This version of the policy will become effective 01/01/2020.
The intent of this policy has not changed, although it has been modified to incorporate Emergency Ground Transportation services including Sea Ambulance Transport. 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 criteria for Emergency Ground Transportation was added to the policy:
EMERGENCY GROUND TRANSPORTATION
Emergency ground ambulance services with transportation is considered medically necessary and, therefore, covered when ALL of the following criteria are met:
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
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
S Scene of accident or acute event
X Intermediate stop at physician’s office on way to hospital (This is a destination code only)