Ambulance billing Guide, Codes and services

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 air ambulance scenarios in which the beneficiary dies. In each case, the assumption is that the ambulance transport would have otherwise been medically necessary. If the flight is aborted for other reasons, such as bad weather, the Medicare payment determination is based on whether the beneficiary was onboard the air ambulance.

Air Ambulance Scenarios: Beneficiary Death
Time of Death Pronouncement	Medicare Payment Determination
Prior to takeoff to point-of-pickup with notice to dispatcher and time to abort the flight.	None. NOTE: This scenario includes situations in which the air ambulance has taxied to the runway, and/or has been cleared for takeoff, but has not actually taken off.)
After takeoff to point-of-pickup, but before the beneficiary is loaded.	Appropriate air base rate with no mileage or rural adjustment; use the QL modifier when submitting the claim.
After the beneficiary is loaded onboard, but prior to or upon arrival at the receiving facility.	As if the beneficiary had not died.

Joint Responses

A.BLS/ALS Joint Responses

In situations where a BLS entity provides the transport of the beneficiary and an ALS entity provides a service that meets the fee schedule definition of an ALS intervention (e.g., ALS assessment, Paramedic Intercept services, etc.), the BLS supplier may bill Medicare the ALS rate provided that a written agreement between the BLS and ALS entities exists prior to submitting the Medicare claim. Providers/suppliers must provide a copy of the agreement or other such evidence (e.g., signed attestation) as determined by their intermediary or carrier upon request. Contractors must refer any issues that cannot be resolved to the regional office.

Medicare does not regulate the compensation between the BLS entity and the ALS entity. If there is no agreement between the BLS ambulance supplier and the ALS entity furnishing the service, then only the BLS level of payment may be made. In this situation, the ALS entity’s services are not covered, and the beneficiary is liable for the expense of the ALS services to the extent that these services are beyond the scope of the BLS level of payment.

B. Ground to Air Ambulance Transports
When a beneficiary is transported by ground ambulance and transferred to an air ambulance, the ground ambulance 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.

Payment may be made for expenses incurred by a patient for ambulance service provided conditions l, 2, and 3 in the left-hand column have been met. The right-hand column indicates the documentation needed to establish that the condition has been met.

Conditions	Review Action
1. Patient was transported by an approved supplier of ambulance services.	1. Ambulance suppliers are explained in greater detail
2. The patient was suffering from an illness or injury, which contraindicated transportation by other means.	2. (a) The contractor presumes the requirement was met if the submitted documentation indicates that the patient: • Was transported in an emergency situation, e.g., as a result of an accident, injury or acute illness, or • Needed to be restrained to prevent injury to the beneficiary or others; or • Was unconscious or in shock; or • Required oxygen or other emergency treatment during transport to the nearest appropriate facility; or • Exhibits signs and symptoms of acute respiratory distress or cardiac distress such as shortness of breath or chest pain; or
	• Exhibits signs and symptoms that indicate the possibility of acute stroke; or
	• Had to remain immobile because of a fracture that had not been set or the possibility of a fracture; or
	• Was experiencing severe hemorrhage; or
	• Could be moved only by stretcher; or
	• Was bed-confined before and after the ambulance trip
	(b) In the absence of any of the conditions listed in (a) above additional documentation should be obtained to establish medical need where the evidence indicates the existence of the circumstances listed below:
	(i) Patient’s condition would not ordinarily require movement by stretcher, or
	(ii) The individual was not admitted as a hospital inpatient (except in accident cases), or
	(iii) The ambulance was used solely because other means of transportation were unavailable, or
	(iv) The individual merely needed assistance in getting from his room or home to a vehicle.
	(c) Where the information indicates a situation not listed in 2(a) or 2(b) above, refer the case to your supervisor.
3. The patient was transported from and to points listed below.	3. Claims should show the ZIP Code of the point of pickup.
(a) From patient’s residence (or other place where need arose) to hospital or skilled nursing facility.	(a) i. Condition met if trip began within the institution’s service area as shown in the carrier’s locality guide. ii. Condition met where the trip began outside the institution’s service area if the institution was the nearest one with appropriate facilities.
(b) Skilled nursing facility to a hospital or hospital to a skilled nursing facility.	(i) Condition met if the ZIP Code of the pickup point is within the service area of the destination as shown in the carrier’s locality guide. (ii) Condition met where the ZIP Code of the pickup point is outside the service area of the destination if the destination institution was the nearest appropriate facility.
(c) Hospital to hospital or skilled nursing facility to skilled nursing facility.	(c) Condition met if the discharging institution was not an appropriate facility and the admitting institution was the nearest appropriate facility.
(d) From a hospital or skilled nursing facility to patient’s residence.	(d) (i) Condition met if patient’s residence is within the institution’s service area as shown in the carrier’s locality guide. (ii) Condition met where the patient’s residence is outside the institution’s service area if the institution was the nearest appropriate facility.
(e) Round trip for hospital or participating skilled nursing facility inpatients to the nearest hospital or nonhospital treatment facility.	(e) Condition met if the reasonable and necessary diagnostic or therapeutic service required by patient’s condition is not available at the institution where the beneficiary is an inpatient.
4. Ambulance services involving hospital admissions in Canada or Mexico are covered if the following conditions are met:	4. (a) The foreign hospitalization has been determined to be covered; and (b) The ambulance service meets the coverage requirements set forth. If the foreign hospitalization has been determined to be covered on the basis of emergency services, the necessity requirement and the destination requirement are considered met.
5. The carrier will make partial payment for otherwise covered ambulance service, which exceeded limits defined in item	5 & 6 (a) From the pickup point to the nearest appropriate facility, or
6. The carrier will base the payment on the amount payable had the patient been transported:	5 & 6 (b) From the nearest appropriate facility to the beneficiary’s residence where he or she is being returned home from a distant institution.

NOTE: A patient’s residence is the place where he or she makes his/her home and dwells permanently, or for an extended period of time. A skilled nursing facility is one, which is listed in the Directory of Medical Facilities as a participating SNF or as an institution which meets §1861(j)(1) of the Act.

NOTE: A claim for ambulance service to a participating hospital or skilled nursing facility should not be denied on the grounds that there is a nearer nonparticipating institution having appropriate facilities.

When an ambulance provider/supplier, or a third party under contract with the provider/supplier, furnishes a Medicare-covered ambulance service to a Medicare beneficiary and the service is not statutorily excluded under the particular circumstances, the provider/supplier must submit a claim to Medicare and accept assignment of the beneficiary's right to payment from Medicare. Managed Care Providers/Suppliers
Mandatory assignment for ambulance services, in effect with the implementation of the ambulance fee schedule, applies to ambulance providers/suppliers under managed care as well as under fee-for-service. The ambulance fee schedule is effective for claims with a date of service on or after April 1, 2002.

Any provider or supplier without a contract establishing payment amounts for services provided to a beneficiary enrolled in a Medicare Advantage (MA) coordinated care plan or MA private fee-for-service plan must accept, as payment in full, the amounts that they could collect if the beneficiary were enrolled in original Medicare. The provider or supplier can collect from the MA plan enrollee the cost-sharing amount required under the MA plan, and collect the remainder from the MA organization.

Beneficiary Signature Requirements Effective: 08-12-14, Implementation: 08-12-14

Medicare requires the signature of the beneficiary, or that of his or her 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:
(1) The beneficiary’s legal guardian.
(2) A relative or other person who receives social security or other governmental benefits on behalf of the beneficiary.
(3) A relative or other person who arranges for the beneficiary’s treatment or exercises other responsibility for his or her affairs.
(4) 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.
(5) A representative of the provider or of the nonparticipating hospital claiming payment for services it has furnished, if the provider or nonparticipating hospital is unable to have the claim signed in accordance with 42 CFR 424.36(b) (1 – 4).
(6) A representative of the ambulance provider or supplier who is present during an emergency and/or nonemergency transport, provided that the ambulance provider or supplier maintains certain documentation in its records for at least 4 years from the date of service. A provider/supplier (or his/her 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 or her representative, at the time of transport, it may obtain this signature any time prior to submitting the claim to Medicare for payment. (Note: there is a 12 month period for filing a Medicare claim, depending upon the date of service.)

If the beneficiary/representative refuses to authorize the submission of a claim, including a refusal to furnish an authorizing signature, then the ambulance provider/supplier may not bill Medicare, but may bill the beneficiary (or his or her 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, then a beneficiary/representative signature is required and the ambulance provider/supplier must afford the beneficiary/representative this option within the claims filing period.

The Medicare program ambulance fee schedule (FS) is effective for ambulance items and services urnished on or after April 1, 2002. Under the FS, payment for ambulance services covered under the program is based on the lower of the actual billed amount or the ambulance fee schedule amount.

The fee schedule was phased in over a 5-year period. The fee schedule replaced the retrospective reasonable cost reimbursement system for providers and the reasonable charge system for ambulance suppliers. During the transition period, payment was based on a blend of the FS amount and the amount under its current billing methodology.

The fee schedule applies to all ambulance services, including volunteer, municipal, private, independent, and institutional providers, i.e., hospitals, skilled nursing facilities and home health agencies covered under Medicare Part B, except for services furnished by certain critical access hospitals (CAH). Payment for ambulance items and services furnished by a CAH, or by an entity that is owned and operated by a CAH, is based on reasonable cost if the CAH or entity is the only provider or supplier of ambulance services that is located within a 35-mile drive of such CAH. The provision is effective for ambulance services furnished on or after December 21, 2000.

Definition of Ambulance Services
There are several categories of ground ambulance services and two categories of air ambulance services under the fee schedule. (Note that “ground” refers to both land and water transportation.)

Ground Ambulance Services
Basic Life Support (BLS)
Definition: Basic life support (BLS) is transportation by ground ambulance vehicle and the provision of medically necessary supplies and services, including BLS ambulance services as defined by the State. The ambulance must be staffed by an individual who is qualified in accordance with State and local laws as an emergency medical technician basic (EMT-Basic). These laws may vary from State to State or within a State. For example, only in some jurisdictions is an EMT-Basic permitted to operate limited equipment onboard the vehicle, assist more qualified personnel in performing assessments and interventions, and establish a peripheral intravenous (IV) line.

Basic Life Support (BLS) - Emergency
Definition: When medically necessary, the provision of BLS services, as specified above, in the context of an emergency response. An emergency response is one that, at the time the ambulance provider or supplier is called, it responds immediately. An immediate response is one in which the ambulance provider/supplier begins as quickly as possible to take the steps necessary to respond to the call.

Application: The determination to respond emergently with a BLS ambulance must be in accord with the local 911 or equivalent service dispatch protocol. If the call came in directly to the ambulance rovider/supplier, then the provider’s/supplier’s dispatch protocol must meet, at a minimum, the standards of the dispatch protocol of the local 911 or equivalent service. In areas that do not have a local 911 or equivalent service, then the protocol must meet, at a minimum, the standards of a dispatch protocol in another similar jurisdiction within the State or, if there is no similar jurisdiction within the State, then the standards of any other dispatch protocol within the State. Where the dispatch was inconsistent with this standard of protocol, including where no protocol was used, the beneficiary’s condition (for example, symptoms) at the scene determines the appropriate level of payment.

Lab codes for drug testing Issue

The 2015 Current Procedural Terminology (CPT®) codes 80100-80102 have been discontinued and replaced with CPT® 80300-80304 (presumptive drug class screening) and 80320-80377 (definitive drug testing). CPT® codes 80300-80377 have incorrectly been tagged with a procedure code status "X” (statutory exclusion), signifying that payment is not made based on the Medicare physician fee schedule database (i.e. not a physician service).

Resolution
First Coast notified the Centers for Medicare & Medicaid Services (CMS) that CPT® codes 80300-80377 have incorrectly been tagged with a procedure code status "X" (statutory exclusion). Until the status/payment indicator has been corrected, CMS has provided approval for First Coast to return claims for services billed with CPT® codes 80300-80377 to the provider.

Status/date resolved Closed/January 7, 2015

Provider action

According to the clinical laboratory fee schedule (CLFS) final determinations listed on the CMS website, providers are to use procedure codes G6030-G6058 to report these services. These procedure codes will be allowed and paid based on the CLFS. Until the status/payment indicator has been corrected, First Coast will return claims for services billed with CPT® codes 80300-80377 to the provider.

Incorporation of Revalidation Policies into Pub. 100-08, “Program Integrity Manual (PIM),” Chapter 15

This MLN Matters® Article is intended for providers and suppliers submitting claims to Medicare Administrative Contractors(MACs), including Home Health & Hospice(HH&H) MACs,for services
provided to Medicare beneficiaries.

The Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 9011 to incorporate various existing Medicare enrollment revalidation policies into Chapter 15 of the
"Program Integrity Manual" (PIM).

CR 9011 incorporates various existing revalidation policies into the PIM. As these policies were previously established via business requirements, those business requirements are not being repeated in this article. The new polices announced in CR9011 are as follows:

•When processing a voluntary termination of a reassignment, the MAC will contact the group to confirm that the group member's Provider Transaction Access Number(PTAN) is being terminated from all locations and, if multiple group member PTANs exist for multiple group locations, each PTAN is terminated.

•Many enrolled providers may actually be subparts of other enrolled providers, and some of those subparts entered their “doing business as name” as their LBN when applying for their NPIs. Once a contractor determines for certain that this situation exists, the contractor shall ask the provider to correct its NPPES information. The provider can (1) change its LBN in NPPES to read in accordance with the IRS CP-575, and (2) report its “doing business as” name in NPPES as an “Other Name”

and indicate the type of other name as a “doing business as” name.

Definition: Advanced life support, level 1 (ALS1) is the transportation by ground ambulance vehicle and the provision of medically necessary supplies and services including the provision of an ALS assessment or at least one ALS intervention.

Advanced Life Support Assessment
Definition: An advanced life support (ALS) assessment is an assessment performed by an ALS crew as part of an emergency response that was necessary because the patient's reported condition at the time of dispatch was such that only an ALS crew was qualified to perform the assessment. An ALS assessment does not necessarily result in a determination that the patient requires an ALS level of service.

Application: The determination to respond emergently with an ALS ambulance must be in accord with the local 911 or equivalent service dispatch protocol. If the call came in directly to the ambulance provider/supplier, then the provider’s/supplier’s dispatch protocol must meet, at a minimum, the standards of the dispatch protocol of the local 911 or equivalent service. In areas that do not have a local 911 or equivalent service, then the protocol must meet, at a minimum, the standards of a dispatch protocol in another similar jurisdiction within the State or, if there is no similar jurisdiction within the State, then the standards of any other dispatch protocol within the State. Where the dispatch was inconsistent with this standard of protocol, including where no protocol was used, the beneficiary’s condition (for example, symptoms) at the scene determines the appropriate level of payment.

Advanced Life Support Intervention
Definition: An advanced life support (ALS) intervention is a procedure that is in accordance with State and local laws, required to be done by an emergency medical technician-intermediate (EMT-Intermediate) or EMT-Paramedic.

Application: An ALS intervention must be medically necessary to qualify as an intervention for payment for an ALS level of service. An ALS intervention applies only to ground transports.

Advanced Life Support, Level 1 (ALS1) - Emergency
Definition: When medically necessary, the provision of ALS1 services, as specified above, in the context of an emergency response. An emergency response is one that, at the time the ambulance provider or supplier is called, it responds immediately. An immediate response is one in which the ambulance provider/supplier begins as quickly as possible to take the steps necessary to respond to the call.

Application: The determination to respond emergently with an ALS ambulance must be in accord with the local 911 or equivalent service dispatch protocol. If the call came in directly to the ambulance provider/supplier, then the provider’s/supplier’s dispatch protocol must meet, at a minimum, the standards of the dispatch protocol of the local 911 or equivalent service. In areas that do not have a local 911 or equivalent service, then the protocol must meet, at a minimum, the standards of a dispatch protocol in another similar jurisdiction within the State or, if there is no similar jurisdiction within the State, then the standards of any other dispatch protocol within the State. Where the dispatch was inconsistent with this standard of protocol, including where no protocol was used, the beneficiary’s condition (for example, symptoms) at the scene determines the appropriate level of payment.

Advanced Life Support, Level 2 (ALS2)
Definition: Advanced life support, level 2 (ALS2) is the transportation by ground ambulance vehicle and the provision of medically necessary supplies and services including (1) at least three separate administrations of one or more medications by intravenous push/bolus or by continuous infusion (excluding crystalloid fluids) or (2) ground ambulance transport, medically necessary supplies and services, and the provision of at least one of the ALS2 procedures listed below:

a. Manual defibrillation/cardioversion;
b. Endotracheal intubation;
c. Central venous line;
d. Cardiac pacing;
e. Chest decompression;
f. Surgical airway; or
g. Intraosseous line.

Application: Crystalloid fluids include fluids such as 5 percent Dextrose in water, Saline and Lactated Ringer’s. Medications that are administered by other means, for example: intramuscular/subcutaneous injection, oral, sublingually or nebulized, do not qualify to determine whether the ALS2 level rate is payable. However, this is not an all-inclusive list. Likewise, a single dose of medication administered fractionally (i.e., one-third of a single dose quantity) on three separate occasions does not qualify for the ALS2 payment rate. The criterion of multiple administrations of the same drug requires a suitable quantity and amount of time between administrations that is in accordance with standard medical practice guidelines. The fractional administration of a single dose (for this purpose meaning a standard or protocol dose) on three separate occasions does not qualify for ALS2 payment.

In other words, the administration of 1/3 of a qualifying dose 3 times does not equate to three qualifying doses for purposes of indicating ALS2 care. One-third of X given 3 times might = X (where X is a standard/protocol drug amount), but the same sequence does not equal 3 times X. Thus, if 3 administrations of the same drug are required to show that ALS2 care was given, each of those administrations must be in accord with local protocols. The run will not qualify on the basis of drug administration if that administration was not according to protocol.

An example of a single dose of medication administered fractionally on three separate occasions that would not qualify for the ALS2 payment rate would be the use of Intravenous (IV) Epinephrine in the treatment of pulseless Ventricular Tachycardia/Ventricular Fibrillation (VF/VT) in the adult patient. Administering this
medication in increments of 0.25 mg, 0.25 mg, and 0.50 mg would not qualify for the ALS2 level of payment. This medication, according to the American Heart Association (AHA), Advanced Cardiac Life Support (ACLS) protocol, calls for Epinephrine to be administered in 1 mg increments every 3 to 5 minutes. Therefore, in order to receive payment for an ALS2 level of service, based in part on the administration of Epinephrine, three separate administrations of Epinephrine in 1 mg increments must be administered for the treatment of pulseless VF/VT.

A second example that would not qualify for the ALS2 payment level is the use of Adenosine in increments of 2 mg, 2 mg, and 2 mg for a total of 6 mg in the treatment of an adult patient with Paroxysmal Supraventricular Tachycardia (PSVT). According to ACLS guidelines, 6 mg of Adenosine should be given by rapid intravenous push (IVP) over 1 to 2 seconds. If the first dose does not result in the elimination of the supraventricular tachycardia within 1 to 2 minutes, 12 mg of Adenosine should be administered IVP. If the supraventricular tachycardia persists, a second 12 mg dose of Adenosine can be administered for a total of 30 mg of Adenosine. Three separate administrations of the drug Adenosine in the dosage amounts outlined in the later case would qualify for ALS2 payment.

Endotracheal intubation is one of the services that qualifies for the ALS2 level of payment; therefore, it is not necessary to consider medications administered by endotracheal intubation for the purpose of determining whether the ALS2 rate is payable.

The monitoring and maintenance of an endotracheal tube that was previously inserted prior to transport also qualifies as an ALS2 procedure.

Advanced Life Support (ALS) Personnel
Definition: ALS personnel are individuals trained to the level of the emergency medical technician-intermediate (EMT-Intermediate) or paramedic.

Q2.1: Can CMS clarify when the 2 midnight benchmark begins for a claim selected for medical review, and how it incorporates outpatient time prior to admission in determining the general appropriateness of the inpatient admission?

A2.1: For purposes of determining whether the 2‑midnight benchmark was met and, therefore, whether inpatient admission was generally appropriate, the Medicare review contractor will consider time the beneficiary spent receiving outpatient services within the hospital. This will include services such as observation services, treatments in the emergency department, and procedures provided in the operating room or other treatment area. From the medical review perspective, while the time the beneficiary spent as a hospital outpatient before the beneficiary was formally admitted as an inpatient pursuant to the physician order will not be considered inpatient time, it will be considered during the medical review process for purposes of determining whether the 2-midnight benchmark was met and, therefore, whether payment for the admission is generally appropriate under Medicare Part A.

Whether the beneficiary receives services in the emergency department (ED) as an outpatient prior to inpatient admission (for example, receives observation services in the emergency room) or is formally admitted as an inpatient upon arrival at the hospital (for example, inpatient admission order written prior to an elective inpatient procedure or a beneficiary who was an inpatient at another hospital and is transferred), the starting point for the 2 midnight timeframe for medical review purposes will be when the beneficiary starts receiving services following arrival at the hospital. CMS notes that this instruction excludes wait times prior to the initiation of care, and therefore triaging activities (such as vital signs before the initiation of medically necessary services responsive to the beneficiary's clinical presentation) must be excluded. A beneficiary sitting in the ED waiting room at midnight while awaiting the start of treatment would not be considered to have passed the first midnight, but a beneficiary receiving services in the ED at midnight would meet the first midnight of the benchmark. The Medicare review contractor will count only medically necessary services responsive to the beneficiary's clinical presentation as performed by medical personnel.

Q2.2: How should providers calculate the 2-midnight benchmark when the beneficiary has been transferred from another hospital?

A2.2: The receiving hospital is allowed to take into account the pre-transfer time and care provided to the beneficiary at the initial hospital. That is, the start clock for transfers begins when the care begins in the initial hospital. Any excessive wait times or time spent in the hospital for non-medically necessary services shall be excluded from the physician’s admission decision. (Note: for the purposes of this question, hospital is defined as acute care hospital, long-term care hospital (LTCH), critical access hospital (CAH), and inpatient psychiatric facility.) Medicare review contractors may request records from the transferring hospital to support the medical necessity of the services provided and to verify when the beneficiary began receiving care to ensure compliance and deter gaming or abuse. Claim submissions for transfer cases will be monitored and any billing aberrancy identified by CMS or the Medicare review contractors may be subject to targeted review. The initial hospital should continue to apply the 2-midnight benchmark based on the expected length of stay of the beneficiary for hospital care within their
facility

Q2.3: How should providers calculate the 2-midnight benchmark when the beneficiary has received care in an Off-Campus ED?

A2.3: If the ED is established as a provider-based/practice location of the hospital, CMS does not separately pay to move the patient from an off-campus location of the Medicare hospital to the campus of the same Medicare hospital. Moving the beneficiary within the hospital that participates in Medicare under a single CMS Certification Number (CCN) from a provider-based off-campus ED to a separate on-campus unit, or moving the bene from an on-campus ED to a specified floor on the same campus would be considered the same from a Medicare perspective.

The provider-based or practice location (off-campus) ED is subject to all of the hospital Conditions of Participation (COPs) and is considered an integral part of the Medicare participating hospital.

Therefore, if a hospital ED is either an on-campus ED or an off-campus provider-based ED/practice location of a Medicare-certified hospital, the ED is considered part of that hospital for purposes of the 2-midnight rule, and therefore the total time in the hospital should be counted for purposes of the 2 midnight benchmark. On the other hand, if the ED is not established as an off-campus provider/practice location (unrelated to that hospital’s CCN), then the beneficiary movement would be considered a transfer and the rules outlined in question 2.2 are applicable.

Specialty Care Transport (SCT)

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

Application: The EMT-Paramedic level of care is set by each State. SCT is necessary when a beneficiary’s condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area. Care above that level that is medically necessary and that is furnished at a level of service above the EMT-Paramedic level of care is considered SCT. That is to say, if EMT-Paramedics - without specialty care certification or qualification - are permitted to furnish a given service in a State, then that service does not qualify for SCT. The phrase “EMT-Paramedic with additional training” recognizes that a State may permit a person who is not only certified as an EMT-Paramedic, but who also has successfully completed additional education as determined by the State in furnishing higher level medical services required by critically ill or critically injured patients, to furnish a level of service that otherwise would require a health professional in an appropriate specialty care area (for example, a nurse) to provide.
“Additional training” means the specific additional training that a State requires a paramedic to complete in order to qualify to furnish specialty care to a critically ill or injured patient during an SCT.

Paramedic Intercept (PI)
Definition: Paramedic Intercept services are ALS services provided by an entity that does not provide the ambulance transport. This type of service is most often provided for an emergency ambulance transport in which a local volunteer ambulance that can provide only basic life support (BLS) level of service is dispatched to transport a patient. If the patient needs ALS services such as EKG monitoring, chest decompression, or I.V. therapy, another entity dispatches a paramedic to meet the BLS ambulance at the scene or once the ambulance is on the way to the hospital. The ALS paramedics then provide services to the patient.

This tiered approach to life saving is cost effective in many areas because most volunteer ambulances do not charge for their services and one paramedic service can cover many communities. Prior to March 1, 1999, Medicare payment could be made for these services, but only when the claim was submitted by the entity that actually furnished the ambulance transport. Payment could not be made directly to the intercept service provider. In those areas where State laws prohibit volunteer ambulances from billing Medicare and other health insurance, the intercept service could not receive payment for treating a Medicare beneficiary and was forced to bill the beneficiary for the entire service.

Paramedic intercept services furnished on or after March 1, 1999, may be payable separate from the ambulance transport, subject to the requirements specified below.

The intercept service(s) is:
• Furnished in a rural area;
• Furnished under a contract with one or more volunteer ambulance services; and,
• Medically necessary based on the condition of the beneficiary receiving the ambulance service.

In addition, the volunteer ambulance service involved must:
• Meet the program’s certification requirements for furnishing ambulance services;
• Furnish services only at the BLS level at the time of the intercept; and,
• Be prohibited by State law from billing anyone for any service.
Finally, the entity furnishing the ALS paramedic intercept service must:
• Meet the program’s certification requirements for furnishing ALS services, and,
• Bill all recipients who receive ALS paramedic intercept services from the entity,
regardless of whether or not those recipients are Medicare beneficiaries.
For purposes of the paramedic intercept benefit, a rural area is an area that is designated as rural by a State law or regulation or any area outside of a Metropolitan Statistical Area or in New England, outside a New England County Metropolitan Area as defined by the Office of Management and Budget. The current list of these areas is periodically published in the Federal Register.

Coverage Indications, Limitations, and/or Medical Necessity

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Compliance with the provisions in this policy may be monitored and addressed through prepayment and/or post payment data analysis and subsequent medical review audits.

The Medicare payment benefit for ambulance services is very restricted. Ambulance suppliers must understand the benefit and refrain from seeking Medicare payment for services that do not conform to the limited benefit requirements as stated in regulation. Physicians and others who order and certify medical necessity of ambulance services must also understand and abide by the limitations of Medicare coverage of ambulance services. This LCD includes, for reference only, portions of CMS national payment policy as found in relevant Internet-Only Manual (IOM) sections and regulations. This LCD further provides “limited coverage” diagnosis to procedure edit requirements for ambulance suppliers who choose to submit ICD-9-CM codes on their claims. The LCD also contains utilization guidelines for the purpose of automated ambulance claim denial by the contractor in its jurisdictions.

CMS National Payment Policy

Medicare covers ambulance services only if furnished to a beneficiary whose medical condition at the time of transport is such that transportation by other means would endanger the patient’s health. A patient whose condition permits transport in any type of vehicle other than an ambulance does not qualify for Medicare payment. Medicare payment for ambulance transportation depends on the patient’s condition at the actual time of the transport regardless of the patient’s diagnosis. To be deemed medically necessary for payment, the patient must require both the transportation and the level of service provided.

Medicare covers both emergency ambulance transportation and non-emergency ambulance transportation as follows:

Medical Necessity

Ambulance transportation is covered when the patient’s condition requires the vehicle itself and/or the specialized services of the trained ambulance personnel. A requirement of coverage is that the needed services of the ambulance personnel were provided and clear clinical documentation validates their medical need and their provision in the record of the service (usually the run sheet).

Emergency Ambulance Services

Medicare will cover emergency ambulance services when the services are medically necessary, meet the destination limits of closest appropriate facilities and are provided by an ambulance service that is licensed by the state. Emergency response means responding immediately at the Basic Life Support (BLS) or Advanced Life Support 1 (ALS1) level of service to a 911 call or the equivalent. An immediate response is one in which the ambulance supplier begins as quickly as possible to take the steps necessary to respond to the call.

Application: The determination to respond emergently with a BLS or ALS1 ambulance must be in accord with the local 911 or equivalent service dispatch protocol (ALS2 has additional requirements). If the call came in directly to the ambulance provider/supplier, then the provider's/supplier's dispatch protocol must meet, at a minimum, the standards of the dispatch protocol of the local 911 or equivalent service. In areas that do not have a local 911 or equivalent service, then the protocol must meet, at a minimum, the standards of a dispatch protocol in another similar jurisdiction within the State or, if there is no similar jurisdiction within the State, then the standards of any other dispatch protocol within the State. Where the dispatch was inconsistent with this standard of protocol, including where no protocol was used, the beneficiary's condition (for example, symptoms) at the scene determines the appropriate level of payment.

The patient’s condition is an emergency that renders the patient unable to be safely transported to the hospital in a moving vehicle (other than an ambulance) for the amount of time required to complete the transport. Emergency ambulance services are services provided after the sudden onset of a medical condition. For the purposes of this LCD, acute signs and/or symptoms of sufficient severity must manifest the emergency medical condition such that the absence of immediate medical attention could reasonably be expected to result in one or more of the following:

•Place the patient’s health in serious jeopardy.
•Cause serious impairment to bodily functions.
•Cause serious dysfunction of any body organ or part.

What factors should the physician take into consideration when making the admission decision and document in the medical record?

A4.2: For purposes of meeting the 2-midnight benchmark, in deciding whether an inpatient admission is warranted, the physician must assess whether the beneficiary requires hospital services and whether it is expected that such services will be required for 2 or more midnights. The decision to admit the beneficiary as an inpatient is a complex medical decision made by the physician in consideration of various factors, including the beneficiary’s age, disease processes, comorbidities, and the potential impact of sending the beneficiary home. It is up to the physician to make the complex medical determination of whether the beneficiary’s risk of morbidity or mortality dictates the need to remain at the hospital because the risk of an adverse event would otherwise be unacceptable under reasonable standards of care, or whether the beneficiary may be discharged. If, based on the physician's evaluation of complex medical factors and applicable risk, the beneficiary may be safely and appropriately discharged, then the beneficiary should be discharged, and hospital payment is not appropriate on either an inpatient or outpatient basis. If the beneficiary is expected to require medically necessary hospital services for 2 or more midnights, then the physician should order inpatient admission and Part A payment is generally appropriate per the 2-midnight benchmark. Except in cases involving services identified by CMS as inpatient-only, if the beneficiary is expected to require medically necessary hospital services for less than 2 midnights, then the beneficiary generally should remain an outpatient and Part A payment is generally inappropriate.

We note that in the FY 2014 IPPS final rule we stated the 2-midnight benchmark provides that hospital stays expected to last less than 2 midnights are generally inappropriate for hospital admission and Medicare Part A payment absent rare and unusual circumstances. In that rule, we stated that we would provide additional subregulatory guidance on those circumstances. We believe that we have already identified many of these rare and unusual exceptions in our Inpatient Only List. In that list, we identify those services that we have said are rarely provided to outpatients and which typically require, for reasons of quality and safety, a significantly protracted stay at the hospital. We believe that it would be rare and unusual for a stay of 0 or 1 midnights, for patients with known diagnoses entering a hospital for a specific minor surgical procedure or other treatment that is expected to keep them in the hospital for less than 2 midnights, to be appropriately classified as inpatient and paid under Medicare Part A. This is consistent with our historical guidance in which we defined certain minor therapeutic and diagnostic services as appropriately furnished outpatient on the basis of an expected short length of stay. We also do not believe that the use of telemetry, by itself, constitutes a rare and unusual circumstance that would justify an inpatient admission in the absence of a 2 midnight expectation. We note that telemetry is neither rare nor unusual, and that it is commonly used by hospitals on outpatients (ER and observation patients) and on patients fitting the historical definition of outpatient observation (that is, patients for whom a brief period of assessment or treatment may allow the patient to avoid an inpatient hospital stay). We also specified in the final rule that we do not believe that the use of an ICU, by itself, would be a rare and unusual circumstance that would justify an inpatient admission in the absence of a 2 midnight expectation. In some hospitals, placement in an ICU is neither rare nor unusual, because an ICU label is applied to a wide variety of facilities providing a wide variety of services. Due to the wide variety of services that can be provided in different areas of a hospital, we do not believe that a patient assignment to a specific hospital location, such as a certain unit or location, would justify an inpatient admission in the absence of a 2 midnight expectation.

CMS identified newly initiated mechanical ventilation (excluding anticipated intubations related to minor surgical procedures or other treatment) as its first rare and unusual exception to the 2 midnight rule (see Question 4.3). We recognize that there could be rare and unusual circumstances that we have not identified that justify inpatient admission absent an expectation of care spanning at least 2 midnights. As we continue to work with facilities and physicians to identify such other situations, we reiterate that we expect these situations to be rare and unusual exceptions to the general rule. If any such additional situations are identified, we will include them in subregulatory instruction, and we will expect that in these situations the physician at the time of admission must explicitly document the reason why the specific case requires inpatient care, as opposed to hospital services in an outpatient status. We do not believe that these rare and unusual circumstances can be imputed from the medical record.

It is important that any staff involved with the clinical decision to admit the patient stay abreast of all CMS national inpatient hospital policy and National and Local Coverage Determinations. Additionally, make sure medical documentation submitted demonstrates evidence of the clinical need for the patient to be admitted to the inpatient facility and fully and accurately identifies any subsequent care that was provided during the inpatient stay.

Background

Some hospitals have recently expressed concern about how the Centers for Medicare & Medicaid Services (CMS) Recovery Audit Contractors (RACs), MACs, FIs, and the Comprehensive Error Rate Testing Contractor (CERT) are utilizing screening criteria to analyze medical documentation and make a medical necessity determination on inpatient hospital claims.

There are several commercially available screening tools that Medicare contractors in specific jurisdictions may use to assist in the review of medical documentation to determine if a hospital admission is medically necessary. These include Interqual, Milliman, and other proprietary systems.

CMS Policy Guidance

To assist hospitals regarding inpatient admission decisions, CMS would refer hospitals to the following:

Program Integrity Manual Guidance Chapter 6, Section 6.5.1, of the Medicare Program Integrity Manual requires that contractor review staff use a screening tool as part of their medical review process for inpatient hospital claims. CMS does not require that the contractor use specific criteria nor endorse any particular brand of screening guidelines. CMS contractors are not required to pay a claim even if screening criteria indicate inpatient admission is appropriate Conversely, CMS contractors are not required to automatically deny a claim that does not meet the admission guidelines of a screening tool. In all cases, in addition to screening instruments, the reviewer shall apply his/her own clinical judgment to make a medical review determination based on the documentation in the medical record.

For each case, the review staff will utilize the following when making a medical necessity determination

• Admission criteria;
• Invasive procedure criteria;
• CMS coverage guidelines;
• Published CMS criteria; and
• Other screens, criteria, and guidelines (e.g., practice guidelines that are well accepted by the medical community).

NOTE: CMS considers the use of screening criteria as only one tool that should be utilized by contractors to assist them in making an inpatient hospital claim determination.

Chapter 6, Section 6.5.2, of the Medicare Program Integrity Manual states that the review of the medical record must indicate that inpatient hospital care was medically necessary, reasonable, and appropriate for the diagnosis and condition of the beneficiary at any time during the stay. The beneficiary must demonstrate signs and/or symptoms severe enough to warrant the need for medical care and must receive services of such intensity that they can be furnished safely and
effectively only on an inpatient basis.

The reviewer will consider, in his/her review of the medical record, any pre-existing medical problems or extenuating circumstances that make admission of the beneficiary medically necessary. Factors that may result in an inconvenience to a beneficiary or family do not, by themselves, justify inpatient admission.

Inpatient care, rather than outpatient care, is required only if the beneficiary's medical condition, safety, or health would be significantly and directly threatened if care was provided in a less intensive setting. Without accompanying medical conditions, factors that would only cause the beneficiary inconvenience in terms of time and money needed to care for the beneficiary at home or for travel to a physician's office, or that may cause the beneficiary to worry, do not justify a continued hospital stay.

Chapter 6 of the Medicare Program Integrity Manual, Section 6.5 is available at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/pim83c06.pdf
on the CMS website.

Medicare Benefit Policy Manual Guidance

The Medicare Benefit Policy Manual, Chapter 1, Section 10 also contains relevant information regarding what constitutes an appropriate inpatient admission. According to that manual section, an inpatient is a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services. Generally, a patient is considered an inpatient if formally admitted as an inpatient with the expectation that he or she will remain at least overnight and occupy a bed even though it later develops that the patient can be discharged or transferred to another hospital and not actually use a hospital bed overnight.

The physician or other practitioner responsible for a patient's care at the hospital is also responsible for deciding whether the patient should be admitted as an
inpatient. Physicians should use a 24-hour period as a benchmark (i.e., they should order admission for patients who are expected to need hospital care for 24
hours or more, and treat other patients on an outpatient basis). However, the decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors, including the patient's medical history and current medical needs, the types of facilities available to inpatients and to outpatients, the hospital's by-laws and admissions policies, and the relative appropriateness of treatment in each setting. Factors to be considered
when making the decision to admit include such things as:

• The severity of the signs and symptoms exhibited by the patient;
• The medical predictability of something adverse happening to the patient;
• The need for diagnostic studies that appropriately are outpatient services (i.e., their performance does not ordinarily require the patient to remain at the
hospital for 24 hours or more) to assist in assessing whether the patient should be admitted; and
• The availability of diagnostic procedures at the time when and at the location where the patient presents.

Admissions of particular patients are not covered or non-covered solely on the basis of the length of time the patient actually spends in the hospital.

Not participating in the Medicare Electronic Health Record (EHR) Incentive Program yet? 2015 is the last year for eligible hospitals to begin and still earn incentive payments. To earn a 2015 incentive payment and avoid a 2016 payment adjustment, first-time participants should:

• Begin their 90-day reporting period no later than April 1, 2015
• Attest by July 1, 2015

Eligible hospitals that miss this deadline can still earn a 2015 incentive payment and avoid the 2017 payment adjustment if they begin their reporting period by July 1 and attest by November 30. However, they will be subject to the 2016 payment adjustment unless they apply and qualify for a hardship exception.

• Hospitals that successfully attest in 2015 will also be eligible to earn a 2016 incentive if they continue to participate.
•Eligible hospitals that begin participating after 2015 will not be able to earn incentive payments. They will also be subject to payment adjustments in 2016 and 2017.

Payment Adjustments & Hardship Exceptions

Payment Adjustments
If a provider is eligible to participate in the Medicare EHR Incentive Program, they must demonstrate meaningful use in either the Medicare EHR Incentive Program or in the Medicaid EHR Incentive Program, to avoid a payment adjustment. Medicaid providers who are only eligible to participate in the Medicaid EHR Incentive Program are not subject to these payment adjustments.

Medicare hospitals began to receive payment adjustments on October 1, 2014, and Medicare eligible professionals will begin to receive payment adjustments on January 1, 2015.

Hardship Exceptions to Avoid Medicare Payment Adjustments
Eligible professionals and eligible hospitals may be exempt from payment adjustments if they can show that demonstrating meaningful use would result in a significant hardship. To be considered for an exception, an eligible professional or eligible hospital must complete a Hardship Exception application along with proof of the hardship. If approved, the hardship exception is valid for 1 payment year only. A new application must be submitted if the hardship continues for the following payment year. In no case may a provider be granted an exception for more than 5 years.
Eligible professionals can use the Hardship Exception Tool to determine if they will avoid the upcoming 2015 and 2016 Medicare EHR Incentive Program payment adjustments by demonstrating meaningful use, or if they should apply for a hardship exception.

Eligible Professional (EP) Hardship Exception Application
•2015 Eligible Professional Hardship application deadline was July 1, 2014
•2016 Eligible Professional Hardship application will be available soon.
Eligible Hospitals Hardship Exception Application
•2015 Eligible Hospital Hardship application deadline was April 1, 2014
•2016 Eligible Hospital Hardship application will be available soon.

Not All Providers Apply for Hardship Exceptions

Some providers will automatically be granted a hardship exception. CMS will use Medicare data on these providers to determine their hardship exception.

The following providers do not need to submit a hardship application:
•New providers to the profession in their first year (both eligible professionals and eligible hospitals)
•Eligible professionals who are hospital-based: a provider is considered hospital-based if he or she provides more than 90% of their covered professional services in either an inpatient (Place of Service 21) or emergency department (Place of Service 23) of a hospital*
•Eligible professionals in which 90% of their claims include Place of Service 21, Place of Service 23 and certain observation services using Place of Service 22.

•Eligible professionals with certain PECOS specialties (05-Anesthesiology, 22-Pathology, 30-Diagnostic Radiology, 36-Nuclear Medicine, 94-Interventional Radiology) 6 months prior to the first day of the payment adjustments. Eligible professionals should verify that their PECOS specialty is up to date.

Claims for transportation services provided on or after September 1st, 2010, that meet the definition of non-emergency medical transportation, must be authorized by and submitted to American Medical Response (AMR) for payment. This covers the following service codes; A0100, A0110, A0140, A0170, A0180, A0190, A0200, A0210, S0215, T2003, T2004.

Claims for transportation services that meet the definition of non-emergency medical transportation provided prior to September 1st, 2010, must be submitted to Molina Medicaid Solutions for payment. This covers the following service codes; A0100, A0110, A0140, A0170, A0180, A0190, A0200, A0210, S0215, T2003, T2004 as well as service codes listed in table below.

HCPCS Description PA Required Modifier Place of Service

Individual Transportation

Non-emergency transportation, per mile A0080 Aged and Disabled (A&D) or Developmental Disabilities (DD) Waiver non-medical transportation, per mile, as authorized by Regional Medicaid Services. 1 Unit = 1 Mile. Maximum allowable of 1,800 waiver miles per year. Yes No 99

Attendant salary T2001 Non-emergency transportation, patient attendant/escort (salary). Spouse or parent of a minor child cannot be paid as attendant. 1 Unit = 15 inutes. Yes No 99

Agency Transportation

Non-emergency transportation, per mile A0080 Aged and Disabled (A&D) or Developmental Disabilities (DD) Waiver non-medical transportation, per mile, as authorized by Regional Medicaid Services. 1 Unit = 1 Mile. Maximum allowable of 1,800 waiver miles per year. Yes No 99

Attendant salary T2001 Non-emergency transportation, patient attendant/escort (salary). Spouse or parent of a minor child cannot be paid as attendants. Yes No 99

Commercial Transportation

Non-emergency transportation, per mile A0080 Aged and Disabled (A&D) or Developmental Disabilities (DD) Waiver non-medical transportation, per mile, as authorized by Regional Medicaid Services. 1 Unit = 1 Mile. Maximum allowable of 1,800 waiver miles per year. Yes (First Trip, No modifier) (Subsequent trips, same day, Modifier 76 required) 99

Attendant salary T2001 Non-emergency transportation, patient attendant/escort (salary). Spouse or parent of a minor child cannot be paid as attendants. Yes No 99

The Centers for Medicare and Medicaid Services (CMS) will implement a 3 year prior authorization program for repetitive scheduled non-emergent ambulance transports in the states of New Jersey, Pennsylvania, and South Carolina based on where the ambulance company is garaged. A repetitive ambulance service is defined as medically necessary ambulance transportation that is furnished 3 or more times during a 10-day period; or at least once per week for at least 3 weeks (round trips)

Who needs to submit a prior authorization request?

Ambulance suppliers that are not institutionally based that provide Part B Medicare covered ambulance services and are enrolled as an independent ambulance supplier.
Prior authorization for repetitive scheduled non-emergent ambulance transport is voluntary; however, if the ambulance supplier elects not to submit a prior authorization request before the fourth round trip, the claim related to the repetitive scheduled non-emergent ambulance transport will be subject to a pre-payment medical review.

When is this effective?
Novitas will begin accepting prior authorization requests for New Jersey and Pennsylvania on December 1, 2014 for repetitive scheduled non-emergent ambulance transports scheduled to occur on or after December 15, 2014.
Claims for non-emergent ambulance transports with a date of service on or after December 15, 2014 must have completed the prior authorization process or the claims will be subject to prepayment medical review.
Cover Sheets submitted prior to 12/1/2014 will be returned, and not processed.
HCPC Codes subject to Prior Authorization
A0425 - BLS/ALS mileage (per mile)
A0426 - Ambulance service, Advanced Life Support (ALS), non-emergency transport, Level 1
A0428 - Ambulance service, Basic Life Support (BLS), non-emergency transport
Requests need to include:
Completed Prior Authorization Cover Sheet
Physician Certification Statement
Documentation to support diagnosis, certification statement and the medical necessity of repetitive scheduled non-emergent ambulance transport. Include the origin and destination of the transports.

How do I submit a prior authorization request?

Process
Prior Authorization Cover Sheet
Prior Authorization Cover Sheet (Expedited) *I certify the standard timeframe could seriously jeopardize the life or health of the beneficiary
Cover Sheet Completion Instructions

Where on the claim should the unique tracking number be populated?
Electronic 837 Professional Claim
The unique tracking number (UTN) can be submitted in either the 2300 – Claim Information loop or 2400 – Service Line loop in the Prior Authorization reference (REF) segment where REF01 = “G1” qualifier and REF02 = UTN. This is in accordance with the requirements of the ASC X12 837 Technical Report 3 (TR3).
Paper CMS 1500 Claim Form

The unique tracking number (UTN) must populate the first 14 positions in item 23. All other data submitted in item 23 must begin in position 15.

BENEFITS AND LIMITATIONS

Missouri Statute 208.152 authorizes MO HealthNet coverage of emergency ambulance services. Only those transports considered an emergency and made to the nearest appropriate hospital are covered and should be submitted to MO HealthNet for payment. This policy can be found in section 13.3.A of the MO HealthNet Ambulance manual located at http://manuals.momed.com/manuals/. Exceptions to this policy can be found in sections 13.3.P, Healthy Children and Youth (HCY) services; 13.3.O, transfer of participants to another hospital; and 13.3.L, transports for specialized testing.

Emergency services are services required when there is a sudden or unforeseen situation or occurrence or a sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in:

• placing the participant’s health in serious jeopardy; or

• serious impairment to bodily functions; or

• serious dysfunction of any bodily organ or part.

“Nearest appropriate hospital” is the hospital equipped and staffed to provide the needed care for the illness or injury involved. It is the institution, its equipment, its personnel and its capability to provide the service necessary to support the required medical care that determines whether it has appropriate facilities. The fact a more distant institution is better equipped, either qualitatively or quantitatively, to care for the participant does not in itself support a conclusion a closer institution does not have appropriate facilities. MO HealthNet does not allow transportation to a more distant facility solely to avail a participant of the services of a specific physician or family or personal preferences when considering the “nearest appropriate facility”.

Services not considered emergent or within the exempted categories should not be submitted to MO HealthNet for processing. Non-emergent trips, as well as services provided to a participant not eligible for MO HealthNet benefits on the date of the transport, may be billed to the participant. MO HealthNet participants who dispute a bill from an ambulance provider may contact the MO HealthNet Participant Services Unit (PSU) at 1-800-392-2161. It is not the responsibility of the ambulance provider to submit a claim to MO HealthNet in order to receive a denial before billing the participant.

If the participant contacts PSU regarding a bill, the ambulance provider may be contacted by PSU staff requesting a copy of the trip ticket. This documentation must be sent to PSU by the requested date in their letter. A medical consultant reviews the trip ticket to determine if the trip was emergent in nature. After review both the ambulance provider and the participant will receive written otification. If the review determines the transport meets the emergency criteria, the provider will be instructed to submit the claim to MO HealthNet and the participant is not financially responsible. If the review determines the transport does not meet policy, the participant is notified they are responsible for payment of the bill. If the ambulance provider does not comply with PSU’s request for documentation, the participant is notified they are not responsible for payment of the bill.

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.

Claims for transportation services provided on or after September 1st, 2010, that meet the definition of non-emergency medical transportation, must be authorized by and submitted to American Medical Response (AMR) for payment.

Claims for transportation services that meet the definition of non-emergency medical transportation provided prior to September 1st, 2010, must be submitted to Molina Medicaid Solutions for payment.

Service HCPCS Description

Advanced life support, level 2 (ALS 2).
A0433

Ambulance service, advanced life support, emergency transport, level 1 (ALS 1 - emergency).
A0427

Ambulance service, advanced life support, non-emergency transport, level 1 (ALS 1).
A0426

Ambulance service, basic life support, emergency transport (BLS - emergency).
A0429

Ambulance service, basic life support, non-emergency transport (BLS).
A0428

Ambulance service, conventional air services, transport, one way (fixed wing).
A0430
Base rate.

Ambulance service, conventional air services, transport, one way (rotary wing).
A0431
Base rate.

Ambulance waiting time (ALS or BLS), 1/2 hour increments.
A0420
1 Unit = 1/2 Hour. Do not count the first 1/2, which is included in the base rate. Must be physician ordered

Extra ambulance attendant, ground (ALS or BLS) or air (fixed or rotary winged).
Requires medical review.
A0424
Attendant must be in the patient compartment of the ambulance and actively treating or attending the patient. 1 Unit = Total charges for 1 extra attendant

Fixed wing air mileage, per statute mile.
A0435

Ground mileage, per statute mile.
A0425

Respond and evaluate no other services (all levels).
A0998
Treat and release (ambulance response and treatment, no transport).

Response and treatment, advanced life support.
A0998

Response and treatment, basic life support.
A0998

Rotary wing air mileage, per statute mile.
A0436

TRANSPORTS TO TWO DIFFERENT HOSPITALS

MO HealthNet covers transportation from the point of pickup to two different hospitals made on the same day by the same ambulance provider when it is medically necessary. This situation can occur when the ambulance transports the participant to the nearest hospital, but before the participant leaves the emergency room it is decided the first hospital is not appropriate and the participant is transported to a second hospital. When it is medically necessary to transport a participant from one hospital to another on the same date of service, providers must bill the base rate procedure code with a quantity of “2”. Mileage and any ancillary charges for both trips are to be combined.

TWO TRIPS ON THE SAME DATE OF SERVICE

Two emergency ambulance trips to a hospital in one day for the same participant may be covered when medically necessary. Proper trip documentation must be maintained in the participant’s record. To bill for two trips on the same day, the same provider must show a quantity of “2” units for the base rate procedure code when appropriate. Mileage and any ancillary charges for both trips are to be combined. If the base rate procedure codes aren't the same for each trip, both trips must be billed on the same claim form as separate line items with the appropriate base rate procedure codes. If two different ambulance services transport the same participant on the same date of service, both providers must maintain proper trip documentation in the participant’s record to substantiate medical necessity.

HOSPITAL TO HOSPITAL TRANSFERS

Ground ambulance transfers of MO HealthNet participants from one hospital to another hospital to receive medically necessary inpatient services not available at the first facility are covered services. Hospital transfers shall be covered when the participant has
been stabilized at the first hospital but needs a higher level of care available only at a second hospital. Examples of medically necessary transfers for services not available at the first facility include, but are not limited to:

• rehabilitation

• burn unit

• ventilator assistance

• other specialized care

The hospital to hospital transfer may not be considered emergent; however, hospital to hospital transfers that meet the transfer criteria listed in section 13.13.O(1) of the MO HealthNet Ambulance provider manual qualify for coverage under the ambulance program.

The documentation in the participant’s record must support the procedure code billed. For accurate reporting purposes, the appropriate base code from the following list should be billed with the “HH” modifier.

• A0428HH – Ambulance service, BLS, non-emergency transport, hospital to hospital transfer

• A0426HH – Ambulance service, ALS 1, non-emergency transport, hospital to hospital transfer

• A0429HH – Ambulance service, BLS, emergency transport, hospital to hospital transfer

• A0427HH – Ambulance service, ALS 1, emergency transport, hospital to hospital transfer

• A0433HH – Ambulance service, ALS 2, emergency transport, hospital to hospital transfer

Transport from a hospital capable of treating the participant because the participant and/or the participant’s family or the participant's physician prefer a specific hospital is not a covered service.

DECEASED PARTICIPANTS

An individual is considered to have expired as of the time the individual is pronounced dead by a person who is legally authorized to make such a pronouncement, usually a physician.

• If the participant was pronounced dead before the ambulance was called, no payment is made by MO HealthNet.

• If the participant was pronounced dead after the ambulance was called but prior to arrival at the scene, payment may only be made for mileage from the base to the point of pickup. Transport from point of pickup to destination is not payable; the base rate is not reimbursable.

• If the participant was pronounced after the ambulance arrived on the scene but prior to transport and life saving measures were performed at the scene, the base rate and mileage from base to point of pickup may be covered. ALS level 1 or 2 must be documented in the participant’s trip documentation (reference section 13.3.D of the MO HealthNet Ambulance provider manual for ALS level 1 and 2 service definitions).

• If the participant was pronounced dead while enroute to or upon arrival at the destination, the base rate and mileage from point of pickup to the destination may be covered. ALS level 1 or 2 must be documented in the participant’s trip documentation.

TRANSPORT FOR SPECIALIZED TESTING

Transporting from one hospital to another hospital and return for specialized testing and/or treatment is covered for ground ambulance. One base charge is payable even though two separate trips or waiting time may be involved. The appropriate place of service when billing for specialized testing and/or treatment is 21 (inpatient hospital) since the hospital is both the point of pickup and final estination after receiving services at the diagnostic or therapeutic site. Mileage may be billed if participant transport from point of pickup to the destination and back is more than five miles. Use procedure code A0428HD to bill for transportation for specialized testing and/or treatment.

Transport from one medical facility to another for specialized testing and/or treatment is non-covered for emergency air ambulance services.

Effect of Beneficiary Death on Program Payment for Air Ambulance Transports

Coverage Guidelines for Ambulance Service Claims

Ambulance Billing Mandatory Assignment Requirements

Implementation of the Ambulance Fee Schedule

Lab Code For Drug Testing and Incorporation of Revalidation Policies

what is Advanced Life Support, Level 1 (ALS1)

What is 2-midnight rule and how to calculate it?

Specialty Care Transport (SCT) and Paramedic Intercept (PI)

Ambulance Service (Ground Ambulance) Coverage Guidance

What document provider to prepare when admit patient if Medicare ask for audit?

Guidance on Hospital Inpatient Admission Decisions

Hospitals Must Start Medicare EHR Participation in 2015 to Earn Incentives

Non emergency transportation CPT codes

Prior Authorization Initiatives Repetitive Scheduled Non-Emergent Ambulance Transport

Nearest Appropriate hospital - Ambulance benifit limitation

Physician Signature Requirements for Diagnostic Testing

Ambulance service CPT code list

Would insurance cover if two trips on same DOS

Hospital to Hospital ambulance service CPT codes A0428, A0433 , HH modifier

Would insurance cover Deceased patient ambulance service