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CPT COD A0100 - Non emergency transport - T2001

April 20, 2016, 8:43 am
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Non Emergenty Transportation providers

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.

Service 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 POS 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 Minutes. Yes No POS 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 POS 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 POS 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) POS 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 POS 99
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How ZIP code determines the Fee schedule amounts

April 22, 2016, 2:17 am
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ZIP Code Determines Fee Schedule Amounts


The POP determines the basis for payment under the FS, and the POP is reported by its 5-digit ZIP Code. Thus, the ZIP Code of the POP determines both the applicable GPCI and whether a rural adjustment applies. If the ambulance transport required a second or subsequent leg, then the ZIP Code of the POP of the second or subsequent leg determines both the applicable GPCI for such leg and whether a rural adjustment applies to such leg. Accordingly, the ZIP Code of the POP must be reported on every claim to determine both the correct GPCI and, if applicable, any rural adjustment. Part B contractors must report the POP ZIP Code, at the line item level, to CWF when they report all other ambulance claim information. CWF must report the POP ZIP Code to the national claims history file, along with the rest of the ambulance claims record.


A. No ZIP Code

In areas without an apparent ZIP Code, it is the provider’s/supplier’s responsibility to confirm that the POP does not have a ZIP Code that has been assigned by the USPS. If the provider/supplier has made a good-faith effort to confirm that no ZIP Code for the POP exists, it may use the ZIP Code nearest to the POP.

Providers and suppliers should document their confirmation with the USPS, or other authoritative source, that the POP does not have an assigned ZIP Code and annotate the claim to indicate that a surrogate ZIP Code has been used (e.g., “Surrogate ZIP Code; POP in No-ZIP”). Providers and suppliers should maintain this documentation and provide it to their contractor upon request.

Contractors must request additional documentation from providers/suppliers when a claim submitted using a surrogate ZIP Code does not contain sufficient information to determine that the ZIP Code does not exist for the POP. They must investigate and report any claims submitted with an inappropriate and/or falsified surrogate ZIP Code.

If the ZIP Code entered on the claim is not in the CMS-supplied ZIP Code File, manually verify the ZIP Code to identify a potential coding error on the claim or a new ZIP Code established by the U.S. Postal Service (USPS). ZIP Code information may be found at the USPS Web site at http://www.usps.com/, or other commercially available sources of ZIP Code information may be consulted.

• If this process validates the ZIP Code, the claim may be processed. All such ZIP Codes are to be considered urban ZIP Codes until CMS determines that the code should be designated as rural, unless the contractor exercises its discretion to designate the ZIP Code as rural. (See Section §20.1.5.B – New ZIP Codes)


• If this process does not validate the ZIP Code, the claim must be rejected as unprocessable using message N53 on the remittance advice in conjunction with reason code 16.


B. New ZIP Codes

New ZIP Codes are considered urban until CMS determines that the ZIP Code is located in a rural area. Thus, until a ZIP Code is added to the Medicare ZIP Code file with a rural designation, it will be considered an urban ZIP Code. However, despite the default designation of new ZIP Codes as urban, contractors have discretion to determine that a new ZIP Code is rural until designated otherwise. If the contractor designates a new ZIP Code as rural, and CMS later changes the designation to urban, then the contractor, as well as any provider or supplier paid for mileage or for air services with a rural adjustment, will be held harmless for this adjustment.

Providers and suppliers should annotate claims using a new ZIP Code with a remark to that effect. Providers and suppliers should maintain documentation of the new ZIP Code and provide it to their contractor upon request.

If the provider or supplier believes that a new ZIP Code that the contractor has designated as urban should be designated as rural (under the standard established by the Medicare FS regulation), it may request an adjustment from the A/MAC or appeal the determination with the B/MAC, as applicable, in accordance with standard procedures.

When processing a claim with a POP ZIP Code that is not on the Medicare ZIP Code file, contractors must search the USPS Web site at http://www.usps.com/, other governmental Web sites, and commercial Web sites, to validate the new ZIP Code. (The Census Bureau Web site located at http://www.census.gov/ contains a list of valid ZIP Codes.) If the ZIP Code cannot be validated using the USPS Web site or other authoritative source such as the Census Bureau Web site, reject the claim as unprocessable.


C. Inaccurate ZIP Codes

If providers and suppliers knowingly and willfully report a surrogate ZIP Code because they do not know the proper ZIP Code, they may be engaging in abusive and/or potentially fraudulent billing. Furthermore, a provider or supplier that specifies a surrogate rural ZIP Code on a claim when not appropriate to do so for the purpose of receiving a higher payment than would have been paid otherwise, may be committing abuse and/or potential fraud.

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Covered POS and Modfier list on Ambulance service

April 25, 2016, 12:15 am
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PLACE OF SERVICE (POS) CODES

The POS code must be one of the following:

21 – Inpatient hospital

23 – Emergency room – hospital

26 – Military treatment facility

51 – Inpatient psychiatric facility

55 – Residential substance abuse treatment facility

56 – Psychiatric residential treatment center

61 – Comprehensive inpatient rehabilitation hospital


Please keep the following in mind when submitting claims:

• HCY services are not limited to the above places of service

• POS codes 55, 56, and 61 are not valid for air transport

• POS codes 41 (land) and 42 (air/water) are Medicare codes and not valid MO HealthNet POS codes


VALID AMBULANCE MODIFIERS

EP – HCY services for participants under 21 years of age

GM – Ground transport for multiple participants

HH – Hospital to hospital transfer

HD – Specialized testing and treatment

SC – Medically necessary service or supply
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Claim Outside US - What is the paymnet in Ambulance billing

April 27, 2016, 11:24 pm
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 Claims Outside of the U.S.

The following policy applies to claims outside of the U.S.:

• Ground transports with pickup and drop off points within Canada or Mexico will be paid at the fee associated with the U.S. ZIP Code that is closest to the POP;

• For water transport from the territorial waters of the U.S., the fee associated with the U.S. port of entry ZIP Code will be paid;

• Ground transports with pickup within Canada or Mexico to the U.S. will be paid at the fee associated with the U.S. ZIP Code at the point of entry; and

• Fees associated with the U.S. border port of entry ZIP Codes will be paid for air transport from areas outside the U.S. to the U.S. for covered claims.

As discussed more fully below, CMS will provide contractors with a file of ZIP Codes that will map to the appropriate geographic location and, where appropriate, with a rural designation identified with the letter “R” or “B.” Urban ZIP Codes are identified with a blank in this position.

Payment for Mileage Charges

Charges for mileage must be based on loaded mileage only, e.g., from the pickup of a patient to his/her arrival at destination. It is presumed that all unloaded mileage costs are taken into account when a supplier establishes his basic charge for ambulance services and his rate for loaded mileage. Suppliers should be notified that separate charges for unloaded mileage will be denied.
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Ambulance claim - What form to use for claim submission

May 5, 2016, 8:33 am
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Introduction to the CMS-1500 Claim Form

Ambulance providers must use the CMS-1500 red claim form (unless submitting electronically) when requesting payment for medical services and supplies provided under the KHPA Medical Plans. Any claim not submitted on the red claim from will be returned to the provider. The Kansas MMIS will be using electronic imaging and optical character recognition (OCR) equipment. Therefore, information will not be recognized if not submitted in the correct fields as instructed.

SUBMISSION OF CLAIM

Send completed first page of each claim and any necessary attachments to:
KHPA Medical Plans
Office of the Fiscal Agent
P.O. Box 3571
Topeka, Kansas 66601-3571



HIPAA Compliance

As a participant in the KHPA Medical Plans, providers are required to comply with compliance reviews and complaint investigations conducted by the Secretary of the Department of Health and Human Services as part of the Health Insurance Portability and Accountability Act (HIPAA) in accordance with section 45 of the code of regulations parts 160 and 164. Providers are required to furnish the Department of Health and Human Services all information required by the Department during its review and investigation. The provider is required to provide the same forms of access to records to the Medicaid Fraud and Abuse Division of the Kansas Attorney General's Office upon request from such office as required by K.S.A. 21-3853 and amendments thereto.

A provider who receives such a request for access to or inspection of documents and records must promptly and reasonably comply with access to the records and facility at reasonable times and places. A provider must not obstruct any audit, review or investigation, including the relevant questioning of employees of the provider. The provider shall not charge a fee for retrieving and copying documents and records related to compliance reviews and complaint investigations.

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Ambulance Inflation Factor (AIF)

May 8, 2016, 11:46 pm
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Section 1834(l)(3)(B) of the Social Security Act (the Act) provides the basis for an update to the payment limits for ambulance services that is equal to the percentage increase in the consumer price index for all urban consumers (CPI-U) for the 12-month period ending with June of the previous year. Section 3401 of the Affordable Care Act amended Section 1834(l)(3) of the Act to apply a productivity adjustment to this update equal to the 10-year moving average of changes in economy-wide private nonfarm business multi-factor productivity beginning January 1, 2011. The resulting update percentage is referred to as the Ambulance Inflation Factor (AIF). These updated percentages are issued via Recurring Update Notifications.

Part B coinsurance and deductible requirements apply to payments under the ambulance fee schedule.

Following is a chart tracking the history of the AIF:

CY       AIF
2003    1.1
2004    2.1
2005    3.3
2006    2.5
2007    4.3
2008    2.7
2009    5.0
2010    0.0
2011    -0.1
2012    2.4
2013    0.8
2014    1.0
2015    1.5
2016   -0.4


Documentation Requirements


In all cases, the appropriate documentation must be kept on file and, upon request, presented to the contractor. 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.



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Ambulance billing covered CPT Codes and how much copay would be collected - Medicaid patient

May 10, 2016, 8:36 am
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BENEFITS AND LIMITATIONS

KMAP beneficiaries will be assigned to one or more benefit plans. These benefit plans entitle the beneficiary to certain services. If there are questions about service coverage for a given benefit plan, refer to Section 2000 of the General Benefits Provider Manual for information on the plastic State of Kansas Medical Card and eligibility verification.

For example, only the following emergency transportation procedure codes are covered under the MediKan program. See Appendix I of the Ambulance Provider Manual for a full listing description of services.

A0225               A0380                A0390                A0427                 A0429                          A0430
A0431              A0433                 A0434               A0435                  A0436


Covered Services

** Emergency ambulance transportation provided by Basic Life Support (BLS)/Advanced Life Support (ALS) services

** Nonemergency ambulance transportation with the exception of adult care home residents (see page 8-4) for the following:

o Discharge from hospital to residence or other less expensive care

o Trips from residence to closest available medically necessary services

o Trips from one institution to another to receive a medical service not available in the first institution

** Supplies

** Waiting Time


BENEFITS AND LIMITATIONS

Nonemergency ambulance transportation requires a copayment from the beneficiary of $3 per date of service. When procedure A0426 or A0428 is billed in conjunction with one of the other nonemergency procedure codes (such as S0215) for the same dates of services, copayment will be collected from the beneficiary only once.

Bill all services occurring on the same date on the same claim form. If multiple claims are submitted for the same date(s) of service, the $3 copayment requirement will be deducted for each claim submitted. Do not reduce the charges or balance due by the copayment amount. This reduction will be made automatically during claim processing.
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Payment for Non-Emergency Trips to/from ESRD Facilities - CPT code A0428

May 13, 2016, 11:51 pm
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Effective for transports occurring on and after October 1, 2013, fee schedule payments for non-emergency basic life support (BLS) transports of individuals with end-stage renal disease (ESRD) to and from renal dialysis treatment be reduced by 10%. The payment reduction affects transports (base rate and mileage) to and from hospital-based and freestanding renal dialysis treatment facilities for dialysis services provided on a non-emergency basis. Non-emergency BLS ground transports are identified by Healthcare Common Procedure Code System (HCPCS) code A0428. Ambulance transports to and from renal dialysis treatment are identified by modifier codes “G” (hospital-based ESRD) and “J” (freestanding ESRD facility) in either the first position (origin code) or second position (destination code) within the two-digit ambulance modifier. (See Section 30 (A) for information regarding modifiers specific to ambulance.)

Effective for claims with dates of service on and after October 1, 2013, the 10% reduction will be calculated and applied to HCPCS code A0428 when billed with modifier code“G” or “J”. The reduction will also be applied to any mileage billed in association with a non-emergency transport of a beneficiary with ESRD to and from renal dialysis treatment. BLS mileage is identified by HCPCS code

A0428 

The 10% reduction will be taken after calculation of the normal fee schedule payment amount, including any add-on or bonus payments, and will apply to transports in rural and urban areas as well as areas designated as “super rural”.

Payment for emergency transports is not affected by this reduction. Payment for non-emergency BLS transports to other destinations is also not affected. This reduction does not affect or change the Ambulance Fee Schedule.

Note: The 10% reduction applies to beneficiaries with ESRD that are receiving non-emergency BLS transport to and from renal dialysis treatment. While it is possible that a beneficiary who is not diagnosed with ESRD will require routine transport to and from renal dialysis treatment, it is highly unlikely. However, contractors have discretion to override or reverse the reduction on appeal if they deem it appropriate based on supporting documentation.
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EMERGENCY AMBULANCE vs. Non Emergency TRANSPORTS

May 15, 2016, 12:16 am
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When participants are transported by ambulance to an emergency room for treatment and then released without admission to the hospital, the return trip is not covered under the MO HealthNet Emergency Ambulance program. Return trips to the nursing home when the participant has been discharged from a hospital stay are also not covered under the Emergency Ambulance program, 13 CSR 70-6.010(6). Additional transports not covered in the Emergency Ambulance program include:

• transportation to a physician or dentist's office or a participant's home;

• ambulance services to a hospital for the first stage of labor; or,

• transport of a participant pronounced dead before the ambulance is called.


Transport by ambulance may be covered under the Non-Emergency Medical
Transportation (NEMT) program for eligible participants if it is the most appropriate mode of transportation based on the participant's medical needs. Hospital staff, nursing home staff, social workers, case managers, family members and other related parties
may call the NEMT broker for MO HealthNet toll free at 1-866-269-5927 to arrange nonemergency medical transportation to and from medical providers for eligible participants. NEMT services are available 24 hours per day, 7 days per week. To provide adequate time for NEMT services to be arranged, a participant or someone calling on their behalf should call at least five (5) calendar days in advance. For hospital discharges it may require up to three (3) hours to arrange the appropriate mode of transportation.


Neither the participant nor MO HealthNet is responsible for payment if physicians, hospital staff, or others arrange ambulance transports for non-emergency trips that are covered under the NEMT program without authorization from the NEMT broker.

Missouri Code of State Regulations 13 CSR 70-4.030 (2) states a "service will not be the liability of the participant if the service would have been otherwise payable by the MO HealthNet agency at the MO HealthNet allowable amount had the provider followed all of the policies, procedures and rules applicable to the service as of the date provided."


The NEMT broker provides the most appropriate mode of transportation based on the patient's medical needs. If a patient is confined to a bed but does not require anymedical equipment or medical attention en route, a stretcher van may be authorized. If the patient required medical attention or equipment en route, an ambulance will be authorized. When arranging non-emergency medical transportation, notify the NEMT broker if the patient is bed confined and whether or not medical attention or equipment is needed. For more information on the NEMT program and all modes of transportation under NEMT, please refer to section 22 of any MO HealthNet provider manual located on the MHD web site.
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Ambulance CPT CODE FULL list

May 18, 2016, 11:58 pm
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HCPCS Codes

The following codes and definitions are effective for billing ambulance services on or after January 1, 2001.


AMBULANCE HCPCS CODES AND DEFINITIONS

HCPCS Code                                         Description of HCPCS Codes

A0425                   BLS mileage (per mile)

A0425                      ALS mileage (per mile)

A0426               Ambulance service, Advanced Life Support (ALS), non-emergency transport, Level 1

A0427              Ambulance service, ALS, emergency transport, Level 1

A0428        Ambulance service, Basic Life Support (BLS), non-emergency transport

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

A0430               Ambulance service, conventional air services, transport, one way, fixed wing (FW)

A0431             Ambulance service, conventional air services, transport, one way, rotary wing (RW)

A0432          Paramedic ALS intercept (PI), rural area transport furnished by a volunteer ambulance company,                                                       which is prohibited by state law from billing third party payers.

A0433            Ambulance service, advanced life support, level 2 (ALS2)

A0434             Ambulance service, specialty care transport (SCT)

A0435               Air mileage; FW, (per statute mile)

A0436            Air mileage; RW, (per statute mile)



NOTE: PI, ALS2, SCT, FW, and RW assume an emergency condition and do not require an emergency designator.

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Ambulance Services Requiring Medical Necessity

May 20, 2016, 8:43 am
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Medical necessity documentation (see Section 4100 of the General Special Requirements Provider Manual) must be attached to the claim form when billing for nonemergency transports, waiting time, multiple patients on one ambulance trip, and air ambulance transportation. When the beneficiary is Kansas Medical Assistance Program (KMAP) eligible plus qualified Medicare
beneficiary (QMB), and Medicare allows the service, medical necessity (MN) need not be attached to the claim. However, it must be available in the provider's file. The documentation must be printed and legible.

MN for nonemergency ambulance transportation must state the reason the trip is required (hospital discharge or medical service) and the medical reason the beneficiary could not be transported by car or van.

MN for air ambulance transportation must indicate the beneficiary's medical condition required immediate and rapid ambulance transportation that could not have been provided by land ambulance and one of the following:

** The point of pickup is inaccessible by land vehicle.

** Great distances or other obstacles are involved in getting the beneficiary to the nearest hospital with appropriate facilities.
** The beneficiary's condition is such that the time needed to transport by land, or the instability of transportation by land, poses a threat to the beneficiary's survival or seriously endangers the beneficiary's health.

If a determination is made that transport by ambulance was necessary, however, land ambulance service would have sufficed, payment for the air ambulance service will be the lesser of the billed charges and the maximum allowable for ground ambulance.

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Importance of Origin and Milage in Ambulance billing - Where to report zip CODE box 23

May 23, 2016, 12:09 am
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Origin

Electronic billers should refer to the Implementation Guide to determine how to report the origin information (e.g., the ZIP Code of the point of pickup). Beginning with the early implementation of version 5010 of the ASC X12 837 professional claim format on January 1, 2011, electronic billers are required to submit, in addition to the loaded ambulance trip’s origin information (e.g., the ZIP Code of the point of pickup), the loaded ambulance trip’s destination information (e.g., the ZIP code of the point of drop-off). Refer to the appropriate Implementation Guide to determine how to report the destination information. Only the ZIP Code of the point of pickup will be used to adjudicate and price the ambulance claim, not the point of drop-off. However, the point of drop-off is an additional reporting requirement on version 5010 of the ASC X12 837 professional claim format.


Where the CMS-1500 Form is used the ZIP code is reported in item 23. Since the ZIP Code is used for pricing, more than one ambulance service may be reported on the same paper claim for a beneficiary if all points of pickup have the same ZIP Code. Suppliers must prepare a separate paper claim for each trip if the points of pickup are located in different ZIP Codes.

Claims without a ZIP Code in item 23 on the CMS-1500 Form item 23, or with multiple ZIP Codes in item 23, must be returned as unprocessable. A/B MACs (B) use message N53 on the remittance advice in conjunction with reason code 16.

ZIP Codes must be edited for validity.

The format for a ZIP Code is five numerics. If a nine-digit ZIP Code is submitted, the last four digits are ignored. If the data submitted in the required field does not match that format, the claim is rejected.

Mileage

Generally, each ambulance trip will require two lines of coding, e.g., one line for the service and one line for the mileage. Suppliers who do not bill mileage would have one line of code for the service.

Beginning with dates of service on or after January 1, 2011, mileage billed must be reported as fractional units in the following situations:

• Where billing is by ASC X12 claims transaction (professional or institutional), and

• Where billing is by CMS-1500 paper form.

Electronic billers should see the appropriate Implementation Guide to determine where to report the fractional units. Item 24G of the Form CMS-1500 paper claim is used.

Fractional units are not required on Form CMS-1450

For trips totaling up to 100 covered miles suppliers must round the total miles up to the nearest tenth of a mile and report the resulting number with the appropriate HCPCS code for ambulance mileage. The decimal must be used in the appropriate place (e.g., 99.9).
For trips totaling 100 covered miles and greater, suppliers must report mileage rounded up to the next whole number mile without the use of a decimal (e.g., 998.5 miles should be reported as 999).

For trips totaling less than 1 mile, enter a “0” before the decimal (e.g., 0.9).

For mileage HCPCS billed on a the ASC X12 837 professional transaction or the CMS-1500 paper form only, contractors shall automatically default to “0.1” units when the total mileage units are missing.

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Air Ambulance Guidelines: Time and Documentation

May 25, 2016, 8:45 am
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Time: If time is a critical factor in the patient’s recovery or survival or duration of ground transport would be excessive and potentially detrimental, air transport may be indicated. In general, if the ground ambulance can arrive at the destination institution within 20 minutes, it is the preferred mode of transport.

Expertise: If the health care institution does not possess the expertise to provide the definitive care required to stabilize the patient (i.e., advanced life support) and the ground ambulance providers in the near vicinity cannot provide assistance in providing that care, air transport may be indicated.

Coverage: If ground ambulance utilization leaves the service area without adequate ground coverage and patient outcome will be compromised by arranging other ground transport, air transport may be indicated.

Documentation: The above guidelines serve as a guide to documentation which is necessary to determine proper reimbursement and must specify the indication and justification for air transport. If guidelines are not met, or are met but not documented, the billed
transportation will be reimbursed at ground ambulance rates or denied altogether.


Services Requiring Prior Authorization:

Wheelchair transportation is not considered ambulance transportation and requires prior authorization by the beneficiary's local SRS office (who also bills the service).
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Medicare payment Guideline for Multiple patient on same trip

May 28, 2016, 12:12 am
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Multiple Patients on One Trip

Ambulance suppliers submitting a claim using the ASC X12 professional format or the CMS-1500 paper form for an ambulance transport with more than one Medicare beneficiary onboard must use the “GM” modifier (“Multiple Patient on One Ambulance Trip”) for each service line item. In addition, suppliers are required to submit documentation to A/B MACs (B) to specify the particulars of a multiple patient transport. The documentation must include the total number of patients transported in the vehicle at the same time and the health insurance claim (HIC) numbers for each Medicare beneficiary. A/B/MACs (B) shall calculate payment amounts based on policy instructions found in Pub.100-02, Medicare Benefit Policy Manual, Chapter 10 – Ambulance Services, Section 10.3.10 – Multiple Patient Ambulance Transport.


Ambulance claims submitted on or after January 1, 2011 in version 5010 of the ASC X12 837 professional claim format require the presence of a diagnosis code and the absence of said diagnosis code will cause the ambulance claim to not be accepted into the claims processing system. The presence of a diagnosis code on an ambulance claim is not required as a condition of ambulance payment policy. The adjudicative process does not take into account the presence (or absence) of a diagnosis code but a diagnosis code is required on the ASC X12 837 professional claim format.


Coding Instructions for Form CMS-1491


Effective April 2, 2007, Form CMS-1491 will no longer be a valid format for submitting claims. Suppliers who wish to submit a paper claim must use CMS-1500 Form.
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Payment for Intra-facility Ambulance Transport

May 30, 2016, 1:24 am
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Medically necessary transports between provider sites will be reimbursed for the following conditions:

1. The two locations have different NPIs

OR

2. The campuses are in two different locations (a campus is defined as areas located within 250 yards of main buildings) AND the patient is not inpatient status at the time of transport.


This policy does not supersede the policy on ambulance transports during inpatient stay which states:

If a patient must be transported by ambulance to another facility for unavailable services (i.e. diagnostic tests or surgical procedures) during an acute hospital inpatient stay, the ambulance provider cannot separately bill this transport. The ambulance provider must have an arrangement with the hospital for appropriate billing and payment. The charges for the ambulance transport are considered part of the inpatient stay and are reimbursed based on the DRG.


Examples of transports eligible for payment:

• A suicidal patient is seen in a provider’s emergency room (ER) and is transported by ambulance for admission to the same provider’s psych unit located outside of the campus containing the ER or to the psych unit that has a different NPI.

• A patient seen in the clinic for physical therapy services has a stroke and requires transport to the hospital for additional care.

• A patient having a surgical procedure done in the Ambulatory Surgery Center (ASC) has a severe hemorrhage and requires transport to the hospital for additional care.

Examples of transports not eligible for separate payment:

• A patient has a procedure performed in a facility’s ASC and is transported to the same facility’s outpatient hospital for additional non-emergent care/routine post-op recovery.

• A patient who is inpatient at a hospital or unit of a hospital needs an MRI and is transported to a different location where the MRI machine is located, then transported back to the original location.



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Valuce Code reporting in Ambuance billing

June 3, 2016, 12:17 am
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 Value Code Reporting

For claims with dates of service on or after January 1, 2001, providers must report on every Part B ambulance claim value code A0 (zero) and the related ZIP Code of the geographic location from which the beneficiary was placed on board the ambulance in the Value Code field. The value code is defined as “ZIP Code of the location from which the beneficiary is initially placed on board the ambulance.” Providers report the number in dollar portion of the form location right justified to the left of the dollar/cents delimiter.

More than one ambulance trip may be reported on the same claim if the ZIP Codes of all points of pickup are the same. However, since billing requirements do not allow for value codes (ZIP Codes) to be line item specific and only one ZIP Code may be reported per claim, providers must prepare a separate claim for a beneficiary for each trip if the points of pickup are located in different ZIP Codes.
For claims with dates of service on or after April 1, 2002, providers must report value code 32 (multiple patient ambulance transport) when an ambulance transports more than one patient at a time to the same destination. Providers must report value code 32 and the number of patients transported in the amount field as a whole number to the left of the delimiter.

NOTE: Information regarding the claim form locator that corresponds to the Value Code field is found in Pub.100-04, Medicare Claims Processing Manual, chapter 25 – Completing and Processing the Form CMS-1450 Data Set.

Applicable Bill Types

The appropriate type of bill (13X, 22X, 23X, 83X, and 85X) must be reported. For SNFs, ambulance cannot be reported on a 21X type of bill.
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Ambulance billing Descripiton, policy and benefits

June 5, 2016, 1:28 am
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Description of Procedure or Service

An ambulance is a specially equipped vehicle designed and supplied with materials and devices to provide life-saving and supportive treatments or interventions during the transportation of ill or injured patients. The patient’s clinical condition is such that the use of any other method of transportation would be contraindicated. The vehicle must be designed and equipped to respond to medical emergencies and, in non-emergency situations, be capable of transporting individuals with acute medical conditions. Ambulance and medical transport services may involve ground, air or sea transport in both emergency and non-emergency situations.


Policy

BCBSNC will provide coverage for Ambulance and Medical Transport Services when they are determined to be medically necessary because the medical criteria and guidelines shown below are met.


Benefits Application

This medical policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this medical policy.

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Revenue Code/HCPCS Code Reporting - cpt code A0380,A0390, A0435

June 7, 2016, 12:23 am
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Providers must report revenue code 054X and, for services provided before January 1, 2001, one of the following CMS HCPCS codes for each ambulance trip provided during the billing period:

A0030 (discontinued 12/31/2000); A0040 (discontinued 12/31/2000);

A0050 (discontinued 12/31/2000); A0320 (discontinued 12/31/2000); A0322 (discontinued 12/31/2000); A0324 (discontinued 12/31/2000); A0326 (discontinued 12/31/2000); A0328, (discontinued 12/31/2000); or A0330 (discontinued 12/31/2000).


In addition, providers report one of A0380 or A0390 for mileage HCPCS codes. No other HCPCS codes are acceptable for reporting ambulance services and mileage. Providers report one of the following revenue codes:

0540;

0542;


0543;

0545;



0546; or

0548.


Do not report revenue codes 0541, 0544, or 0547.

For claims with dates of service on or after January 1, 2001, providers must report revenue code 540 and one of the following HCPCS codes for each ambulance trip provided during the billing period:

A0426; A0427;

A0428; A0429; A0430; A0431; A0432; A0433; or

A0434.

Providers using an ALS vehicle to furnish a BLS level of service report HCPCS code, A0426 (ALS1) or A0427 (ALS1 emergency), and are paid accordingly. In addition, all providers report one of the following mileage HCPCS codes: A0380; A0390; A0435; or A0436.

Since billing requirements do not allow for more than one HCPCS code to be reported for per revenue code line, providers must report revenue code 0540 (ambulance) on two separate and consecutive lines to accommodate both the Part B ambulance service and the mileage HCPCS codes for each ambulance trip provided during the billing period. Each loaded (e.g., a patient is onboard) 1-way ambulance trip must be reported with a unique pair of revenue code lines on the claim. Unloaded trips and mileage are NOT reported.

However, in the case where the beneficiary was pronounced dead after the ambulance is called but before the ambulance arrives at the scene: Payment may be made for a BLS service if a ground vehicle is dispatched or at the fixed wing or rotary wing base rate, as applicable, if an air ambulance is dispatched. Neither mileage nor a rural adjustment would be paid. The blended rate amount will otherwise apply. Providers report the A0428 (BLS) HCPCS code. Providers report modifier QL (Patient pronounced dead after ambulance called) in Form Locator (FL) 44 “HCPCS/Rates” instead of the origin and destination modifier. In addition to the QL modifier, providers report modifier QM or QN.


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What situation ambulance service would be covered and not covered

June 10, 2016, 1:29 am
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When Ambulance and Medical Transport Services are covered

1. Ground emergency ambulance service for the transport of a patient is considered medically necessary when all the following criteria are met:

a. The ambulance must be equipped with appropriate emergency and medical supplies and equipment;

b. The patient’s condition must be such that any other form of transportation would be medically contraindicated;

c. The patient must be transported to the nearest hospital with the appropriate facilities for the treatment of the patient’s illness or injury.

2. Non-emergency medical transport services for the transport of a hospital inpatient to another facility for specialized services are considered eligible for coverage when all of the following criteria are met:

a. The patient is a registered inpatient in an acute care hospital;

b. The specialized services are not available in the hospital in which the patient is registered Ambulance and Medical Transport Services  and those specialized services are considered reasonable, medically necessary, and covered under the members benefit plan;

c. The provider of the specialized services is the nearest one with the required capabilities.


3. Air or Sea Ambulance services may be medically necessary in exceptional circumstances. All of the criteria pertaining to ground transportation must be met, as well as one of the following additional conditions:

a. The patient’s medical condition must require immediate and rapid ambulance transport to the nearest appropriate medical facility that could not have been provided by land ambulance;

b. The point of pick-up is inaccessible by land vehicle;

c. Great distances, limited time frames, or other obstacles are involved in getting the patient to the nearest hospital with appropriate facilities for treatment;

d. The patient’s condition is such that the time needed to transport a patient by land to the nearest appropriate medical facility poses a threat to the patient’s health.


4. Ambulance or medical transport services are considered eligible for coverage if the patient is legally pronounced dead after the ambulance was called, but before pickup, or enroute to the hospital.


5. Transportation from a hospital, skilled nursing facility or rehabilitation facility to a patient’s residence when the patient’s condition requires skilled monitoring during transport with the services of an EMT attendant or other licensed healthcare practitioner.


When Ambulance and Medical Transport Services are not covered

1. When the medical guidelines shown above are not met:

2. If the patient is legally pronounced dead before the ambulance is called, the services are not considered medically necessary.

3. Transportation provided primarily for the convenience of the patient, patient’s family or physician is not covered.

4. Transportation for the purpose of receiving a service considered NOT medically necessary is also considered NOT medically necessary, even if the destination is an appropriate facility.

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DOS and unit reporting on CMS 1450 - cpt code A0030, A0040, A0322 AND A0427

June 12, 2016, 12:26 am
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F. Line-Item Dates of Service Reporting

Providers are required to report line-item dates of service per revenue code line. This means that they must report two separate revenue code lines for every ambulance trip provided during the billing period along with the date of each trip. This includes situations in which more than one ambulance service is provided to the same beneficiary on the same day. Line-item dates of service are reported in the Service Date field.

NOTE: Information regarding the claim form locator that corresponds to the Service Date is found in Pub. 100-04, Medicare Claims Processing Manual, Chapter 25 – Completing and Processing the Form CMS-1450 Data set.


G. Service Units Reporting

For line items reflecting HCPCS code A0030, A0040, A0050, A0320, A0322, A0324, A0326, A0328, or A0330 (services before January 1, 2001) or code A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434 (services on and after January 1, 2001), providers are required to report in Service Units each ambulance trip provided during the billing period. Therefore, the service units for each occurrence of these HCPCS codes are always equal to one. In addition, for line items reflecting HCPCS code A0380 or A0390, the number of loaded miles must be reported. (See examples below.)

Therefore, the service units for each occurrence of these HCPCS codes are always equal to one. In addition, for line items reflecting HCPCS code A0380, A0390, A0435, or A0436, the number of loaded miles must be reported.
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