Physician Documentation Information in ambulance billing

June 15, 2016, 1:31 am

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This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page. Applicable codes: A0021, A0080, A0090, A0100, A0110, A0120, A0130, A0140, A0160, A0170, A0180, A0190, A0200, A0210, A0225, A0380, A0382, A0384, A0390, A0392, A0394, A0396, A0398, A0420, A0422, A0424, A0425, A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, A0434, A0435, A0436, A0888, A0998, A0999, S0207, S0208, S0209, S0215, S9960, S9961 All ambulance transport codes and mileage codes must be reported with both the corresponding origin and destination modifiers. BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.

Policy Guidelines

Ambulance and medical transport services are regulated by local, state and federal laws. The ambulance and medical transport services should be operated according to all applicable laws and must have all the appropriate, valid licenses and permits.

Reusable devices are considered an integral part of the general ambulance and medical transport services and are not eligible for coverage as separate services. Unusual ambulance and medical transport services, such as advanced life support charges, and those situa-tions involving air or sea transport should be reviewed by individual consideration.

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Does Amublance billing covered under part A ?

June 20, 2016, 1:24 am

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Summary of the Benefit

Ambulance services are covered under Medicare Part B. However, a Part B payment for an ambulance service furnished to a Medicare beneficiary is available only if the following, fundamental conditions are met:

• Actual transportation of the beneficiary occurs.

• The beneficiary is transported to an appropriate destination.

• The transportation by ambulance must be medically necessary, i.e., the beneficiary’s medical condition is such that other forms of transportation are medically contraindicated.

• The ambulance provider/supplier meets all applicable vehicle, staffing, billing, and reporting requirements.

• The transportation is not part of a Part A service.

Other requirements specified in this chapter or in the above-cited CMS Manuals may also apply to the provider/supplier or to a particular transport or billing.

Payment Rules

Medicare covered ambulance services are paid based on the Medicare ambulance fee schedule.

The following subsections describe how contractors calculate the payment amount. Section 20.1 and its subsections describe how the payment amount is calculated for the fee schedule. The other subsections in §20 provide information on certain components of the payment amount (e.g., mileage) or specialized payment amounts (e.g., air ambulance).

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How to report total charges on UB 04 WITH example

June 22, 2016, 12:32 am

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H. Total Charges Reporting

For line items reflecting HCPCS codes A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434;

Providers are required to report in Total Charges the actual charge for the ambulance service including all supplies used for the ambulance trip but excluding the charge for mileage. For line items reflecting HCPCS code A0380, A0390, A0435, or A0436, report the actual charge for mileage.

NOTE: There are instances where the provider does not incur any cost for mileage, e.g., if the beneficiary is pronounced dead after the ambulance is called but before the ambulance arrives at the scene. In these situations, providers report the base rate ambulance trip and mileage as separate revenue code lines. Providers report the base rate ambulance trip in accordance with current billing requirements. For purposes of reporting mileage, they must report the appropriate HCPCS code, modifiers, and units as a separate line item. For the related charges, providers report $1.00 in FL48 for non- covered charges. A/B MACs (A) should assign remittance adjustment Group Code OA to the $1.00 non- covered mileage line, which in turn informs the beneficiaries and providers that they each have no liability.

Prior to submitting the claim to CWF, the A/B MAC (A) will remove the entire revenue code line containing the mileage amount reported in Non-covered Charges to avoid non-acceptance of the claim.

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

EXAMPLES: The following provides examples of how bills for Part B ambulance services should be completed based on the reporting requirements above. These examples reflect ambulance services furnished directly by providers. Ambulance services provided under arrangement between the provider and an ambulance company are reported in the same manner except providers report a QM modifier instead of a QN modifier.

EXAMPLE 1: Claim containing only one ambulance trip:

For the hard copy CMS-1450 Form, providers report as follows:

Revenue Code HCPCS/ Modifiers Date of Service Units Total Charges

0540 A0428RHQN 082701 1 (trip) 100.00

0540 A0380RHQN 082701 4 (mileage) 8.00

EXAMPLE 2: Claim containing multiple ambulance trips:

For the hard copy Form CMS-1450, providers report as follows:

0540 A0429 RH QN 082801 1 (trip) 100.00

0540 A0380 RH QN 082801 2 (mileage) 4.00

0540 A0330 RH QN 082901 1 (trip) 400.00

0540 A0390 RH QN 082901 3 (mileage) 6.00

EXAMPLE 3: Claim containing more than one ambulance trip provided on the same day:

For the hard copy CMS-1450, providers report as follows:

0540 A0429 RH QN 090201 1 (trip) 100.00

0540 A0380 RH QN 090201 2 (mileage) 4.00

0540 A0429 HR QN 090201 1 (trip) 100.00

0540 A0380 HR QN 090201 2 (mileage) 4.00

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DOS and POint of Pickup, Provider in Ambulance billing ? Definition

June 25, 2016, 1:28 am

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Definitions

Most of the definitions previously found in this chapter can now be found in IOM Pub. 100-02, Medicare Benefit Policy Manual, chapter 10 - Ambulance Services. Other definitions pertaining to payment and claims processing follow.

A/B MAC (A)

Definition: For the purposes of this chapter only, the term refers to those contractors that process claims for institutionally-based ambulance providers billed on the ASC X12 837 institutional claim transaction or Form CMS-1450.

A/B MAC (B)

Definition: For the purposes of this chapter only, the term refers to those contractors that process claims for ambulance suppliers billed on the ASC X12 837professional claim transaction or a CMS-1500 form.

Date of Service

Definition: The date of service (DOS) of an ambulance service is the date that the loaded ambulance vehicle departs the point of pickup. In the case of a ground transport, if the beneficiary is pronounced dead after the vehicle is dispatched but before the (now deceased) beneficiary is loaded into the vehicle, the DOS is the date of the vehicle’s dispatch. In the case of an air transport, if the beneficiary is pronounced dead after the aircraft takes off to pick up the beneficiary, the DOS is the date of the vehicle’s takeoff.

Point of Pickup (POP)

Definition: Point of pickup is the location of the beneficiary at the time he or she is placed on board the ambulance.

Application: The ZIP Code of the POP must be reported on each claim for ambulance services so that the correct Geographic Adjustment Factor (GAF) and Rural Adjustment Factor (RAF) may be applied, as appropriate.

Provider
Definition: For the purposes of this chapter only, the term “provider” is used to reference a hospital-based ambulance provider which is owned and/or operated by a hospital, critical access hospital, skilled nursing facility, comprehensive outpatient rehabilitation facility, home health agency, hospice program, or, for purposes of section 1814(g) and section 1835(e), a fund.

Supplier

Definition: For the purposes of this chapter, the term supplier is defined as any ambulance service that is not institutionally based. A supplier can be an independently owned and operated ambulance service company, a volunteer fire and/or ambulance company, a local government run firehouse based ambulance, etc., that provides Part B Medicare covered ambulance services and is enrolled as an independent ambulance supplier.

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HCPCS Codes Reporting on Form CMS-1450

June 27, 2016, 12:32 am

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Providers report the HCPCS codes established for the ambulance fee schedule. No other HCPCS codes are acceptable for the reporting of ambulance services and mileage. The HCPCS code must be used to reflect the type of service the beneficiary received, not the type of vehicle used.

Providers must report one of the following HCPCS codes in FL 44 “HCPCS/Rates” for each base rate ambulance trip provided during the billing period:

A0426;

A0427;

A0428;

A0429;

A0430;

A0431;

A0432;

A0433; or

A0434.

These are the same codes required effective for services January 1, 2001.

In addition, providers must report one of HCPCS mileage codes:

A0425;

A0435; or

A0436.

Since billing requirements do not allow for more than one HCPCS code to be reported per revenue code line, providers must report revenue code 540 (ambulance) on two separate and consecutive line items to accommodate both the 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.

For Form CMS-1450 claims submission prior to August 1, 2011, providers code one mile for trips less than a mile. Miles must be entered as whole numbers. If a trip has a fraction of a mile, round up to the nearest whole number.

Beginning with dates of service on or after January 1, 2011, for Form CMS-1450 hard copy claims submissions August 1, 2011 and after, mileage must be reported as fractional units. When reporting fractional mileage, providers must round the total miles up to the nearest tenth of a mile and the decimal must be used in the appropriate place (e.g., 99.9).

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

For electronic claims submissions prior to January 1, 2011, providers code one mile for trips less than a mile. Miles must be entered as whole numbers. If a trip has a fraction of a mile, round up to the nearest whole number.

Beginning with dates of service on or after January 1, 2011, for electronic claim submissions only, mileage must be reported as fractional units for trips totaling up to 100 covered miles. When reporting fractional mileage, providers must round the total miles up to the nearest tenth of a mile and the decimal must be used in the appropriate place (e.g., 99.9).

For trips totaling 100 covered miles and greater, providers must report mileage rounded up to the nearest whole number mile (e.g., 999) and not use a decimal when reporting whole number miles over 100 miles.

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

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Ambulance Fee schedule

June 30, 2016, 1:45 am

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Payment Under the Ambulance Fee Schedule

Payment under the fee schedule for ambulance services:

• Includes a base rate payment plus a separate payment for mileage;

• Covers both the transport of the beneficiary to the nearest appropriate facility and all items and services associated with such transport; and

• Does not include a separate payment for items and services furnished under the ambulance benefit.
Payment for items and services is included in the fee schedule payment. Such items and services include but are not limited to oxygen, drugs, extra attendants, and EKG testing (e.g., ancillary services) - but only when such items and services are both medically necessary and covered by Medicare under the ambulance benefit.

For additional information on the fee schedule, contractors may refer to the “Ambulance Services Center” on the CMS Web site at http://www.cms.hhs.gov/center/ambulance.asp.

Jurisdiction

Claims jurisdiction for suppliers is considered to be where the ambulance vehicle is garaged or hangared. Claims jurisdiction for institutional based providers is based on the primary location of the institution.

Services Provided

Payment is based on the level of service provided, not on the vehicle used. Occasionally, local jurisdictions require the dispatch of an ambulance that is above the level of service that ends up being provided to the Medicare beneficiary. In this, as in most instances, Medicare pays only for the level of service provided, and then only when the service provided is medically necessary.

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Modifier and Units reporting on CMS 1450 FORM

July 3, 2016, 12:36 am

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C. Modifier Reporting

Providers must report an origin and destination modifier for each ambulance trip provided and either a QM (Ambulance service provided under arrangement by a provider of services) or QN (Ambulance service furnished directly by a provider of services) modifier in FL 44 “HCPCS/Rates".

D. Service Units Reporting

For line items reflecting HCPCS codes A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434, providers are required to report in “Service Units” for each ambulance trip provided. Therefore, the service units for each occurrence of these HCPCS codes are always equal to one. In addition, for line items reflecting HCPCS code A0425, A0435, or A0436, providers must also report the number of loaded miles.

E. Total Charges Reporting

For line items reflecting HCPCS codes A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434, providers are required to report in Total Charges the actual charge for the ambulance service including all supplies used for the ambulance trip, but excluding the charge for mileage.

For line items reflecting HCPCS codes A0425, A0435, or A0436, providers are to report the actual charge for mileage.

NOTE: There are instances where the provider does not incur any cost for mileage, e.g., if the beneficiary is pronounced dead after the ambulance is called but before the ambulance arrives at the scene. In these situations, providers report the base rate ambulance trip and mileage as separate revenue code lines. Providers report the base rate ambulance trip in accordance with current billing requirements. For purposes of reporting mileage, they must report the appropriate HCPCS code, modifiers, and units. For the related charges, providers report $1.00 in non-covered charges. A/B MACs (A) should assign remittance adjustment Group Code OA to the $1.00 non-covered mileage line, which in turn informs the beneficiaries and providers that they each have no liability.

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Components of the Ambulance Fee Schedule - Part 1

July 5, 2016, 1:56 am

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The mileage rates provided in this section are the base rates that are adjusted by the yearly ambulance inflation factor (AIF). The payment amount under the fee schedule is determined as follows:

• For ground ambulance services, the fee schedule amount includes:

1. A money amount that serves as a nationally uniform base rate, called a “conversion factor” (CF), for all ground ambulance services;

2. A relative value unit (RVU) assigned to each type of ground ambulance service;

3. A geographic adjustment factor (GAF) for each ambulance fee schedule locality area (geographic practice cost index (GPCI));

4. A nationally uniform loaded mileage rate;

5. An additional amount for certain mileage for a rural point-of-pickup; and

6. For specified temporary periods, certain additional payment amounts as described in section

• For air ambulance services, the fee schedule amount includes:

1. A nationally uniform base rate for fixed wing and a nationally uniform base rate for rotary wing;

2. A geographic adjustment factor (GAF) for each ambulance fee schedule locality area (GPCI);

3. A nationally uniform loaded mileage rate for each type of air service; and

4. A rural adjustment to the base rate and mileage for services furnished for a rural point-of-pickup.

A. Ground Ambulance Services

1. Conversion Factor

The conversion factor (CF) is a money amount used to develop a base rate for each category of ground ambulance service. The CF is updated annually by the ambulance inflation factor and for other reasons as necessary.

2. Relative Value Units

Relative value units (RVUs) set a numeric value for ambulance services relative to the value of a base level ambulance service. Since there are marked differences in resources necessary to furnish the various levels of ground ambulance services, different levels of payment are appropriate for the various levels of service. The different payment amounts are based on level of service. An RVU expresses the constant multiplier for a particular type of service (including, where appropriate, an emergency response). An RVU of 1.00 is assigned to the BLS of ground service, e.g., BLS has an RVU of 1; higher RVU values are assigned to the other types of ground ambulance services, which require more service than BLS.

The RVUs are as follows:

Service Level RVU

BLS 1.00

BLS - Emergency 1.60

ALS1 1.20

ALS1- Emergency 1.90

ALS2 2.75

SCT 3.25

PI 1.75

3. Geographic Adjustment Factor (GAF)

The GAF is one of two factors intended to address regional differences in the cost of furnishing ambulance services. The GAF for the ambulance FS uses the non-facility practice expense (PE) of the geographic practice cost index (GPCI) of the Medicare physician fee schedule to adjust payment to account for regional differences. Thus, the geographic areas applicable to the ambulance FS are the same as those used for the physician fee schedule.

The location where the beneficiary was put into the ambulance (POP) establishes which GPCI applies. For multiple vehicle transports, each leg of the transport is separately evaluated for the applicable GPCI. Thus, for the second (or any subsequent) leg of a transport, the POP establishes the applicable GPCI for that portion of the ambulance transport.

For ground ambulance services, the applicable GPCI is multiplied by 70 percent of the base rate. Again, the base rate for each category of ground ambulance services is the CF multiplied by the applicable RVU. The GPCI is not applied to the ground mileage rate.

4. Mileage

In the context of all payment instructions, the term “mileage” refers to loaded mileage. The ambulance FS provides a separate payment amount for mileage. The mileage rate per statute mile applies for all types of ground ambulance services, except Paramedic Intercept, and is provided to all Medicare contractors electronically by CMS as part of the ambulance FS. Providers and suppliers must report all medically necessary mileage, including the mileage subject to a rural adjustment, in a single line item.

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When provider can submit to PART B - SNF Ambulance claims

July 8, 2016, 12:41 am

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SNF Billing

The following ambulance transportation and related ambulance services for residents in Part A stays are not included in the PPS rate. They may be billed as Part B services by the supplier only in the following situations:

• The ambulance trip is to the SNF for admission (the second character (destination) of any ambulance HCPCS code modifier is N (SNF) other than modifier QN, and the date of service is the same as the SNF 21X admission date.)

• The ambulance trip is from the SNF to home (the first character (origin) of any HCPCS code ambulance modifier is N (SNF)), and date of ambulance service is the same date as the SNF through date, and the SNF patient status (FL 22) is other than 30.)

• The ambulance trip is to a hospital based or non-hospital based ESRD facility (either one of any HCPCS code ambulance modifier codes is G (Hospital based dialysis facility) or J (Non-hospital based dialysis facility).

• The ambulance trip is from the SNF to another SNF (the first and second character (origin and destination) of any ambulance HCPCS code modifier is “N” (SNF)) and the beneficiary is not in a Part A stay.

Ambulance payment associated with the following outpatient hospital service exclusions is paid under the ambulance fee schedule:

• Cardiac catheterization;

• Computerized axial tomography (CT) scans;

• Magnetic resonance imaging (MRIs);

• Ambulatory surgery involving the use of an operating room, including the insertion, removal, or replacement of a percutaneous esophageal gastrostomy (PEG) tube in the hospital’s gastrointestinal (GI) or endoscopy suite;

• Emergency services;

• Angiography;

• Lymphatic and Venous Procedures; and

• Radiation therapy.

The following ambulance transportation and related ambulance services for residents in a Part A stay are included in the SNF PPS rate and may not be billed as Part B services by the supplier. In these scenarios, the services provided are subject to SNF CB and the first SNF is responsible for billing the services to the A/MAC:

• A beneficiary’s transfer from one SNF to another before midnight of the same day. The first and second characters (origin and destination) of any HCPCS code ambulance modifier are “N” (SNF).

• A transport between two SNFs is not separately payable when a beneficiary is in a Part A covered SNF stay, and will result in a denial of a claim for such a transport. When billing for ambulance transports, suppliers should indicate whether the transport was part of a SNF Part A covered stay, using the appropriate origin/destination modifier (e.g., “NH” for a transport from a SNF to a hospital).

• Suppliers should bill with an “NN” origin/destination modifier when a SNF to SNF transport occurs. A transport between two SNFs is not separately payable when a beneficiary is in a Part A covered SNF stay, and will result in a denial of a claim for such a transport.

o Ambulance transports to or from a diagnostic or therapeutic site other than a hospital or renal dialysis facility (e.g., an independent diagnostic testing facility (IDTF), cancer treatment center, radiation therapy center, wound care center, etc.). The first or second character (origin or destination) of any HCPCS code ambulance modifier is “D” (Diagnostic or therapeutic site other than P or H), and the other modifier (origin or destination) is “N” (SNF).

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Components of the Ambulance Fee Schedule - Part 2

July 10, 2016, 2:04 am

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5. Adjustment for Certain Ground Mileage for Rural Points of Pickup (POP)

The payment rate is greater for certain mileage where the POP is in a rural area to account for the higher costs per ambulance trip that are typical of rural operations where fewer trips are made in any given period.

Ambulance billing definiton

If the POP is a rural ZIP Code, the following calculations should be used to determine the rural adjustment portion of the payment allowance. For loaded miles 1-17, the rural adjustment for ground mileage is 1.5 times the rural mileage allowance.

For services furnished during the period July 1, 2004 through December 31, 2008, a 25 percent increase is applied to the appropriate ambulance FS mileage rate to each mile of a transport (both urban and rural POP) that exceeds 50 miles (i.e., mile 51 and greater).

The following chart summarizes the above information:

Service Dates of Service Bonus Calculation

Loaded miles 1-17, Rural POP Beginning 4/1/02 50% FS Rural mileage * 1.5

Loaded miles 18-50, Rural POP 4/1/02 – 12/31/03 25% FS Rural mileage * 1.25

All loaded miles 7/1/04 – 12/31/08 25% FS Urban or Rural

(Urban or Rural POP) 51+ mileage * 1.25

The POP, as identified by ZIP Code, establishes whether a rural adjustment applies to a particular service. Each leg of a multi-leg transport is separately evaluated for a rural adjustment application. Thus, for the second (or any subsequent) leg of a transport, the ZIP Code of the POP establishes whether a rural adjustment applies to such second (or subsequent) transport.

For the purpose of all categories of ground ambulance services except paramedic intercept, a rural area is defined as a U.S. Postal Service (USPS) ZIP Code that is located, in whole or in part, outside of either a Metropolitan Statistical Area (MSA) or in New England, a New England County Metropolitan Area (NECMA), or is an area wholly within an MSA or NECMA that has been identified as rural under the “Goldsmith modification.” (The Goldsmith modification establishes an operational definition of rural areas within large counties that contain one or more metropolitan areas. The Goldsmith areas are so isolated by distance or physical features that they are more rural than urban in character and lack easy geographic access to health services.)

For Paramedic Intercept, an area is a rural area if:

• It is designated as a rural area by any law or regulation of a State;

• It is located outside of an MSA or NECMA; or

• It is located in a rural census tract of an MSA as determined under the most recent Goldsmith modification.

http://www.ambulancebillingtips.com/2010/10/ambulance-billing-abbreviation-term.html Ambulance Services, section 30.1.1 – Ground Ambulance Services for coverage requirements for the Paramedic Intercept benefit. Presently, only the State of New York meets these requirements.

Although a transport with a POP located in a rural area is subject to a rural adjustment for mileage, Medicare still pays the lesser of the billed charge or the applicable FS amount for mileage. Thus, when rural mileage is involved, the contractor compares the calculated FS rural mileage payment rate to the provider’s/supplier’s actual charge for mileage and pays the lesser amount.

The CMS furnishes the ambulance FS files to claims processing contractors electronically. A version of the Ambulance Fee Schedule is also posted to the CMS website (http://www.cms.hhs.gov/AmbulanceFeeSchedule/02_afspuf.asp) for public consumption. To clarify whether a particular ZIP Code is rural or urban, please refer to the most recent version of the Medicare supplied ZIP Code file.

6. Regional Ambulance FS Payment Rate Floor for Ground Ambulance Transports

For services furnished during the period July 1, 2004 through December 31, 2009, the base rate portion of the payment under the ambulance FS for ground ambulance transports is subject to a minimum amount. This minimum amount depends upon the area of the country in which the service is furnished. The country is divided into 9 census divisions and each of the census divisions has a regional FS that is constructed using the same methodology as the national FS. Where the regional FS is greater than the national FS, the base rates for ground ambulance transports are determined by a blend of the national rate and the regional rate in accordance with the following schedule:

Year National FS Percentage Regional FS Percentage

7/1/04 - 12/31/04 20% 80%

CY 2005 40% 60%

CY 2006 60% 40%

CY 2007 – CY 2009 80% 20%

CY 2010 and thereafter 100% 0%

Where the regional FS is not greater than the national FS, there is no blending and only the national FS applies. Note that this provision affects only the FS portion of the blended transition payment rate. This floor amount is calculated by CMS centrally and is incorporated into the FS amount that appears in the FS file maintained by CMS and downloaded by CMS contractors. There is no calculation to be done by the Medicare B/MAC or A/MAC in order to implement this provision.

7. Adjustments for FS Payment Rate for Certain Rural Ground Ambulance Transports

For services furnished during the period July 1, 2004 through December 31, 2010, the base rate portion of the payment under the FS for ground ambulance transports furnished in certain rural areas is increased by a percentage amount determined by CMS . Section 3105 (c) and 10311 (c) of the Affordable Care Act amended section 1834 (1) (13) (A) of the Act to extend this rural bonus for an additional year through December 31, 2010. This increase applies if the POP is in a rural county (or Goldsmith area) that is comprised by the lowest quartile by population of all such rural areas arrayed by population density. CMS will determine this bonus amount and the designated POP rural ZIP Codes in which the bonus applies. Beginning on July 1, 2004, rural areas qualifying for the additional bonus amount will be identified with a “B” indicator on the national ZIP Code file. Contractors must apply the additional rural bonus amount as a multiplier to the base rate portion of the FS payment for all ground transports originating in the designated POP ZIP Codes.

Subsequently, section of 106 (c) of the MMEA again amended section 1843 (l) (13) (A) of the Act to extend the rural bonus an additional year, through December 31, 2011.

8. Adjustments for FS Payment Rates for Ground Ambulance Transports

The payment rates under the FS for ground ambulance transports (both the fee schedule base rates and the mileage amounts) are increased for services furnished during the period July 1, 2004 through December 31, 2006 as well as July 1, 2008 through December 31, 2010. For ground ambulance transport services furnished where the POP is urban, the rates are increased by 1 percent for claims with dates of service July 1, 2004 through December 31, 2006 in accordance with Section 414 of the Medicare Modernization Act (MMA) of 2004 and by 2 percent for claims with dates of service July 1, 2008 through December 31, 2010 in accordance with Section 146(a) of the Medicare Improvements for Patients and Providers Act of 2008 and Sections 3105(a) and 10311(a) of the Patient Protection and Affordable Care Act (ACA) of 2010. For ground ambulance transport services furnished where the POP is rural, the rates are increased by 2 percent for claims with dates of service July 1, 2004 through December 31, 2006 in accordance with Section 414 of the Medicare Modernization Act (MMA) of 2004 and by 3 percent for claims with dates of service July 1, 2008 through December 31, 2010 in accordance with Section 146(a) of the Medicare Improvements for Patients and Providers Act of 2008 and Sections 3105(a) and 10311(a) of the Patient Protection and Affordable Care Act (ACA) of 2010. Subsequently, section 106 (a) of the Medicare and Medicaid Extenders Act of 2010 (MMEA) again amended section 1834 (1) (12) (A) of the Act to extend the payment increases for an additional year, through December 31, 2011. These amounts are incorporated into the fee schedule amounts that appear in the Ambulance FS file maintained by CMS and downloaded by CMS contractors. There is no calculation to be done by the Medicare carrier or intermediary in order to implement this provision.

The following chart summarizes the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 payment changes for ground ambulance services that became effective on July 1, 2004 as well as the Medicare Improvement for Patients and Providers Act (MIPPA) of 2008 changes that became effective July 1, 2008 and were extended by the Patient Protection and Affordable Care Act of 2010 and the Medicare and Medicaid Extenders Act of 2010 (MMEA).

Summary Chart of Additional Payments for Ground Ambulance Services Provided by MMA, MIPPA and MMEA

Service Effective Dates Payment Increase*

All rural miles 7/1/04 - 12/31/06 2%

All rural miles 7/1/08 – 12/31/11 3%

Rural miles 51+ 7/1/04 - 12/31/08 25% **

All urban miles 7/1/04 - 12/31/06 1%

All urban miles 7/1/08 – 12/31/11 2%

Urban miles 51+ 7/1/04 - 12/31/08 25% **

All rural base rates 7/1/04 - 12/31/06 2%

All rural base rates 7/1/08 – 12/31/11 3%

Rural base rates (lowest quartile) 7/1/04 - 12/31/11 22.6 %**

All urban base rates 7/1/04 - 12/31/06 1%

All urban base rates 7/1/08 – 12/31/11 2%

All base rates (regional fee schedule blend) 7/1/04 - 12/31/09 Floor

NOTES: * All payments are percentage increases and all are cumulative.

**Contractor systems perform this calculation. All other increases are incorporated into the CMS Medicare Ambulance FS file.

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Basics of Air Ambulance billing

July 15, 2016, 2:07 am

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Air Ambulance Services

1. Base Rates

Each type of air ambulance service has a base rate. There is no conversion factor (CF) applicable to air ambulance services.

2. Geographic Adjustment Factor (GAF)

The GAF, as described above for ground ambulance services, is also used for air ambulance services. However, for air ambulance services, the applicable GPCI is applied to 50 percent of each of the base rates (fixed and rotary wing).

3. Mileage

The FS for air ambulance services provides a separate payment for mileage.

4. Adjustment for Services Furnished in Rural Areas

The payment rates for air ambulance services where the POP is in a rural area are greater than in an urban area. For air ambulance services (fixed or rotary wing), the rural adjustment is an increase of 50 percent to the unadjusted FS amount, e.g., the applicable air service base rate multiplied by the GAF plus the mileage amount or, in other words, 1.5 times both the applicable air service base rate and the total mileage amount.

The basis for a rural adjustment for air ambulance services is determined in the same manner as for ground services. That is, whether the POP is within a rural ZIP Code as described above for ground services.

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Limitation of payment on Ambulance services

July 20, 2016, 8:38 am

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Limitations

** The medical condition of the beneficiary must necessitate ambulance transportation.

Emergency situations in which services are performed after the providers response to the onset of a medical condition manifested by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in one of the following:

o Place the beneficiary's health in serious jeopardy

o Seriously impair bodily functions; or

o Result in serious dysfunction of any bodily organ or part

** Trips that could have been scheduled are not considered emergencies.

Nonemergency transportation when the beneficiary's condition is such that a car or van cannot be used, e.g.:

o Beneficiary unconscious

o Beneficiary cannot sit up

o Oxygen or other life support required

o Extreme obesity or position of cast(s)

o Restraints required

Ambulance transportation for a deceased person is covered only if the person was pronounced dead while enroute to or upon arrival at destination. If the person was pronounced dead after the ambulance was called, but before pickup, the service to the point of pickup is covered. When an ambulance responds to a 911 call that is determined upon patient assessment to be nonemergent and the patient is transported, the ambulance provider must bill one of the nonemergency ambulance transportation procedure codes.
Emergency 911 calls that do not result in transporting the patient are not covered and may be billed to the patient.

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Indian Health Service (IHS)/Tribal Billing

July 23, 2016, 12:46 am

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Ambulance services furnished by IHS/Tribal hospitals including Critical Access Hospitals (CAHs) will be paid according to the appropriate payment methodology.

For dates of service on or after December 21, 2000 and prior to January 1, 2004, medically necessary ambulance services furnished by an IHS/Tribal CAH or by an entity that is owned and operated by an IHS/Tribal CAH are paid based on 100 percent of the reasonable cost if the 35 mile rule for cost-based payment is met. In order for the 35 mile rule to be met, the IHS/Tribal CAH or the entity that is owned and operated by the IHS/Tribal CAH, must be the only provider or supplier of ambulance services that is located within a 35 mile drive of the IHS/Tribal CAH or the entity. Those CAHs that meet the 35 mile rule for cost-based payment shall report condition code B2 (CAH ambulance attestation) on their bills.

For dates of service on or after January 1, 2004, ambulance services furnished by an IHS/Tribal CAH or by an entity that is owned and operated by an IHS/Tribal CAH are paid based on 101 percent of the reasonable cost if the 35 mile rule for cost-based payment is met.

When the 35 mile rule for cost-based payment is not met, the IHS/Tribal CAH ambulance service or the ambulance service furnished by the entity that is owned and operated by the IHS/Tribal CAH is paid based on the ambulance fee schedule.

Other IHS/Tribal hospital based ambulance services are reimbursed based on the ambulance fee schedule.

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CPT code A0431 and A0430

July 25, 2016, 2:50 am

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CPT A0431

A0431 its a HCPCS code. Ambulance service, conventional air services, transport, one way (rotary wing) (RW).

The Healthcare Common Prodecure Coding System (HCPCS) is a collection of codes that represent procedures, supplies, produts and services which may be provided to Medicare beneficiaries and to indivisuals enrolled in private health insurance programs.

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

Emergency Fix Wing Air Ambulance (A0430) and Emergency Rotary Air Ambulance (A0431)

Emergency Air Ambulance rate calculation:

1. “Both Fixed Wing and Rotary Air Ambulance claims will paid using the following State Plan rates:

a. Mile “1” = $586.00 Additional Miles = $13.00

Example: Trip was for 83 loaded miles. First (1) mile = $ 586.00 82 miles x $13.00 = $1,066.00 Total charge $1,652.00

2. For your convenience an Emergency Air Ambulance State Plan rate table is listed on page 4. The rate table is calculated up to 200 miles. DO NOT use rate table for trips over 200 miles. You would be adding in the base rate twice. Trips over 200 miles can be calculated by adding the rate of $3,173.00 for 200 miles plus $13.00 per mile over 200.

Note: All claims must have attachments that include ambulance Pre-hospital Patient Care Report (PPCR) that establish medical necessity for emergency ground service. Beginning and ending mileage must be included on PPCR.

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Non-covered Charges on Institutional Ambulance Claims

July 27, 2016, 12:50 am

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Medicare law contains a restriction that miles beyond the closest available facility cannot be billed to Medicare. Non-covered miles beyond the closest facility are billed with HCPCS procedure code A0888 (“non-covered ambulance mileage per mile, e.g., for miles traveled beyond the closest appropriate facility”). These non-covered line items can be billed on claims also containing covered charges. Ambulance claims may use the –GY modifier on line items for such non-covered mileage, and liability for the service will be assigned correctly to the beneficiary.

The method of billing all miles for the same trip, with covered and non-covered portions, on the same claim is preferable in this scenario. However, billing the non-covered mileage using condition code 21 claims is also permitted, if desired, as long as all line items on the claims are non-covered and the beneficiary is liable. Additionally, unless requested by the beneficiary or required by specific Medicare policy, services excluded by statute do not have to be billed to Medicare.

When the scenario is point of pick up outside the United States, including U.S. territories but excepting some points in Canada and Mexico in some cases, mileage is also statutorily excluded from Medicare coverage. Such billings are more likely to be submitted on entirely non-covered claims using condition code 21. This scenario requires the use of a different message on the Medicare Summary Notice (MSN) sent to beneficiaries.

Another scenario in which billing non-covered mileage to Medicare may occur is when the beneficiary dies after the ambulance has been called but before the ambulance arrives. The –QL modifier should be used on the base rate line in this scenario, in place of origin and destination modifiers, and the line is submitted with covered charges. The –QL modifier should also be used on the accompanying mileage line, if submitted, with non-covered charges. Submitting this non-covered mileage line is optional for providers.

Non-covered charges may also apply is if there is a subsidy of mileage charges that are never charged to Medicare. Because there are no charges for Medicare to share in, the only billing option is to submit non-covered charges, if the provider bills Medicare at all (it is not required in such cases). These non-covered charges are unallowable, and should not be considered in settlement of cost reports. However, there is a difference in billing if such charges are subsidized, but otherwise would normally be charged to Medicare as the primary payer. In this latter case, CMS examination of existing rules relating to grants policy since October 1983, supported by
Federal regulations (42CFR 405.423), generally requires providers to reduce their costs by the amount of grants and gifts restricted to pay for such costs. Thereafter, section 405.423 was deleted from the regulations.

Thus, providers were no longer required to reduce their costs for restricted grants and gifts, and charges tied to such grants/gifts/subsidies should be submitted as covered charges. This is in keeping with Congress’s intent to encourage hospital philanthropy, allowing the provider receiving the subsidy to use it, and also requiring Medicare to share in the unreduced cost. Treatment of subsidized charges as non-covered Medicare charges serves to reduce Medicare payment on the Medicare cost report contrary to the 1983 change in policy.

Medicare requires the use of the –TQ modifier so that CMS can track the instances of the subsidy scenario for non-covered charges. The –TQ should be used whether the subsidizing entity is governmental or voluntary. The -TQ modifier is not required in the case of covered charges submitted when a subsidy has been made, but charges are still normally made to Medicare as the primary payer.

If providers believe they have been significantly or materially penalized in the past by the failure of their cost reports to consider covered charges occurring in the subsidy case, since Medicare had previous billing instructions that stated all charges in the case of a subsidy, not just charges when the entity providing the subsidy never charges another entity/primary payer, should be submitted as non-covered charges, they may contact their FI about reopening the reports in question for which the time period in 42 CFR 405.1885 has not expired. FIs have the discretion to determine if the amount in question warrants reopening. The CMS does not expect many such cases to occur.

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AMBULANCE FEE SCHEDULE FILE RECORD DESCRIPTION

July 30, 2016, 11:36 pm

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CMS will also provide contractors with a national Ambulance FS file that will contain payment amounts for the applicable HCPCS codes. The file will include FS payment amounts by locality for all FS localities. The FS file will be available via the CMS Mainframe Telecommunications System. Contractors are responsible for retrieving this file when it becomes available. The full FS amount will be included in this file. CMS will notify contractors of updates to the FS and when the updated files will be available for retrieval. CMS will send a full-replacement file for annual updates and for any other updates that may occur.

The following is a record layout of the Ambulance Fee Schedule file:

Field Name Position Format Description

HCPCS 1-5 X(5) Level 2 HCPCs code number for the service.

Carrier Number 6-10 X(5) Contractor Number

Locality Code 11-12 X(2) Identification of Pricing Locality

RVU 13-18 9(4)V2 Relative Value Units set a numeric value for ambulance services relative to the value of a base level ambulance service.

GPCI (PE) 19-22 9V3 The GPCI for the practice expense portion of the Medicare physician fee schedule is used to adjust payment to account for regional differences.

Base Rate 23-29 9(5)V2 A nationally uniform “base” amount used to calculate each HCPCS’ payment amount.

Urban Rate 30-36 9(5)V2 Urban Ground/Air mileage rate.

Rural Rate 37-43 9(5)V2 Rural Ground/Air mileage rate.

Current Year 44-47 x(4) 4 digit current effective year.

Current Quarter 48-48 x(1) 1 digit current effective quarter: 1=January, 2=April, 3=July, 4 =October.

Current Date 49-56 x(8) Current Effective Start Date.

Filler 57-80 X(26) Future use

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What is Ambulatory Infusion - CPT CODE 99601, 99602

August 3, 2016, 2:39 am

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Ambulatory infusion services include the administration of drug therapy by infusion or inhalation and related services, under the supervision of a licensed health care professional to ambulatory patients in the a room or office at an organization’s site, which has been designated as an ambulatory infusion suite. All ambulatory infusion service providers submit claims utilizing a CMS-1500 form.
Specific billing requirements by place service are:

Ambulatory Infusion Suite

o Place of service 11 for services rendered in an Ambulatory Infusion Suite AIS

o SS modifier to be billed with nursing service (99601 and/or 99602)

o Appropriate home infusion per diem HCPCS

o Appropriate HCPCS for medication administered/infused

Note: Self-administered medication; medications covered by a member’s pharmacy benefit; durable medical equipment, medical supplies and/or disposable supplies are not separately reimbursable.

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Air Ambulance billing basic - CPT cod A0430, A0431

August 5, 2016, 11:42 pm

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Air Ambulance

Ambulance Services, section 10.4 – Air Ambulance Services, and section 30.1.2 – Definitions of Air Ambulance Services for additional information on the coverage and definitions of air ambulance services. Under certain circumstances, transportation by airplane or helicopter may qualify as covered ambulance services. If the conditions of coverage are met, payment may be made for the air ambulance services.

Air ambulance services are paid at different rates according to two air ambulance categories:

• AIR ambulance service, conventional air services, transport, one way, fixed wing (FW) (HCPCS code A0430)

• AIR ambulance service, conventional air services, transport, one way, rotary wing (RW) (HCPCS code A0431)

Covered air ambulance mileage services are paid when the appropriate HCPCS code is reported on the claim:

• HCPCS code A0435 identifies FIXED WING AIR MILEAGE

• HCPCS code A0436 identifies ROTARY WING AIR MILEAGE

Effective for claims with dates of service on or after January 1, 2011, air mileage must be reported in fractional numbers of loaded statute miles flown. Contractors must ensure that the appropriate air transport code is used with the appropriate mileage code.

Air ambulance services may be paid only for ambulance services to a hospital. Other destinations e.g., skilled nursing facility, a physician’s office, or a patient’s home may not be paid air ambulance. The destination is identified by the use of an appropriate modifier as defined in Section 30(A) of this chapter.

Claims for air transports may account for all mileage from the point of pickup, including where applicable: ramp to taxiway, taxiway to runway, takeoff run, air miles, roll out upon landing, and taxiing after landing. Additional air mileage may be allowed by the contractor in situations where additional mileage is incurred, due to circumstances beyond the pilot’s control. These circumstances include, but are not limited to, the following:

• Military base and other restricted zones, air-defense zones, and similar FAA restrictions and prohibitions;

• Hazardous weather; or

• Variances in departure patterns and clearance routes required by an air traffic controller.

If the air transport meets the criteria for medical necessity, Medicare pays the actual miles flown for legitimate reasons as determined by the Medicare contractor, once the Medicare beneficiary is loaded onto the air ambulance.

IOM Pub. 100-08, Medicare Program Integrity Manual, chapter 6 – Intermediary MR Guidelines for Specific Services contains instructions for Medical Review of Air Ambulance Services

Contractor Determination of Fee Schedule Amounts

The FS amount is determined by the FS locality, based on the POP of the ZIP Code. Use the ZIP Code of the POP to electronically crosswalk to the appropriate FS amount. All ZIP Codes on the ZIP Code file are urban unless identified as rural by the letter “R” or the letter “B.” Contractors determine the FS amount as follows:

• If an urban ZIP Code is reported with a ground or air HCPCS code, the contractors determine the amount for the service by using the FS amount for the urban base rate. To determine the amount for mileage, multiply the number of reported miles by the urban mileage rate.

• If a rural ZIP Code is reported with a ground HCPCS code, the contractor determines the amount for the service by using the FS amount for the rural base rate. To determine the amount for mileage, contractors must use the following formula:

o For services furnished on or after July 1, 2004, for rural miles 1-17, the rate equals 1.5 times the rural ground mileage rate per mile. Therefore, multiply 1.5 times the rural mileage rate amount on the FS to derive the appropriate FS rate per mile;

o For services furnished during the period July 1, 2004 through December 31, 2008, for all ground miles greater than 50 (i.e., miles 51+), the FS rate equals 1.25 times the applicable mileage rate (urban or rural). Therefore, multiply 1.25 times the urban or rural, as appropriate, mileage rate amount on the FS to derive the appropriate FS rate per mile.

? If a rural ZIP Code is reported with an air HCPCS code, the contractor determines the FS amount for the service by using the FS amount for rural air base rate. To determine the amount allowable for the mileage, multiply the number of loaded miles by the rural air mileage rate.

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Modifiers used in Ambualnce billing

August 10, 2016, 11:55 pm

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General Billing Guidelines

Independent ambulance suppliers may bill on the ASC X12 837 professional claim transaction or the CMS-1500 form. These claims are processed using the Multi-Carrier System (MCS).

nstitution based ambulance providers may bill on the ASC X12 837 institutional claim transaction or Form CMS 1450. These claims are processed using the Fiscal Intermediary Shared System (FISS).

A. Modifiers Specific to Ambulance Service Claims

For ambulance service claims, institutional-based providers and suppliers must report an origin and destination modifier for each ambulance trip provided in HCPCS/Rates. Origin and destination modifiers used for ambulance services are created by combining two alpha characters. Each alpha character, with the exception of “X”, represents an origin code or a destination code. The pair of alpha codes creates one modifier. The first position alpha code equals origin; the second position alpha code equals destination. Origin and destination codes and their descriptions are listed below:

D = Diagnostic or therapeutic site other than P or H when these are used as origin codes;

E = Residential, domiciliary, custodial facility (other than 1819 facility);

G = Hospital based ESRD facility;

H = Hospital;

I = Site of transfer (e.g. airport or helicopter pad) between modes of ambulance transport;

J = Freestanding ESRD facility;

N = Skilled nursing facility;

P = Physician’s office;

R = Residence;

S = Scene of accident or acute event;

X = Intermediate stop at physician’s office on way to hospital (destination code only)

In addition, institutional-based providers must report one of the following modifiers with every HCPCS code to describe whether the service was provided under arrangement or directly:

QM - Ambulance service provided under arrangement by a provider of services; or

QN - Ambulance service furnished directly by a provider of services.

While combinations of these items may duplicate other HCPCS modifiers, when billed with an ambulance transportation code, the reported modifiers can only indicate origin/destination.

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UHC insurance coverage for ambulance service

August 13, 2016, 7:39 am

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Emergency Ambulance (Ground, Water, or Air):

Coverage includes Emergency ambulance transportation (including wait time and treatment at the scene) by a licensed ambulance service from the location of the sudden illness or injury, to the nearest hospital where Emergency health services can be performed.
Check enrollee specific benefit document for prior authorization and notification requirements.

The following Emergency ambulance services are covered:

1. Ground ambulance or air ambulance transportation requiring basic life support or advanced life support.

2. Treatment at the scene (paramedic services) without ambulance transportation.

3. Wait time associated with covered ambulance transportation.

4. To a hospital that provides a required higher level of care that was not available at the original hospital.

Air Ambulance:

As a general guideline, when it would take a ground ambulance 30-60 minutes or more to transport an enrollee whose medical condition at the time of pick-up required immediate and rapid transport due to the nature and/or severity of the enrollee’s illness/injury, air transportation may be appropriate.

Air ambulance transportation should meet the following criteria;

1. The patient’s destination is an acute care hospital, and

2. The patient’s condition is such that the ground ambulance (basic or advanced life support) would endanger the enrollee’s life or health, or

3. Inaccessibility to ground ambulance transport or extended length of time required to transport the patient via ground ambulance transportation could endanger the enrollee, or

4. Weather or traffic conditions make ground ambulance transportation impractical, impossible, or overly time consuming.

Refer to #4 (Medicare Benefit Policy Manual) in the References section below.

Additional Information:

• For covered Emergency ambulance, supplies that are needed for advanced life support or basic life support to stabilize a patient’s medical condition are covered under the ambulance benefit.

Non-Emergency Ambulance (Ground or Air) Between Facilities:

Coverage includes non-Emergency ambulance transportation by a licensed ambulance service (either ground or air ambulance), between health care facilities when the ambulance transportation is any of the following:

1. From a non-network hospital to a network hospital

2. To a hospital that provides a required higher level of care that was not available at the original hospital

3. To a more cost-effective acute care facility

4. From an acute facility to a sub-acute setting.

Cost Effective Alternatives (UHIC 2007 COC and 2009 Amendment):

If an alternate method of ambulance transportation is clinically appropriate and more cost effective, we reserve the right to adjust the amount of eligible expenses. As we determine to be appropriate, the coverage determination is based on the enrollee’s medical condition, and geographic location.

Medically Necessary (UHIC 2011 COC):

Non-Emergency ambulance transportation is medically necessary when the patient's condition requires treatment at another facility and when another mode of transportation would endanger the patient’s medical condition. If another mode of transportation could be used safely and effectively, then ambulance transportation is not medically necessary.

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