Notification

Air Ambulance Services


Notification Issue Date: 12/02/2019

This version of the policy will become effective 01/01/2020. The intent of this policy remains unchanged; however, the policy, guidelines and description sections of the document have been revised to remove sea ambulance transport because this service has been added to policy #MA12.002b Ground Ambulance Transport Services (Emergency and Nonemergency).

In addition, the policy has been updated to convey a change in the Company’s reimbursement position for services including oxygen, drugs, disposable supplies (e.g, gauze, dressings, cervical collar), the use of extra attendants, and EKG testing from eligible for separate reimbursement to not eligible for separate reimbursement, because they are always integral to the primary ambulance service.

The following CPT code has been added to the policy:
93005

The following HCPCS codes have been added to the policy as not covered:
S9960 Ambulance service, conventional air services, nonemergency transport, one way (fixed wing)

S9961 Ambulance service, conventional air service, nonemergency transport, one way (rotary wing)

The following revenue codes have been added to the policy:
0541 Ambulance-Supplies
0544 Ambulance-Oxygen
0547 Ambulance-Pharmacy
0548 Ambulance-EKG Transmission

The following Origin and destination modifiers have been added to the policy:
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 (This is a destination code only)

The following HCPCS code has been deleted from this policy:
A0999 Unlisted ambulance service



Medicare Advantage Policy

Title:Air Ambulance Services
Policy #:MA12.007a

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

EMERGENCY TRANSPORT

In unique circumstances, air ambulance services may be considered medically necessary. In these situations, the service must be medically appropriate and meet all of the following criteria:
  • The individual's medical condition requires immediate and rapid transport that cannot be provided by land ambulance.
  • The individual's medical condition is one for which the time needed to transport by land may pose a threat to the individual's health.
  • Great distances, limited time-frames, or other obstacles are involved in transporting the individual from his or her home, scene of an accident, or medical emergency to the nearest hospital or other emergency care facility that can appropriately manage the individual's emergency.
OR
  • The point of pick-up is inaccessible by land vehicle and the individual's medical condition requires immediate and rapid transport.

In products with worldwide coverage for emergency care, emergency transport for individuals in a foreign country or in non-US territory waters may be covered to the nearest appropriate facility with the capability of treating the member’s medical condition. Once the individual is admitted to the hospital and stabilized, transport back to the US is not covered.

NON-EMERGENCY TRANSPORT

Individuals enrolled in Medicare Advantage plans are specifically limited to emergency air ambulance transport. Non-emergency air transport is considered a non-covered service by Medicare.

HOSPITAL TO HOSPITAL

Air ambulance transport may be considered medically necessary to transfer an individual from one acute care hospital to the nearest Participating Facility Provider within the member’s service area (HMO) or to a Preferred Facility Provider (PPO) within a reasonable distance, as determined by the Carrier, with the capability of treating the condition for which transfer is necessary, if transportation by land ambulance would endanger the member's health and the transferring hospital does not have adequate facilities to provide the medical services needed by the member.

MISCELLANEOUS ITEMS AND SERVICES

When the air ambulance transport is covered, miscellaneous items and services associated with the transport are also covered. However, reimbursement eligibility varies as follows:
  • Services including oxygen, drugs, disposable supplies (e.g., gauze, dressings, cervical collars), the use of extra attendants, and EKG testing are not eligible for separate reimbursement, regardless of the provider's participation status with the Company, because they are always integral to the primary ambulance service.
  • Reusable devices and equipment (e.g., backboards, inflatable splints) are not eligible for separate reimbursement, regardless of the provider's participation status with the Company, because they are always integral to the primary ambulance service.
  • Waiting time is not eligible for separate reimbursement because it is always integral to the primary ambulance service.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Policy Guidelines

The vehicle and crew utilized for air ambulance transport should meet all applicable local, state, and federal regulatory certification and licensing requirements.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, an emergency air ambulance is covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as not covered are not eligible for coverage or reimbursement by the Company.

Description

AIR AMBULANCE

There are two categories of air ambulance services: fixed wing (airplane) and rotary wing (helicopter). An air ambulance is an aircraft used for emergency medical assistance in situations where either a traditional ambulance cannot reach the scene easily or quickly enough, or the individual needs to be transported over a distance or terrain that makes air transportation the most practical transport mode. Air ambulance crews are supplied with equipment that enables them to provide medical treatment to a critically injured or ill individual.

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)(A0430)
Fixed wing air ambulance is furnished when the member’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 member’s condition requires rapid transport to a treatment facility, and either great distances or other obstacles, e.g., heavy traffic, preclude such rapid delivery to the nearest appropriate facility. Transport by fixed wing air ambulance may also be necessary because the member is inaccessible by a ground or water ambulance vehicle.

ROTARY WING AIR AMBULANCE (RW)(A0431)
Rotary wing air ambulance is furnished when the member’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 member’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 member is inaccessible by a ground or water ambulance vehicle.

Any vehicle used as an ambulance must be designed and equipped to respond to medical emergencies and, in non-emergency situations, be capable of transporting members 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. Ambulances must be staffed by at least two people, with at least one of them certified by the State or local authority at the appropriate level of first aid training.
References

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 10: Ambulance services. [CMS Web site]. (Revision #243: 4/13/2018). Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c10.pdf. Accessed April 19, 2019.

Centers for Medicare & Medicaid Services (CMS). Medicare Managed Care Manual. Chapter 4: Benefits and beneficiary protections. 130.2: Emergency and urgently needed services. [CMS Web site]. (Revision # 121: 4/22/2016). Available at: http://www.cms.hhs.gov/manuals/downloads/mc86c04.pdf. Accessed April 19, 2019.

Centers for Medicare & Medicaid Services (CMS). Medical Ambulance Transports. Effective: December 2017. Available at:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Medicare-Ambulance-Transports-Booklet-ICN903194.pdf. Accessed April 19, 2019.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual Chapter 15 – Ambulance. (Revision #4205: 01/18/19). Available at:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c15.pdf. Accessed April 19, 2019.

Evidence of Coverage.


Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

THE FOLLOWING SERVICE IS ALWAYS INTEGRAL TO THE PRIMARY AMBULANCE SERVICE AND, THEREFORE, IS NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT CONSIDERATION:

93005


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

Report the most appropriate diagnosis code in support of medically necessary criteria as listed in the policy


HCPCS Level II Code Number(s)



MEDICALLY NECESSARY

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

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

A0435 Fixed wing air mileage, per statute mile

A0436 Rotary wing air mileage, per statute mile

THE FOLLOWING SERVICES ARE ALWAYS INTEGRAL TO THE PRIMARY AMBULANCE SERVICE AND, THEREFORE, ARE NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT CONSIDERATION:

A0382 BLS routine disposable supplies

A0384 BLS specialized service disposable supplies; defibrillation (used by ALS ambulances and BLS ambulances in jurisdictions where defibrillation is permitted in BLS ambulances)

A0392 ALS specialized service disposable supplies; defibrillation (to be used only in jurisdictions where defibrillation cannot be performed by BLS ambulances)

A0394 ALS specialized service disposable supplies; IV drug therapy

A0396 ALS specialized service disposable supplies; esophageal intubation

A0398 ALS routine disposable supplies

A0420 Ambulance waiting time (ALS or BLS), one-half (1/2) hour increments

A0422 Ambulance (ALS or BLS) oxygen and oxygen supplies, life sustaining situation

A0424 Extra ambulance attendant, ground (ALS or BLS) or air (fixed or rotary winged);


NOT COVERED

A0140 Nonemergency transportation and air travel (private or commercial) intra- or interstate

S9960 Ambulance service, conventional air services, nonemergency transport, one way (fixed wing)

S9961 Ambulance service, conventional air service, nonemergency transport, one way (rotary wing)



Revenue Code Number(s)



MEDICALLY NECESSARY

0545 Ambulance-Air Ambulance


THE FOLLOWING SERVICES ARE ALWAYS INTEGRAL TO THE PRIMARY AMBULANCE SERVICE AND, THEREFORE, ARE NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT CONSIDERATION:

0541 Ambulance-Supplies
0544 Ambulance-Oxygen
0547 Ambulance-Pharmacy
0548 Ambulance-EKG Transmission




Misc Code

n/a:

ORIGIN AND DESTINATION MODIFIERS

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 (This is a destination code only)


Coding and Billing Requirements






Policy History

MA12.007a
01/01/2020This version of the policy will become effective 01/01/2020. The intent of this policy remains unchanged; however, the policy, guidelines and description sections of the document have been revised to remove sea ambulance transport because this service has been added to policy #MA12.002b Ground Ambulance Transport Services (Emergency and Nonemergency).

In addition, the policy has been updated to convey a change in the Company’s reimbursement position for services including oxygen, drugs, disposable supplies (e.g, gauze, dressings, cervical collar), the use of extra attendants, and EKG testing from eligible for separate reimbursement to not eligible for separate reimbursement, because they are always integral to the primary ambulance service.

The following CPT code has been added to the policy:
93005

The following HCPCS codes have been added to the policy as not covered:
S9960 Ambulance service, conventional air services, nonemergency transport, one way (fixed wing)

S9961 Ambulance service, conventional air service, nonemergency transport, one way (rotary wing)

The following revenue codes have been added to the policy:
0541 Ambulance-Supplies
0544 Ambulance-Oxygen
0547 Ambulance-Pharmacy
0548 Ambulance-EKG Transmission

The following Origin and destination modifiers have been added to the policy:
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 (This is a destination code only)

The following HCPCS code has been deleted from this policy:
A0999 Unlisted ambulance service

MA12.007
05/10/2017This policy has been reviewed and reissued to communicate the Company’s continuing position on emergency air or sea ambulance.
11/23/2016This policy has been reviewed and reissued to communicate the Company’s continuing position on emergency air or sea ambulance.
10/14/2015The policy has been reviewed and reissued to communicate the Company’s continuing position on emergency air or sea ambulance.
01/01/2015This is a new policy.




Version Effective Date: 01/01/2020
Version Issued Date: 12/31/2019
Version Reissued Date: N/A