of the patient’s condition (to demonstrate that the treatment and/or monitoring was medically necessary) is inadequate on its own merit to justify payment for the ambulance service.

 The patient’s progress, responses to treatment and changes as treatment is given (e.g., monitoring of vital signs after medication has been given).

· Point of pickup (identify place and complete address).

 Number of loaded miles/cost per mile/mileage charge. For services rendered with dates of service on or after January 1, 2011, miles must be reported as fractional units. For instructions on fractional units refer to “Mileage” under the “Services and Procedure Codes” section in this manual.

 Minimal or base charge and charge for special items or services with an explanation/itemization of the special items or services.

 For hospital-to-hospital transports, the trip record must clearly indicate the precise treatment or procedure (or medical specialist) that is available only at the receiving hospital. Non-specific or vague statements such as “needs cardiac care” or “needs higher level of care” are insufficient.

 Any additional available documentation that supports medical necessity of ambulance transport (e.g., emergency room report, Skilled Nursing Facility (SNF) record, End-Stage Renal Disease (ESRD) facility record, hospital record).

 A separate run sheet for each transport (e.g., two run sheets for round trips).

 Date and legible identity of the observer. Note: Refer to Signature Guidelines for Medical Review Purposes in this section.

Note: The HCPCS codes and ICD-9-CM codes reported on the health insurance claim must be supported by the documentation on the run sheet

Denied Services

Program payment will not be made when other transportation could be utilized without endangering the patient’s health, whether such means of transportation is actually available.

A claim may be denied on the grounds that the use of an ambulance service was unreasonable in the treatment of the illness or injury involved.

Non-Covered Services

Medicare does not cover the following services:

 Transportation in Ambi-buses, ambulettes (Mobility Assistance Vehicle (MAV)), Medi-cabs, vans, privately owned vehicles, taxicabs or wheelchair vans.

 Parking fees.

 Tolls for bridges, tunnels and highways.

TRICARE covers ambulance services in the following circumstances:

•    Emergency transport to a hospital

•    Transfer from one hospital to another hospital more capable of providing the required care as ordered by a physician

•    Transfers between a hospital or SNF and another facility for outpatient therapy or diagnostic services ordered by a physician

•    Transfers to and from a SNF when medically indicated

Note: Payment of ambulance transfers to and from a SNF may be included in the SNF prospective payment system (PPS).

Air or boat ambulance is only covered when the pickup point is inaccessible by a land vehicle, or when great distance or other obstacles are involved in transporting the patient to the nearest hospital with appropriate facilities, and the patient’s medical condition warrants speedy admission or is such
that transfer by other means is contraindicated. TRICARE does not cover ambulance services for these conditions:

•    Non-emergency ambulance services used instead of a taxi service or other normal transportation means when the patient’s condition would permit
use of regular transportation (Ambulance transportation is covered under the TRICARE Extended Care Health Option [ECHO] benefit when the beneficiary is being transported to and from institutions or facilities when the
beneficiary is receiving institutional care.)

•    Transport or tra nsfer of a patient primarily for the purpose of having the patient closer to home, family, friends, or a physician

•    Any type of medicabs or ambicabs that function as public passenger services transporting patients to and from medical appointments

Admission Date REQUIRED

What this means: For the trading partner, Payer Path, this is a required field for ambulance claims. This must be added in order for the claims to go through.

Provider action: Add the admission date

Rejection Removal: Rejections will not be removed by Gateway EDI as they are valid.

Re-filing:Once this is corrected, you would want to re-file any claims that rejected for this reason

Ambulance Drop-Off Location is required for Ambulance Claims.

What this means: One of the requirements for ambulance claims is that a drop off city, state and zip code are required

Provider action: Add the drop off location to your claim.

Rejection removal: Rejections will not be removed by Gateway EDI as they are valid.

Re-filing: Once this is corrected, you would want to re-file any claims that rejected for this reason.

Ambulance Pick-Up Location is required for Ambulance Claims.

What this means: One of the requirements for ambulance claims is that a pick up city, state and zip code are required

Provider action: Add the pick up location to your claim.

Rejection removal: Rejections will not be removed by Gateway EDI as they are valid.

Re-filing: Once this is corrected, you would want to re-file any claims that rejected for this reason.

Providers participating in the 2014 Physician Quality Reporting System (PQRS) program may be eligible to report their quality data one time only to earn credit for multiple Medicare quality reporting programs. Individual eligible professionals and group practices will be able to report once on a single set of clinical quality measures (CQMs) and satisfy some of the various requirements of several of the following programs, depending on eligibility:
•    PQRS
•    Value-Based Payment Modifier (VM)
•    Medicare Electronic Health Record (EHR) Incentive Program
•    Medicare Shared Savings Program Accountable Care Organization (ACO)
•    Pioneer ACO
•    Comprehensive Primary Care Initiative (CPCI)

CMS aligned some of the reporting requirements for these programs starting in 2014 to reduce the burden of data collection. Those eligible professionals who choose to report once will reap several benefits:
•    Earn the 2014 PQRS incentive and avoid the 2016 PQRS payment adjustment.
•    Satisfy the CQM requirements of the Medicare EHR Incentive Program.
•    Satisfy requirements for the 2016 VM, ACO, and/or CPCI, if eligible.
Note: aligned reporting options are only available to eligible professionals beyond their first year of participation in the Medicare EHR Incentive Program.

How to Report Once

Individual eligible professionals and group practices must submit a full year (January 1 through December 31, 2014) of data to receive credit for the various programs. The following resources will help explain how providers can report their quality data one time for 2014 participation in applicable quality programs:
•    Reporting Once Interactive Tool: Provides reporting guidance based on how the eligible professional plans to participate in PQRS in 2014.

•    eHealth University Reporting Once Module: Explains how to report quality measures one time during the 2014 program year and satisfy quality reporting requirements PQRS, the Medicare EHR Incentive Program, the VM, and ACOs.

•    2014 CQM Electronic Reporting Guide: Provides an overview of 2014 CQMs and options for reporting them to CMS.

2014 QRDA III SEVT Testing Available

The Submission Engine Validation Tool (SEVT) for 2014 Quality Reporting Document Architecture (QRDA) III submission is available on the QualityNet Portal. CMS recommends QRDA submitters and certified EHR technology vendors use this tool for 2014 submission testing.

Effective date October 1, 2014
Implementation date: February 10, 2015

Summary
The Centers for Medicare & Medicaid Services (CMS) recently announced changes to the Medicare Claims Processing Manual related to payment policies regarding payment of Medicare Part B inpatient services.

When an inpatient admission is found to be not reasonable and necessary, Medicare will allow payment of all hospital services that were furnished and would have been reasonable and necessary if the beneficiary had been treated as an outpatient. All hospitals billing Part A services are eligible to bill the Part B inpatient services, including short term acute care hospitals paid under the inpatient prospective payment system (IPPS), hospitals paid under the outpatient prospective payment system (OPPS), long term care hospitals (LTCHs), inpatient psychiatric facilities (IPFs) and IPF hospital units, inpatient rehabilitation facilities (IRFs) and IRF hospital units, Critical Access Hospitals (CAHs), children's hospitals, cancer hospitals, and Maryland waiver hospitals.
Implementing the Payment Policies Related to Patient Status from the CMS-1599-F

Provider Type Affected
This MLN Matters Article is intended for hospital submitting claims to Medicare Administrative Contrators (MACs) for services provided to Medicare beneficiaries.

What You Need to Know
Change Request (CR)959 incorporates changes to the "Medicare Claims Processing Manual" related to the payment policies regarding Patient Status from final rule CMS-1599-F. This includes payment of Medicare Part B inpatient services, and admission and medical review criteria for payment of hospital inpatient services under Medicare Part A.

Background
When an inpatient admission is found to be not reasonable and necessary, Medicare will allow payment of all hospital services that were furnished and would have been reasonable and necessary if the beneficiary had been treated as an outpatient, rather than admitted to the hospital as an inpatient, provided the allowed timeframe for submitting claims is not expired. Medicare will not allowed timeframe for submitting claims is not expired. Medicare will not allow payment for services that specifically require an outpatient status, such as outpatient visits, emergency department visits, and observation services that are, by definition, provided to hospital outpatients and not inpatients.

Specific changes to the "Medicare Claims Processing Manual" as a result of CR8959 involve Chapter 240 of that manual. Specifically, inpatient routine services in a hospital generally are those services included by the provider in a daily service charge--sometimes referred to as the "Room and Board" charge. They include the regular room, dietary and nursing services, minor medical and surgical supplies, medical social services, psychiatric social services, and the use of certain equipment and facilities for which a separate charge is not customarily made to Medicare Part A. Many nursing services provided by the floor nurse (such as IV infusions and injections, blood administration, and nebulizer treatments, etc.) may or may not have a separate charge established depending upon the classification of an item or service as routine or ancillary among providers of the same class in the same State. Some providers established customary charging practice resulting in separate charges for these services following the "Provider Reimbursement Manual" )PRM-1) instructions. However, in order for a provider's customary charging practice to be recognized it must consistently follow those instructions for all patients and this must not result in as inequitable apportionment of cost to the program. If the PRM-1 instructions have not been followed, a provider cannot bill these services as separate charges. Additionally, it is important that the charges for services rendered and documentation meet the definition of the Healthcare Common Procedure Coding System (HCPCS) in order to separately bill.

All hospital billing Part A services are eligible to bill the Part B inpatient services, including short term acute care hospitals paid under the Inpatient Prospective Payment System (IPPS), hospital paid under the Outpatient Prospective Payment System (OPPS), long term care hospitals (LTCHs), inpatient psychiatric facilities (IPFs) and IPF hospital units, inpatient rehabilitation facilities (IRFs) and IRF hospital units, Critical Access Hospitals (CAHs), children's hospitals, cancer hospitals, and Maryland waiver hospitals.

Hospitals paid under the OPS would continue billing the OPPS for Part B inpatient services. Hospitals that are excluded from payment under the OPPS in 42 Codes of Federal Regulations (CFR) 419.20 (b) would be eligible to bill Part B inpatient services under their non-OPPS Part B payment methodologies.

Beneficiaries are liable for their usual Part B financial liability. Beneficiaries would be liable for Part B copayments for each hospital Part B inpatient service and for the full cost of drugs that are usually self-administered. If the beneficiary's liability under Part A for the initial claim submitted for inpatient services they received, the hospital must refund the beneficiary the difference between the applicable Part A and Part B amounts. Conversely, if the beneficiary's liability under Part A is less than the beneficiary's liability under Part B for the inpatient services they received, the beneficiary may face greater cost sharing.

Timely filing restrictions will apply for Part B inpatient services. Claims that are filed beyond one (1) calendar year from the date of service will be rejected as untimely and will not be paid.

Medicare has identified a recent increase in the number of CERT errors attributed to the lack of physician orders for diagnostic tests. A diagnostic test includes all diagnostic x-ray tests, all diagnostic laboratory tests, and other diagnostic tests furnished to a beneficiary.

An 'order' is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physician/practitioner (e.g., if test X is negative, then perform test Y). An order may be delivered via the following forms of communication:

A written document signed by the treating physician/practitioner, which is hand-delivered, mailed, or faxed to the testing facility;

A telephone call by the treating physician/practitioner or his/her office to the testing facility; and
An electronic mail by the treating physician/practitioner or his/her office to the testing facility.
If the order is communicated via telephone, both the treating physician/practitioner or his/her office, and the testing facility must document the telephone call in their respective copies of the beneficiary's medical records.

NOTE: While a physician order is not required to be signed on orders for clinical diagnostic tests paid on the basis of the clinical laboratory fee schedule, the physician fee schedule, or for physician pathology services; the physician must clearly document, in the medical record, his or her intent that the test be performed.    Failure to do so may result in denial of the service which may subsequently lead to the patient being responsible for payment.   Furthermore, the absence of a signature on an order may lead to a medical record audit of the ordering physician to verify that the physician's intent is indeed documented as directed in the regulation.   Therefore, Novitas recommends that physicians provide their signature on all orders for diagnostic and laboratory services.

Make sure that your office, billing, and/or laboratory staffs are aware of this updated guidance regarding the signature requirement for diagnostic tests and are complying with this regulation.   Also, note that in keeping with standard auditing principles, items such as signatures, attestations, and other addendums which are added to the medical record after the date of the Additional Documentation Request (ADR) letter will generally not be considered as acceptable documentation.   Furthermore, providers who exhibit a pattern of adding documentation after ADR requests could be subject to corrective action.

If you receive a request for medical records from the CERT contractor or Novitas Solutions, it is critical that the signed physician order for all diagnostic tests be included.   Without the order, the services could be determined to be medically unnecessary and the claim will be denied.

Fact sheets: Prior Authorization Process for Repetitive Scheduled Non-Emergent Ambulance Transport

OVERVIEW

The Centers for Medicare & Medicaid Services (CMS) will begin implementing a prior authorization demonstration program for repetitive scheduled non-emergent ambulance transport in New Jersey, Pennsylvania, and South Carolina. CMS will test whether prior authorization helps reduce expenditures, while maintaining or improving quality of care. CMS believes using a prior authorization process will help ensure services are provided in compliance with applicable Medicare coverage, coding, and payment rules before services are rendered and claims are paid.

BACKGROUND
In 2012, CMS launched a prior authorization process for certain power mobility devices in seven demonstration states (California, Florida, Illinois, Michigan, New York, North Carolina, and Texas). Since implementing the demonstration, CMS has observed a decrease in expenditures for power mobility devices. CMS will leverage this success by creating a prior authorization process for certain non-emergent services under Medicare. CMS seeks to use this process to address growing concerns about beneficiaries receiving non-medically necessary repetitive scheduled non-emergent ambulance transport services. New Jersey, Pennsylvania, and South Carolina were selected for initial implementation of this process because of their high utilization and improper payment rates for these services.

Under Section 1115A of the Social Security Act, the Secretary has authority to test innovative payment and service delivery models to reduce program expenditures, while preserving or enhancing the quality of care furnished to individuals under such titles.

Prior authorization will not create new clinical documentation requirements. Instead, it will require the same information necessary to support Medicare payment, just earlier in the process. Prior authorization allows providers and suppliers to address issues with claims prior to rending services and to avoid an appeal process. This will help ensure that all relevant coverage, coding, and clinical documentation requirements are met before the service is rendered to the beneficiary and before the claim is submitted for payment.

PRIOR AUTHORIZATION PROCESS
The model will establish a prior authorization process for repetitive scheduled non-emergent ambulance transport services. This process will allow all relevant documentation to be submitted for review prior to rendering services. CMS or its contractors will review the request and provide an affirmative or non-affirmative decision. A claim submitted with an affirmative prior authorization will be paid so long as all other requirements are met. A claim submitted with a non-affirmative decision will be denied. Unlimited resubmissions are allowed. If a provider or supplier chooses to forego prior authorization and submits a claim without prior authorization decision, that claim shall undergo pre-payment review.

CMS Medicare Review Contractors will review prior authorization requests to ensure requests are consistent with all existing applicable regulations, National Coverage Determination and Local Coverage Determination requirements, and other CMS policies. Decisions on initial requests will be postmarked within 10 business days and subsequent requests will be processed within 20 business days. A provisional affirmative prior authorization decision will affirm a specified number of trips within a specific amount of time. The prior authorization decision, justified by the beneficiary’s condition, may affirm up to 40 round trips (which equates to 80 trips) per prior authorization request in a 60-day period.

To address circumstances where applying the standard timeframe for making a prior authorization decision could seriously jeopardize the life or health of the beneficiary, CMS will include an expedited review process. The request for an expedited review must provide rationale supporting the expedited review request. Such a request must include documentation that shows that applying the standard timeframe for making a decision could seriously jeopardize the life or health of the beneficiary. In these situations, the review entity will make reasonable efforts to communicate the decision within 2 business days of receipt of all applicable Medicare required documentation.

Under this model, if a prior authorization has not been requested before the fourth round trip in a 30-day period, claims will be subject to pre-payment medical review. CMS believes that the repetitive scheduled non-emergent ambulance transport trips for a beneficiary will generally be scheduled through one provider or supplier at the beginning of the authorization period. CMS will allow one ambulance provider or supplier to request prior authorization per beneficiary per time period. Any provider or supplier submitting claims for which no prior authorization request is recorded will be subject to 100 percent medical review.

Medicare has broad coverage, but there are some services that are not covered because they are considered reasonable, medically necessary, and appropriate. The purpose of the ABN is to give you the necessary information to make informed decisions about whether or not to get the services your provider is suggesting.

The following are some examples of when an ABN can be used for non-covered services:
•    Services where there is no legal obligation to pay (e.g., for the purchase of some vaccines). In those cases, your doctor can charge Medicare for administering the vaccine, but they cannot charge Medicare for the vaccine.
•    Services paid for by a government entity other than Medicare
•    Personal comfort items
•    Routine eye care
•    Dental care
•    Routine foot care

ABNs cannot be issued for services that the provider knows is medically necessary and is covered by Medicare. In addition, an ABN cannot be issued for emergency ambulance transportation because the patient is presumed to be under ‘great duress’. An ABN cannot be issued to a patient if they are under great duress.

An ABN must be given to you (or your representative) prior to receiving the item or service in question. The Centers for Medicare & Medicaid (CMS) mandates your provider give you the ABN far enough in advance for you to have time to consider your options and make an informed choice.
CMS has created a standardized ABN form to use; however, it does allow your health care provider to use their own form, as long as it contains the same information.

If your provider asks you to sign an ABN, the document must:
•    Give the name or description of the service they are providing
•    Provide a statement that explains why they believe the services may not be covered by Railroad Medicare. Some common statements are: 'Medicare does not pay for this test for your condition,''Medicare does not pay for this test as often as this (denied as too frequent)', or 'Medicare does not pay for experimental or research tests.'
•    Give you the estimated cost of the service or procedure
•    Provide you with three options, worded in the following ways:
o    Option 1. 'I want the (service or procedure) listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.'
o    Option 2. 'I want the (service or procedure) listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.'
o    Option 3. 'I don’t want the (service or procedure) listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.'
The ABN will also have a place for additional information, such as a dated witness signature.
There must be a place on the ABN for you to sign and date, which indicates you have reviewed the document and understand the information in it. You cannot sign the ABN in advance of the rest of the notice.

Some points to remember:
•    Just because you sign an ABN does not mean Railroad Medicare will not pay for the service. Federal law still requires the claim be submitted for proper review.
•    Even if you sign the ABN and Railroad Medicare denies payment, you are still entitled to appeal the decision. You can pay the provider and later have your money returned to you from the provider if your appeal is successful.
•    If you have a secondary insurance, have the provider submit the claim to Railroad Medicare for denial. Some secondary insurances may cover services that Railroad Medicare does not.

HCPCS	Code Descriptor
G0464	Colorectal cancer screening; stool-based dna and fecal occult hemoglobin (e.g., kras, ndrg4 and bmp3)
G6030	Amitriptyline
G6031	Benzodiazepines
G6032	Desipramine
G6034	Doxepin
G6035	Gold
G6036	Assay of imipramine
G6037	Nortriptyline
G6038	Salicylate
G6039	Acetaminophen
G6040	Alcohol (ethanol) any specimen except breath
G6041	Alkaloids, urine, quantitative
G6042	Amphetamine or methamphetamine
G6043	Barbiturates, not elsewhere specified
G6044	Cocaine or metabolite
G6045	Dihydrocodeinone
G6046	Dihydromorphinone
G6047	Dihydrotestosterone
G6048	Dimethadione
G6049	Epiandrosterone
G6050	Ethchlorvynol
G6051	Flurazepam
G6052	Meprobamate
G6053	Methadone
G6054	Methsuximide
G6055	Nicotine
G6056	Opiate(s), drug and metabolites, each procedure
G6057	Phenothiazine
G6058	Drug confirmation, each procedure
80163	Digoxin level
80165	Valproic acid level
80300-80304	Drug screen
80320-80377	Alcohols levels
81246	Test for detecting genes associated with blood cancer
81288	Test for detecting genes associated with colon cancer
81313	Test for detecting genes associated with prostate cancer
81410	Test for detecting genes associated with heart disease
81411	Test for detecting genes associated with heart disease
81415	Test for detecting genes associated with diseases
81416	Test for detecting genes associated with disease
81417	Reevaluation test for detecting genes associated with disease
81420	Test for detecting genes associated with fetal disease
81425	Test for detecting genes associated with disease
81426	Test for detecting genes associated with disease
81427	Reevaluation test for detecting genes associated with disease
81430	Test for detecting genes causing hearing loss
81431	Test for detecting genes causing hearing loss
81435	Test for detecting genes associated with colon cancer
81436	Test for detecting genes associated with colon cancer
81440	Test for detecting genes associated with cancer of body organ
81445	Test for detecting genes associated with cancer of body organ
81450	Test for detecting genes associated with blood related cancer
81455	Test for detecting genes associated with cancer
81460	Test for detecting genes associated with disease
81465	Test for detecting genes associated with disease
81470-81471	Test for detecting genes associated with intellectual disability
81519	Test for detecting genes associated with breast cancer
87505-87507	Detection test for digestive tract pathogen;
83006	Test for detecting genes associated with growth stimulation
87623-87625	Detection test for human papillomavirus (hpv)
87806	Detection test for HIV1
88341	Special stained specimen slides to examine tissue
88344	Special stained specimen slides to examine tissue
88364	Cell examination
88366	Cell examination
88369	Microscopic genetic examination manual
88373	Microscopic genetic examination using computerassisted technology
88374	Microscopic genetic examination using computerassisted technology
88377	Microscopic genetic examination manual.

Ambulance Service - Part B

Ambulance services are separately payable only under Part B. There are certain
circumstances in which the service is covered and payable as a beneficiary transportation service under Part A; however in this case the service cannot be classified and paid for as an ambulance service under Part B. Payment may be made for expenses incurred for ambulance service provided the conditions specified in the following subsections are met.

The Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service. When multiple ground and/or air ambulance providers/suppliers respond, payment may be made only to the ambulance provider/supplier that actually furnishes the transport.

Vehicle and Crew Requirement
Any vehicle used as an ambulance must be designed and equipped to respond to medical emergencies and, in nonemergency 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 2-way voice radio or wireless telephone.

Vehicle Requirements for Basic Life Support and Advanced
Life Support
Basic Life Support ambulances must be staffed by at least two people, at least one of
whom must be certified as an emergency medical technician (EMT) by the State or local
authority where the services are being furnished and be legally authorized to operate all
lifesaving and life-sustaining equipment on board the vehicle. Advanced Life Support
(ALS) vehicles must be staffed by at least two people, at least one of whom must be
certified by the State or local authority as an EMT-Intermediate or an EMT-Paramedic.

Verification of Compliance

In determining whether the vehicles and personnel of each supplier meet all of the above requirements, carriers may accept the supplier’s statement (absent information to the contrary) that its vehicles and personnel meet all of the requirements if:
1. The statement describes the first aid, safety, and other patient care items with
which the vehicles are equipped;
2. The statement shows the extent of first aid training acquired by the personnel
assigned to those vehicles;
3. The statement contains the supplier’s agreement to notify the carrier of any
change in operation which could affect the coverage of ambulance services; and
4. The information provided indicates that the requirements are met.

The statement must be accompanied by documentary evidence that the ambulance has the equipment required by State and local authorities. Documentary evidence could include a letter from such authorities, a copy of a license, permit, certificate, etc., issued by the authorities. The carrier will keep the statement and supporting documentation on file.

When a supplier does not submit such a statement or whenever there is a question about a supplier’s compliance with any of the above requirements for vehicle and crew (including suppliers who have completed the statement), carriers will take appropriate action including, where necessary, on-site inspection of the vehicles and verification of the qualifications of personnel to determine whether the ambulance service qualifies for reimbursement under Medicare. Since the requirements described above for coverage of ambulance services are applicable to the overall operation of the ambulance supplier’s service, information regarding personnel and vehicles need not be obtained on an individual trip basis.

The Part A intermediary is responsible for the processing of claims for ambulance service furnished under arrangements by participating hospitals, skilled nursing facilities, and home health agencies. Since provider ambulance services furnished “under arrangements” with suppliers can be covered only if the supplier meets the above requirements, the Part A intermediary may ask the carrier to identify those suppliers who meet the requirements. Where the "under arrangement" supplier also supplies ambulance services directly to Medicare beneficiaries, i.e., services that are not pursuant to an arrangement with a provider, the intermediary contacts the Part B carrier to ascertain whether it has already determined whether the crew and ambulance requirements are met.

In such a situation, the intermediary should accept the carrier’s determination without
pursuing its own investigation.

Equipment and Supplies

As mentioned above, the ambulance must have customary patient care equipment and
first aid supplies, including reusable devices and equipment such as backboards,
neck boards, and inflatable leg and arm splints. These are all considered part of the
general ambulance service and payment for them is included in the payment rate for the
transport.

Necessity and Reasonableness

To be covered, ambulance services must be medically necessary and reasonable.

Necessity for the Service

Medical necessity is established when the patient's condition is such that use of any other method of transportation is contraindicated. In any case in which some means of transportation other than an ambulance could be used without endangering the individual's health, whether or not such other transportation is actually available, no payment may be made for ambulance services. In all cases, the appropriate documentation must be kept on file and, upon request, presented to the carrier/intermediary. It is important to note that the presence (or absence) of a physician’s order for a transport by ambulance does not necessarily prove (or disprove) whether the transport was medically necessary. The ambulance service must meet all program coverage criteria in order for payment to be made.
In addition, the reason for the ambulance transport must be medically necessary. That is, the transport must be to obtain a Medicare covered service, or to return from such a service.

Reasonableness of the Ambulance Trip
Under the FS payment is made according to the level of medically necessary services actually furnished. That is, payment is based on the level of service furnished (provided they were medically necessary), not simply on the vehicle used. Even if a local government requires an ALS response for all calls, payment under the FS is made only for the level of service furnished, and then only when the service is medically necessary.

Medicare Policy Concerning Bed-Confinement
As stated above, medical necessity is established when the patient’s condition is such that the use of any other method of transportation is contraindicated. Contractors may presume this requirement is met under certain circumstances, including when the beneficiary was bed-confined before and after the ambulance trip.

A beneficiary is bed-confined if he/she is:
• Unable to get up from bed without assistance;
• Unable to ambulate; and
• Unable to sit in a chair or wheelchair.
The term "bed confined" is not synonymous with "bed rest" or "nonambulatory". Bedconfinement, by itself, is neither sufficient nor is it necessary to determine the coverage for Medicare ambulance benefits. It is simply one element of the beneficiary's condition that may be taken into account in the intermediary's/carrier's determination of whether means of transport other than an ambulance were contraindicated.

Documentation Requirements
In all cases, the appropriate documentation must be kept on file and, upon request, presented to the carrier. It is important to note that neither the presence nor absence of a signed physician’s order for an ambulance transport necessarily proves (or disproves) whether the transport was medically necessary. The ambulance service must meet all program coverage criteria in order for payment to be made.

Transport of Persons Other Than the Beneficiary

No payment may be made for the transport of ambulance staff or other personnel when the beneficiary is not onboard the ambulance (e.g., an ambulance transport to pick up a specialty care unit from one hospital to provide services to a beneficiary at another hospital). This policy applies to both ground and air ambulance transports.

Effect of Beneficiary Death on Medicare Payment for Ground
Ambulance Transports
Because the Medicare ambulance benefit is 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.

Thus, in a situation where the beneficiary dies, whether any payment under the Medicare ambulance benefit 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.

Ground Ambulance Scenarios: Beneficiary Death
Time of Death Pronouncement	Medicare Payment Determination
Before dispatch.	None.
After dispatch, before beneficiary is loaded onboard ambulance (before or after arrival at the point-ofpickup).	The provider’s/supplier’s BLS base rate, no mileage or rural adjustment; use the QL modifier when submitting the claim.
After pickup, prior to or upon arrival at the receiving facility.	Medically necessary level of service furnished.

The Destination
An ambulance transport is covered to the nearest appropriate facility to obtain necessary diagnostic and/or therapeutic services (such as a CT scan or cobalt therapy) as well as the return transport. In addition to all other coverage requirements, this transport situation is covered only to the extent of the payment that would be made for bringing the service to the patient.

Medicare covers ambulance transports (that meet all other program requirements for
coverage) only to the following destinations:
• Hospital;
• Critical Access Hospital (CAH);
• Skilled Nursing Facility (SNF);
• Beneficiary’s home;
• Dialysis facility for ESRD patient who requires dialysis; or
• A physician’s office is not a covered destination. However, under special
circumstances an ambulance transport may temporarily stop at a physician’s
office without affecting the coverage status of the transport.

As a general rule, only local transportation by ambulance is covered, and therefore, only mileage to the nearest appropriate facility equipped to treat the patient is covered. However, if two or more facilities that meet the destination requirements can treat the patient appropriately and the locality of each facility encompasses the place where the ambulance transportation of the patient began, then the full mileage to any one of the facilities to which the beneficiary is taken is covered. Because all duly licensed hospitals and SNFs are presumed to be appropriate sources of health care, only in exceptional situations where the ambulance transportation originates beyond the locality of the institution to which the beneficiary was transported, may full payment for mileage be considered. And then, only if the evidence clearly establishes that the destination institution was the nearest one with appropriate facilities under the particular circumstances. The institution to which a patient is transported need not be a participating institution but must meet at least the requirements of the Social Security Act (the Act.).

Institution to Beneficiary’s Home
Ambulance service from an institution to the beneficiary’s home is covered when the home is within the locality of such institution or where the beneficiary’s home is outside of the locality of such institution but the institution, in relation to the home, is the nearest one with appropriate facilities.

Institution to Institution

Occasionally, the institution to which the patient is initially taken is found to have inadequate or unavailable facilities to provide the required care, and the patient is then transported to a second institution having appropriate facilities. In such cases, transportation by ambulance to both institutions would be covered to the extent of the mileage to be the nearest institution with appropriate facilities. Responsibility for payment would follow the rules in § 10.3.3. In these cases, transportation from such second institution to the patient's home could be covered if the home is within the locality served by that institution, or the locality served by the first institution to which the patient was taken.

Patient Transportation that is Covered Under a Packaged Hospital Service
Transportation of a beneficiary from his or her home, an accident scene, or any other point of origin is covered under Part B as an ambulance service only to the nearest hospital, critical access hospital (CAH), or skilled nursing facility (SNF) that is capable of furnishing the required level and type of care for the beneficiary's illness or injury and only if medical necessity and other program coverage criteria are met.

Medicare-covered ambulance services are paid either as separately billed services, in which case the entity furnishing the ambulance service bills Part B of the program, or as a packaged service, in which case the entity furnishing the ambulance service must seek payment from the provider who is responsible for the beneficiary’s care. If either the origin or the destination of the ambulance transport is the beneficiary’s home, then the ambulance transport is paid separately by Medicare Part B, and the entity that furnishes the ambulance transport may bill its Medicare carrier or intermediary directly. If both the origin and destination of the ambulance transport are providers, e.g., a hospital, critical access hospital (CAH), skilled nursing facility (SNF), then responsibility for payment for the ambulance transport is determined in accordance with the following sequential criteria.

NOTE: These criteria must be applied in sequence as a flow chart and not independently of one another.

1. Provider Numbers:
If the Medicare-assigned provider numbers of the two providers are different, then the
ambulance service is separately billable to the program. If the provider number of both
providers is the same, then consider criterion 2, “campus”.

2. Campus:
Following criterion 1, if the campuses of the two providers (sharing the same provider numbers) are the same, then the transport is not separately billable to the program. In this case the provider is responsible for payment. If the campuses of the two providers are different, then consider criterion 3, “patient status.” “Campus” means the physical area immediately adjacent to the provider’s main buildings, other areas and structures that are not strictly contiguous to the main buildings, but are located within 250 yards of the main buildings, and any of the other areas determined on an individual case basis by the CMS regional office to be part of the provider’s campus.

3. Patient Status: Inpatient vs. Outpatient
Following criteria 1 and 2, if the patient is an inpatient at both providers (i.e., inpatient status both at the origin and at the destination, providers sharing the same provider number but located on different campuses), then the transport is not separately billable. In this case the provider is responsible for payment. All other combinations (i.e., outpatient-to-inpatient, inpatient-to-outpatient, outpatient-to-outpatient) are separately
billable to the program.

In the case where the point of origin is not a provider, Part A coverage is not available because, at the time the beneficiary is being transported, the beneficiary is not an inpatient of any provider paid under Part A of the program and ambulance services are excluded from the 3-day preadmission payment window.

The transfer, i.e., the discharge of a beneficiary from one provider with a subsequent admission to another provider, is also payable as a Part B ambulance transport, provided all program coverage criteria are met, because, at the time that the beneficiary is in transit, the beneficiary is not a patient of either provider and not subject to either the inpatient preadmission payment window or outpatient payment packaging requirements. This includes an outpatient transfer from a remote, off-campus emergency department (ER) to becoming an inpatient or outpatient at the main campus hospital, even if the ER is owned and operated by the hospital.

Once a beneficiary is admitted to a hospital, CAH, or SNF, it may be necessary to transport the beneficiary to another hospital or other site temporarily for specialized care while the beneficiary maintains inpatient status with the original provider. This movement of the patient is considered "patient transportation" and is covered as an inpatient hospital or CAH service and as a SNF service when the SNF is furnishing it as a covered SNF service and payment is made under Part A for that service. (If the beneficiary is a resident of a SNF and must be transported by ambulance to receive dialysis or certain other high-end outpatient hospital services, the ambulance transport may be separately payable under Part B.) Because the service is covered and payable as a beneficiary transportation service under Part A, the service cannot be classified and paid for as an ambulance service under Part B. This includes intra-campus transfers between different departments of the same hospital, even where the departments are located in separate buildings. Such intra-campus transfers are not separately payable under the Part B ambulance benefit. Such costs are accounted for in the same manner as the costs of such a transfer within a single building.

Ambulance transports to and from a covered destination (i.e., two 1-way trips) furnished to a beneficiary who is not an inpatient of a provider for the purpose of obtaining covered medical services are covered, if all program requirements for coverage are met.

In addition, coverage of ambulance transports to and from a destination under these circumstances is limited to those cases where the transportation of the patient is less costly than bringing the service to the patient. For frequent transports of this kind subject to the contractor’s discretion, additional information may be required supporting the need for ambulance services relative to the option of admission to a treatment facility.

Specialized services are covered services that are not available at the facility in which the beneficiary is a patient.

Locality
The term “locality” with respect to ambulance service means the service area surrounding the institution to which individuals normally travel or are expected to travel to receive hospital or skilled nursing services.

EXAMPLE: Mr. A becomes ill at home and requires ambulance service to the hospital. The small community in which he lives has a 35-bed hospital. Two large metropolitan hospitals are located some distance from Mr. A's community and both regularly provide hospital services to the community's residents. The community is within the "locality" of both metropolitan hospitals and direct ambulance service to either of these (as well as to the local community hospital) is covered.

Appropriate Facilities
The term “appropriate facilities” means that the institution is generally equipped to provide the needed hospital or skilled nursing care for the illness or injury involved. In the case of a hospital, it also means that a physician or a physician specialist is available to provide the necessary care required to treat the patient’s condition. However, the fact that a particular physician does or does not have staff privileges in a hospital is not a consideration in determining whether the hospital has appropriate facilities. Thus, ambulance service to a more distant hospital solely to avail a patient of the service of a specific physician or physician specialist does not make the hospital in which the physician has staff privileges the nearest hospital with appropriate facilities.

The fact that a more distant institution is better equipped, either qualitatively or quantitatively, to care for the patient does not warrant a finding that a closer institution does not have “appropriate facilities.” Such a finding is warranted, however, if the beneficiary’s condition requires a higher level of trauma care or other specialized service available only at the more distant hospital. In addition, a legal impediment barring a patient’s admission would permit a finding that the institution did not have “appropriate facilities.” For example, the nearest tuberculosis hospital may be in another State and that State’s law precludes admission of nonresidents.

An institution is also not considered an appropriate facility if there is no bed available.

The contractor, however, will presume that there are beds available at the local institutions unless the claimant furnished evidence that none of these institutions had a bed available at the time the ambulance service was provided.

EXAMPLE: Mr. A becomes ill at home and requires ambulance service to the hospital. The hospitals servicing the community in which he lives are capable of providing general hospital care. However, Mr. A requires immediate kidney dialysis, and the needed equipment is not available in any of these hospitals. The service area of the nearest hospital having dialysis equipment does not encompass the patient’s home. Nevertheless, in this case, ambulance service beyond the locality to the hospital with the equipment is covered since it is the nearest one with appropriate facilities.

Ambulance Service to Physician’s Office

These trips are covered only under the following circumstances:
• The ambulance transport is enroute to a Medicare covered destination
• During the transport, the ambulance stops at a physician's office because of the patient's dire need for professional attention, and immediately thereafter, the ambulance continues to the covered destination.

In such cases, the patient will be deemed to have been transported directly to a covered destination and payment may be made for a single transport and the entire mileage of the transport, including any additional mileage traveled because of the stop at the physician’s office.

Transportation Requested by Home Health Agency
Where a home health agency has a beneficiary transported by ambulance to a hospital or skilled nursing facility to obtain needed medical services not otherwise available to the individual, the trip is covered as a Part B service only if the requirements are met for ambulance transportation from wherever the patient is located (place of origin). Such transportation is not covered as a home health service.

Multiple Patient Ambulance Transport
If two patients are transported to the same destination simultaneously, for each Medicare beneficiary, Medicare will allow 75 percent of the payment allowance for the base rate applicable to the level of care furnished to that beneficiary plus 50 percent of the total mileage payment allowance for the entire trip.

If three or more patients are transported to the same destination simultaneously, then the payment allowance for the Medicare beneficiary (or each of them) is equal to 60 percent of the base rate applicable to the level of care furnished to the beneficiary. However, a single payment allowance for mileage will be prorated by the number of patients onboard.

This policy applies to both ground and air transports.
Medically appropriate air ambulance transportation is a covered service regardless of the State or region in which it is rendered. However, contractors approve claims only if the beneficiary’s medical condition is such that transportation by either basic or advanced life support ground ambulance is not appropriate.

There are two categories of air ambulance services: fixed wing (airplane) and rotary wing (helicopter) aircraft. The higher operational costs of the two types of aircraft are recognized with two distinct payment amounts for air ambulance mileage. The air ambulance mileage rate is calculated per actual loaded (patient onboard) miles flown and is expressed in statute miles (not nautical miles).

1. Fixed Wing Air Ambulance (FW)
Fixed wing air ambulance is furnished when the beneficiary’s medical condition is such that transport by ground ambulance, in whole or in part, is not appropriate. Generally, transport by fixed wing air ambulance may be necessary because the beneficiary’s condition requires rapid transport to a treatment facility, and either great distances or other obstacles, e.g., heavy traffic, preclude such rapid delivery to the nearest appropriate facility. Transport by fixed wing air ambulance may also be necessary because the beneficiary is inaccessible by a ground or water ambulance vehicle.

2. Rotary Wing Air Ambulance (RW)
Rotary wing air ambulance is furnished when the beneficiary’s medical condition is such that transport by ground ambulance, in whole or in part, is not appropriate. Generally, transport by rotary wing air ambulance may be necessary because the beneficiary’s condition requires rapid transport to a treatment facility, and either great distances or other obstacles, e.g., heavy traffic, preclude such rapid delivery to the nearest appropriate facility. Transport by rotary wing air ambulance may also be necessary because the beneficiary is inaccessible by a ground or water ambulance vehicle.

Coverage Requirements

Air ambulance transportation services, either by means of a helicopter or fixed wing aircraft, may be determined to be covered only if:

• The vehicle and crew requirements are met;
• The beneficiary’s medical condition required immediate and rapid ambulance transportation that could not have been provided by ground ambulance; and either

1. The point of pickup is inaccessible by ground vehicle (this condition could be met in Hawaii, Alaska, and in other remote or sparsely populated areas of the continental United States), or

2. Great distances or other obstacles are involved in getting the patient to the nearest hospital with appropriate facilities. Additionally, 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. In such a circumstance, the allowed amount is the appropriate air base rate, i.e., fixed wing or rotary wing. However, no amount shall be allowed for mileage or for a rural adjustment that would have been allowed had the transport of a living beneficiary or of a beneficiary not yet pronounced dead been completed.

For the purpose of this policy, a pronouncement of death is effective only when made by an individual authorized under State law to make such pronouncements. This policy also states no amount shall be allowed if the dispatcher received pronouncement of death and had a reasonable opportunity to notify the pilot to abort the flight. Further, no amount shall be allowed if the aircraft has merely taxied but not taken off or, at a controlled airport, has been cleared to take off but not actually taken off.

Medical Reasonableness
Medical reasonableness is only established when the beneficiary’s condition is such that the time needed to transport a beneficiary by ground, or the instability of transportation by ground, poses a threat to the beneficiary’s survival or seriously endangers the beneficiary’s health. Following is an advisory list of examples of cases for which air ambulance could be justified. The list is not inclusive of all situations that justify air transportation, nor is it intended to justify air transportation in all locales in the circumstances listed.

• Intracranial bleeding - requiring neurosurgical intervention;
• Cardiogenic shock;
• Burns requiring treatment in a burn center;
• Conditions requiring treatment in a Hyperbaric Oxygen Unit;
• Multiple severe injuries; or
• Life-threatening trauma.

Time Needed for Ground Transport

Differing Statewide Emergency Medical Services (EMS) systems determine the amount and level of basic and advanced life support ground transportation available. However, there are very limited emergency cases where ground transportation is available but the time required to transport the patient by ground as opposed to air endangers the beneficiary’s life or health. As a general guideline, when it would take a ground ambulance 30-60 minutes or more to transport a beneficiary whose medical condition at the time of pick-up required immediate and rapid transport due to the nature and/or severity of the beneficiary’s illness/injury, contractors should consider air transportation to be appropriate.

Hospital to Hospital Transport
Air ambulance transport is covered for transfer of a patient from one hospital to another if the medical appropriateness criteria are met, that is, transportation by ground ambulance would endanger the beneficiary’s health and the transferring hospital does not have adequate facilities to provide the medical services needed by the patient. Examples of such specialized medical services that are generally not available at all type of facilities may include but are not limited to: burn care, cardiac care, trauma care, and critical care. A patient transported from one hospital to another hospital is covered only if the hospital to which the patient is transferred is the nearest one with appropriate facilities. Coverage is not available for transport from a hospital capable of treating the patient because the patient and/or the patient’s family prefer a specific hospital or physician.

Special Coverage Rule
Air ambulance services are not covered for transport to a facility that is not an acute care hospital, such as a nursing facility, physician’s office, or a beneficiary’s home.

Special Payment Limitations
If a determination is made to order transport by air ambulance, but ground ambulance transport would have sufficed, payment for the air ambulance transport is based on the amount payable for ground ambulance transport.

If the air transport was medically appropriate (that is, ground transportation was contraindicated, and the beneficiary required air transport to a hospital), but the beneficiary could have been treated at a hospital nearer than the one to which they were transported, the air transport payment is limited to the rate for the distance from the point of pickup to that nearer hospital.

Documentation
In order to determine the medical appropriateness of air ambulance services the
contractor may request that documentation be submitted that indicates the air ambulance services are reasonable and necessary to treat the beneficiary’s life-threatening condition. The contractor’s medical staff may consider reviewing all claims for air ambulance services.

Air Ambulance Transports Canceled Due to Weather or Other Circumstances Beyond the Pilot’s Control

The chart below shows the Medicare payment determination for various air ambulance scenarios in which the flight is aborted due to bad weather, or other circumstance beyond the pilot’s control.

Air Ambulance Scenarios: Aborted Flights
Aborted Flight Scenario	Medicare Payment Determination
Any time before the beneficiary is loaded onboard (i.e., prior to or after take-off to point-of-pickup.)	None.
Transport after the beneficiary is loaded onboard.	Appropriate air base rate, mileage, and rural adjustment.

HIPAA
The Administrative Simplification provisions of HIPAA require that health plans, including private, commercial, Medicaid and Medicare, healthcare clearinghouses and healthcare providers use standard electronic health transactions. A major intent of the law is to allow providers to meet the data needs of every insurer electronically with one billing format using health care industry standard sets of data and codes. HCPCS is the specified code set for procedures and services. Additional information on HIPAA can be obtained from the CMS website at:

http://www.hhs.gov/ocr/hipaa
dhmh.maryland.gov/hipaa/SitePages/Home.aspx

NATIONAL PROVIDER IDENTIFIER (NPI)

NPI is a HIPAA mandate requiring a standard unique identifier for health care providers. Providers must use this unique 10-digit identifier on all electronic transactions. When billing on paper, this unique number and the provider’s 9-digit Medicaid provider number will be required in order to be reimbursed appropriately. Details about placement of the NPI and the Medicaid provider number are contained within the block-to-block information beginning on page 10. Additional information on NPI can be obtained from the CMS website at:

http://www.cms.hhs.gov/NationalProvIdentStand/
http://mmcp.dhmh.maryland.gov/SitePages/NPI%20New%20Billing%20Instructions.aspx

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