Contractor Name

Wheatlands Administrative Services

Contractor Number

00650

Contractor Type

Carrier

LCD Database ID Number

L22201

LCD Title

Ambulance

Contractor’s Determination Number

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2005 American Medical Association (or such other data of publication of CPT).  All Rights Reserved.  Applicable FARS/DFARS Clauses Apply.  CDT-4 codes and descriptions are © 2002 American Dental Association.  All rights reserved.

CMS National Coverage Policy

·            Title XVIII of the Social Security Act, section 1862 (a) (7).  This section excludes routine physical examinations.

·            Title XVIII of the Social Security Act, section 1862 (a) (1) (A).  This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.

·            Title XVIII of the Social Security Act, section 1861 (s) (7).  Ambulance service where the use of other methods of transportation is contraindicated by the individual’s condition, but only to the extent provided in regulations.

·            Code of Federal Regulations §42 CFR 410.40 for coverage of ambulance services

·            Code of Federal Regulations §42 CFR 411.9 for exclusions of services furnished outside the United States

·            Federal Register: February 27, 2002 (Volume 67, Number 39) gives a Q&A of comments made on the “Proposals Based on Negotiated Rulemaking” and further defines the 3 medications needed to qualify for a ALS2 transport.

·            Medicare Benefit Policy Manual, Pub.100-2, Chapter 10, §10 for ambulance service and to include information on non-transports

·            Medicare Benefit Policy Manual, Pub.100-2, Chapter 10, §20 for coverage guidelines for ambulance service claims

·            Medicare Claims Processing Manual, Pub.100-4, Chapter 3, §110.5 for coverage requirements for emergency hospital services furnished in Canada or Mexico

·            Medicare Claims Processing Manual, Pub.100-4, Chapter 3, §110.7 for coverage of physician and ambulance services furnished outside the U.S.

·            Medicare Claims Processing Manual, Pub.100-4, Chapter 15, §10.2 for ambulance services-billing methods

·            Medicare Claims Processing Manual, Pub.100-4, Chapter 15, §10.4 for inherent reasonableness (IR) provisions for ambulance

·            Program Memorandum B-99-12, CR#783, dated March 1999 for Paramedic Intercept.

·            Program Memorandum B-00-01, CR#783, dated January 2000 for Paramedic Intercept.

·            Program Memorandum AB-00-88, CR#1281, dated September 18, 2000 for Implementation of Ambulance Fee Schedule.

·            Program Memorandum AB-00-103, CR#905 dated November 2, 2000 Final rule revising and updating Medicare policy concerning ambulance services.

·            Program Memorandum AB-00-118, CR#1461, dated November 30, 2000 for Delay of Implementation of Ambulance Fee Schedule.

·            Program Memorandum AB-00-131, CR#1476, dated December 22, 2000 for Implementation of Ambulance Fee Schedule.

·            Program Memorandum AB-01-22, CR#1542, dated February 2, 2001 Payment Limit Update for Ambulance Services

·            Program Memorandum AB-01-148, CR#1875, dated October 18, 2001 Ambulance Inflation Factor for 2002

·            Program Memorandum AB-01-165, CR#1555, dated November 14, 2001 Implementation of an ambulance fee schedule

·            Program Memorandum AB-01-184, CR#1476, dated December 13, 2001 for clarification to implementation of ambulance fee schedule

·            Program Memorandum AB-01-185, CR#1281, dated December 14, 2001 for implementation of ambulance fee schedule

·            Program Memorandum AB-02-016, CR#2014, dated February 7, 2002 for effective date of Q3017.

·            Program Memorandum AB-02-018, CR#2036 dated February 8, 2002 for first update to the 2002 Medicare fee schedule database

·            Program Memorandum AB-02-031, CR#1961, dated March 7, 2002 for payment policy for air ambulance transport of deceased beneficiary

·            Program Memorandum AB-02-033, CR#2075, dated March 15, 2002, for provider education training activities to implement updates to the ambulance fee schedule.

·            Program Memorandum AB-02-036, CR#2047, dated March 21, 2002 for temporary codes for ambulance fee schedule

·            Program Memorandum AB-02-117, CR#2303, dated August 7, 2002 gives transition schedule for implementation of the ambulance fee schedule

·            Program Memorandum AB-02-130, CR#2295, dated September 27, 2002 for definitions of ambulance services

·            Program Memorandum B-02-060, CR#1945, dated September 27, 2002 for payment policy when more than one patient is onboard an ambulance

·            Program Memorandum AB-02-148, CR#2262, dated October 25, 2002 for Remittance Advice messages for ambulance services

·            Program Memorandum B-03-045, CR#2725, dated June 6, 2003 for ICD-9-CM coding requirements for claims submitted to Medicare carriers

·            Program Memorandum AB-03-007, CR#2470, dated January 24, 2003 for second clarification of Medicare policy regarding the implementation of the ambulance fee schedule

·            Program Memorandum AB-03-106, CR#2770, dated July 25, 2003 for third clarification of Medicare policy regarding the implementation of the ambulance fee schedule

·            Program Memorandum AB-03-110, CR#2767, dated August 1, 2003 for adjustment to the rural mileage payment rate for ground ambulance services

·            Transmittal 59, CR#3035, dated January 2, 2004, gives instructions for HCPCS code A0800

·            Transmittal 163, CR#3196, dated April 30, 2004 implements a change to the processing of SNF claims for ambulance transports in a Part A stay to or from a diagnostic or therapeutic site other than physician’s office or hospital when billed separately as Part B services to the carrier.

·            Transmittal 185, CR#3212, dated May 28, 2004, notifies carriers of additional HCPCS codes for drugs and CPT codes for electrocardiogram testing

·            Transmittal 14, CR#3225, dated May 28, 2004 clarifies when payment for ambulance services is bundled into packaged prospective payment to hospitals, and when it is separately payable

·            Transmittal 220, CR#3099, dated June 25, 2004, announces the bonus amount for ambulance transports originating in low-density population areas

·            Transmittal 789, CR#4221, dated December 23, 2005, gives Ambulance Fee Schedule Medical Conditions List: Manualization – Note that use of this document does not ensure payment by this contractor.

·            Transmittal 799, CR#4217, dated December 30, 2005, gives a reminder notice of the implementation of ambulance transition schedule

·            Transmittal 806, CR#4251, dated January 6, 2006, gives termination of HCPCS codes payable during the transition to the ambulance fee schedule

·            CMS Frequently Asked Question #1559, dated January 10, 2003, concerning non-transport services

·            Transmittal 68, CR#5533, dated March 30, 2007 for Revision to the Specialty Care Transport (SCT) definition

Primary Geographic Jurisdiction

Kansas, Nebraska, N.W. Missouri

Oversight Region

Region VII

CMS Consortium

Midwest

Original Policy Effective Date

08/15/1995

Original Policy Ending Date

Revision Effective Date

08/15/2007

Revision Ending Date

Indications and Limitations of Coverage and/or Medical Necessity

Medicare will help pay for ambulance transportation by an approved ambulance service to a hospital or skilled nursing facility only when transportation by any other means could endanger the patient's health.  Under similar restrictions, Medicare B will help pay for ambulance service from a patient's home, (or other place where need arose) to a hospital or skilled nursing facility, between a hospital and a skilled nursing facility, or from a hospital or skilled nursing facility to a patient's home when other means of transportation are contraindicated. In order for an ambulance to be a covered benefit, transportation must be to the nearest institution with appropriate facilities for the treatment of the illness or injury involved.  (Medicare Benefit Policy Manual, Pub.100-2, Chapter 10, §10).  The facility should be capable of diagnosing and treating the suspected illness or injury and its potential complications.

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

Basic Life Support ambulances must be staffed by at least two people, one of whom must be certified as an emergency medical technician (EMT) by the State or local authority where the services are being furnished and be legally authorized to operate all lifesaving and life‑sustaining equipment on board the vehicle.  Advanced Life Support (ALS) vehicles must be staffed by two people with one of the two staff members certified as a paramedic or an EMT who is trained and certified, by the State or local authority where the services are being furnished, to perform one or more ALS service.  Medicare payment for ambulance transport is based on the level of service provided; not the vehicle used.

Ground Ambulance Services:

There are seven categories of ground ambulance service and two categories of air ambulance services under the fee schedule.  The term “ground” refers to both land and water transportation.

Basic Life Support (BLS)

When medically necessary, the provision of BLS services as defined in the National EMS Education and Practice Blueprint for the EMT-Basic, including the establishment of the peripheral intravenous (IV) line.

Basic Life Support (BLS)-Emergency

When medically necessary, the provision of BLS services, as specified above, in the context of an emergency response.  An emergency response is one that, at the time the ambulance supplier is called, is provided after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the beneficiary’s health in serious jeopardy; in impairment to bodily functions; or in serious dysfunction to any bodily organ or part.

Advanced Life Support, Level 1 (ALS1)

When medically necessary, the provision of an assessment by an advanced life support (ALS) provider or supplier or the provision of one or more ALS interventions.  An ALS provider/supplier is defined as a provider trained to the level of the EMT-Intermediate or Paramedic as defined in the National EMS Education and Practice Blueprint.  An ALS intervention is defined as procedure beyond the scope of an EMT-Basic.

Advanced Life Support, Level 1 (ALS1)-Emergency

When medically necessary, the provision of ALS1 services, as specified above, in the context of an emergency response.  An emergency response is one that, at the time the ambulance supplier is called, is provided after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the beneficiary’s health in serious jeopardy; in impairment to bodily functions; or in serious dysfunction to any bodily organ or part.

Advanced Life Support, Level 2 (ALS2)

When medically necessary, the administration of three or more different medications* OR the provision of at least one of the following ALS procedures:

·         Manual defibrillation/ cardioversion

·         Chest decompression

·         Endotracheal intubation

·         Surgical airway

·         Central venous line

·         Intraaosseous line

·         Cardiac pacing

*CMS further defines the three or more medications as 3 different medications or the same medication administered 3 times.

Specialty Care Transport (SCT)

When medically necessary, for a critically injured or ill beneficiary, a level of inter-facility service provided beyond the scope of the paramedic as defined in the National EMS Education and Practice Blueprint.  This is necessary when a beneficiary’s condition requires ongoing care that must be provided by one or more health professionals in an appropriate specialty area, e.g., nursing, medicine respiratory care, cardiovascular care, or a paramedic with additional training.

Paramedic Intercept (PI)

Paramedic intercept services are ALS services provided by an entity that does not provide the ambulance transport.  Under a limited number of circumstances, Medicare payment may be made for these services.  Refer to Program Memorandum B-99-12 and B-00-01 for descriptions of paramedic intercept provisions.

Air Ambulance Services:

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

Fixed Wing Air Ambulance (FW)

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

appropriate facility.  Transport by fixed wing may also be necessary because the beneficiary is inaccessible by a land or water ambulance vehicle.

Rotary Wing Air Ambulance (RW)

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

To be covered, ambulance service must be medically necessary and reasonable.  Medical necessity is established when the patient's clinical condition and ambulatory status are such that use of any other method of transportation is contraindicated.  In any case in which some means of transportation other than an ambulance could be utilized without endangering the individual's health, whether or not such other transportation is actually available, no payment may be made for the ambulance service.

Medical necessity must be clearly indicated.  Coverage will not be allowed for ambulance services if the only documentation of medical necessity is "not ambulatory".  "Not ambulatory" does not constitute sufficient documentation because it does not specify whether or not the patient could have ridden in a car in a sitting position.  (For example, a quadriplegic patient with an ingrown toenail does not require emergency transport.)

Emergency service is that service provided after the onset of a medical condition, manifested by signs or symptoms of such severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in any of the following: 1) place the patient's health in serious jeopardy; 2) serious impairment to bodily functions; or 3) serious dysfunction of any bodily organ or part.

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

A.

The vehicle and crew requirements that apply to land ambulance vehicles must be met.

B.

The beneficiary’s medical condition requires immediate and rapid ambulance transportation that cannot be provided by land ambulance in whole and in part and either:

1.

The point of pickup is inaccessible by land vehicle or

2.

Great distances or other obstacles are involved in getting the patient to the nearest hospital with appropriate facilities.

MEDICAL NECESSITY FOR EMERGENCY OR NON-EMERGENCY

AMBULANCE TRANSPORTATION: GROUND OR AIR

Ambulance transport is indicated for emergency situations and when other means of transport would be contraindicated (i.e., will further endanger the individual’s condition significantly). Medical necessity is presumed if the record adequately documents one or more of the following:

A.

Emergency Transport Services

1.

Emergency situations such as injury resulting from an accident, or illness with acute symptoms.  Examples include hemorrhage, shock, chest pain, neurologic dysfunction, respiratory distress.  (Please see ICD-9 codes on attached list).

2.

The patient requires restraints by a professionally trained ambulance attendant.  A description why restraints are required is necessary.  Examples include that the patient is violent, psychotic, convulsing, or may be harmful to themselves or others.  A simple diagnosis of senile, forgetful, Alzheimer's, etc. would not qualify.

3.

A newly developed state of altered consciousness, such as unconsciousness or unresponsiveness.  Claims for patients whose usual status is that of diminished consciousness should include documentation of the medical necessity for ambulance transport.

4.

Oxygen is required by the patient during transport.  The administration of oxygen itself does not satisfy the requirement that a patient needs ambulance transportation.  If the patient travels for any other reason (i.e., church, grocery store, shopping, etc.) with portable oxygen then they are not a candidate for ambulance transportation solely because of their oxygen requirements.  The administration of oxygen for oxygen dependent patients, unless there is an emergency situation described, does not in and of itself justify ambulance transportation.

5.

When emergency measures or treatments are indicated.  Examples include emergency drugs, IV fluids, cardiopulmonary resuscitation, cardiac monitoring, oxygen, respiratory support, control of life threatening hemorrhage.  The medical necessity needs to be well documented.

6.

Immobilization of the patient is necessary in order to prevent complications because of an unstable major fracture.  The presence of a possible major compound fracture, or the presence of severe pain, requiring immobilization or pain medication, would usually indicate the need for ambulance transport.  Minor upper extremity fractures or ankle injuries (without apparent complications) generally would not require an ambulance.  If there is suspicion of neurologic injury and head or spine immobilization is needed, ambulance transport is reasonable.

7.

A patient transfer is made between institutions to obtain necessary services not available at the transferring institution and the patient meets any of the criteria in 1-6 above.  Examples are patients with cardiac disease requiring cardiac catheterization or coronary bypass, not available at the transferring institution, or a bed is unavailable at transferring institution for a patient requiring emergency admission.

B.

Non-Emergency Transport Services

1.

For nonemergency ambulance transportation, transportation by ambulance is appropriate if the beneficiary is bed-confined and it is documented that the beneficiary’s medical condition is such that other methods of transportation are contraindicated, or if his or her medical condition, regardless of bed-confinement, is such that transportation by ambulance is medically required.  In determining whether a beneficiary is bed-confined, the following criteria must be met:

a)

unable to get up from bed without assistance,

b)

unable to ambulate; and

c)

is unable to sit in a chair or wheelchair.

2.

Any ambulance trip that does not meet the "emergency" criteria would be a non-emergency service.  This includes all scheduled runs (regardless of origin and destination), as well as transports to nursing homes or to the patient's residence.  Medically necessary transports to and from ESRD facilities for maintenance dialysis are scheduled, and therefore are non-emergency ambulance services.  (However, if the patient is in acute renal failure, it could be considered an emergency run.)

3.

On non-emergency ambulance transport, the reason for oxygen administration must be established and documented on the claim or in the free form comment section of an electronic claim.

C.

Air Ambulance

Medical appropriateness is only established when the beneficiary’s condition is such that the time to transport by land or the instability of land transportation poses a threat to the beneficiary’s survival or seriously endangers his/her health.

Establishing an ALS Transport Based on an ALS Assessment

When a BLS ambulance is dispatched and an ALS assessment is performed,the transport may be billed as ALS only for emergency transports. Medicarepays the BLS-level rate for non-emergency transports regardless of whether anALS assessment is performed.

Mandated ALS Response

During the transition period, Medicare allows the ALS-level payment for emergency and non-emergency transports when an ALS vehicle is used but no ALS service is furnished in areas where an ALS-only response is mandated.  HCPCS code Q3019 applies when an ALS vehicle is used for an emergency transport, but no ALS level service is furnished. HCPCS code Q3020 applies when an ALS vehicle is used for a non-emergency transport, but no ALS level service is furnished.  Codes Q3019 and Q3020 were deleted per Transmittal 806, CR#4251, dated January 6, 2006, effective for services on or after January 1, 2006.

Multiple patients

When more than one patient is transported in an ambulance, the Medicare allowed charge for each beneficiary is a percentage of the allowed charge for a single beneficiary transport (the “allowed charge” for a single beneficiary transport is the lower of the submitted charge and the fee schedule amount for the service – which, during the fee schedule transition period, is a blended amount.) The applicable percentage is based on the total number of patients transported, including both Medicare beneficiaries and non- Medicare patients.  This policy applies to both ground and air transports. For purposes of this PM, the term “ground transport” includes transports by water ambulance.

If two patients are transported at the same time in one ambulance to the same destination, the adjusted payment allowance for each Medicare beneficiary would equal 75 percent of the single-patient allowed amount applicable to the level of service furnished a beneficiary, plus 50 percent of the total mileage payment allowance for the entire trip. If three or more patients are transported at the same time in one ambulance to the same destination, the adjusted payment for each Medicare beneficiary would equal 60 percent of the single-patient allowed amount applicable to the level of service furnished that beneficiary plus a proportional mileage allowed amount, i.e., the total mileage allowed amount divided by the number of all the patients onboard.

The fact that the level of medically necessary service among the patients may be different is not relevant to this payment policy. The percentage is applied to the allowed amount applicable to the level of service that is medically necessary for each beneficiary. If a multi-patient transport includes multiple destinations, then the Medicare allowed amount for mileage depends upon whether it is for an emergency versus non-emergency ground transport. For an emergency ground transport, which includes BLS-E, ALS1-E, ALS2, and SCT, the mileage payment shall be based on the number of miles to the nearest appropriate facility for each patient, divided by the number of patients on board when the vehicle arrives at the facility. This formula applies cumulatively for beneficiaries who are the 2nd or 3rd patient to be delivered. Absent evidence to the contrary, carriers should assume that the sequence of deliveries was predicated on the medical needs of each patient.  For a non-emergency ground transport, which includes BLS and ALS1, the mileage payment shall be based on the number of miles from the point of pick-up to the nearest appropriate facility for each beneficiary, divided by the number of beneficiaries on board at the point of pick-up. This formula applies cumulatively for beneficiaries for multiple points of pick-up. Mileage other than the mileage that would be incurred by transporting the beneficiary directly from the point of pick-up to the nearest appropriate facility is not covered. Thus, for non-emergency transports, the extra mileage that may be incurred by

having multi-destinations shall not be taken into account.  For air transports the policy is the same as for emergency ground transports.

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

Pronouncement of Death

The following four scenarios that apply to payment for ambulance services when the beneficiary dies.

• The beneficiary is pronounced dead after the ambulance is called but before the ambulance arrived 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.  (For suppliers, there will be only one line item for this situation.)  Neither mileage nor a rural adjustment would be paid.  Suppliers continue to use the QL modifier.

• The beneficiary is pronounced dead after being loaded into the ambulance (regardless of whether the pronouncement is made during or subsequent to the transport): payment is made following the usual rules of payment as if the beneficiary had not died.  This scenario includes a determination of “dead on arrival” (DOA) at the facility to which the beneficiary was transported.

• No payment will be made if the beneficiary was pronounced dead prior to the time the ambulance is called.

• Medicare allows payment for an air ambulance service when the air ambulance takes off to pick up a Medicare beneficiary, but the beneficiary is pronounced dead before being loaded onto the ambulance (either before or after the ambulance arrives on the scene).  This is provided the air ambulance service would otherwise have been medically necessary.  In such a circumstance, the allowed amount is the appropriate air base rate, i.e. fixed wing or rotary wing.  However, no amount shall be allowed for mileage or for a rural adjustment that would have been allowed, had the transport of a living beneficiary or of a beneficiary not yet pronounced dead, been completed.

NOTE:  Notwithstanding the beneficiary’s apparent condition, the death of a beneficiary should be recognized only when the pronouncement of death is made by an individual who is licensed or otherwise authorized under State law to pronounce death in the State where such pronouncement is made.

NOTE:  No amount will be allowed for air ambulance service if the dispatcher received pronouncement of death and had a reasonable opportunity to notify the pilot to abort the flight.  Further, no amount shall be allowed if the aircraft has merely taxied, but not taken off; or, at a controlled airport, has been cleared to take off, but has not actually taken off.

Multiple Arrivals

When multiple units respond to a call for services, Medicare will pay the entity that provides the transport for the beneficiary.  The transporting entity bills for all services furnished.  For example, if BLS and ALS entities respond to a call and the BLS entity furnishes the transport after an ALS assessment was furnished, the BLS entity will bill using the ALS1 rate.  Payment will be made to the BLS entity at the ALS1 rate.  The BLS entity and the ALS entity must settle payment for the ALS assessment.

Point of Pickup Zip Code for ER pickup outside United States

For services with a point of pickup outside the United States, we will follow coverage as listed in the Medicare Intermediary Manual (MIM) §3698.4 and Code of Federal Regulations (CFR) §42 CFR 411.9.

Reasons for Non-Coverage

1.

Ambulance trip to a funeral home.

2.

Transfer from one residence to another (including domiciliary or nursing home) without medical necessity.

3.

Transfer from a hospital, which has appropriate facilities and staff for treatment to another hospital.  For example: to accommodate the patient or the family preference to receive care by a personal physician or in a facility nearer home.

4.

Transportation to a dialysis facility for routine maintenance dialysis unless bed confined  (See B 1 of the Indications & Limitations of Coverage and/or Medical Necessity section).

5.

The patient refuses to be transported.

6.

Beneficiary pronounced dead before ambulance pick-up.

IN MOST CASES, AMBULANCE SERVICES ARE NOT COVERED IF:

1.

The patient is ambulatory;

2.

The trip is a routine trip to return the patient home (when the patient had been transported to the hospital);

3.

The patient is transported from home or nursing home to the hospital outpatient department for treatment that could have been performed elsewhere (e.g., patient's home or nursing home).

4.

If a patient in a covered Part A stay within a SNF is transferred to a hospital outpatient department for tests, the transport is covered, but not separately reimbursable.  Reimbursement is included in the prospective payment for the SNF.

Comments

Title XVIII of the Social Security Act, section 1862 (a) (1) (A).  This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.  The cost of the ambulance transport was less than it would have cost to bring the service to the patient.

Coverage Topic

Ambulance Services

CPT/HCPCS Codes

A0425

Ground mileage (per statute mile)

A0426

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

A0427

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

A0428

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

A0429

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

A0430

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

A0431

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

A0432

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

A0433

Advanced life support, level 2 (ALS 2)

A0434

Specialty care transport (SCT)

A0435

Fixed wing air mileage, per statute mile

A0436

Rotary wing air mileage, per statute mile

99289

Physician constant attention of the critically ill or injured patient during an interfacility transport; first 30-74 minutes

99290

Physician constant attention of the critically ill or injured patient during an interfacility transport; each additional 30 minutes (list separately in addition to primary code)

ICD-9 Codes that Support Medical Necessity

CATEGORY I -- EMERGENCY CODES:

250.30

Diabetes with other coma; type II or unspecified type, not stated as uncontrolled

250.31

Diabetes with other coma; type I [juvenile type], not stated as uncontrolled