Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Ground Ambulance Transport Services (Emergency and Nonemergency)
Policy #:MA12.002b

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.

Refer to the following News Articles:

Ground Ambulance Transport Services (Emergency and Nonemergency) for Medicare Advantage Members


EMERGENCY GROUND TRANSPORTATION

MEDICALLY NECESSARY
Emergency ground ambulance services with transportation is considered medically necessary and, therefore, covered when ALL of the following criteria are met:
  • The services provided are medically necessary to stabilize the individual’s medical condition.
  • The responding emergency medical services (EMS) ambulance, in accordance with state regulations, is a specially designed and equipped vehicle used to transport the sick or injured.
  • The responding EMS ambulance, in accordance with state regulations, is staffed by state certified or qualified staff who are able to provide basic life support or advanced life support services, as appropriate, at the treating location during the time of the emergency.
  • The EMS staff is able to provide assessment, monitoring, assistance, treatment and observation during transportation.
  • Transportation of the individual will be from the individual’s home, or the scene of the accident or medical emergency, to the nearest acute care hospital or other emergency care facility, where emergency health services can be provided to the individual.

Acute Care Facility to Acute Care Facility Transport of a Registered Inpatient (Emergency)

Emergency ground ambulance transport from one acute care facility of a registered inpatient to another acute care facility to obtain necessary specialized diagnostic and/or therapeutic services, is considered medically necessary and, therefore, covered when ALL of the following criteria are met:
  • There is a medical condition that is life or limb threatening, or treating personnel deem to be life or limb threatening, and the individual's condition is such that a delay in treatment poses a threat to the individual's survival or seriously endangers the individual's health, or could result in serious impairment to the individual's bodily functions and/or serious dysfunction of any of the individual's bodily organs or parts;
  • The necessary diagnostic and/or therapeutic services must be provided in the inpatient setting;
  • The necessary diagnostic and/or therapeutic services are not available at the facility in which the member is admitted.
  • The necessary diagnostic and/or therapeutic services are available at the facility to which the member is being transported.

Other Facility to Facility Transport (Emergency)

Emergency ground ambulance transport from one facility to another facility to obtain necessary specialized diagnostic and/or therapeutic services is considered medically necessary and, therefore, covered when ALL of the following criteria are met:
  • There is a medical condition that is life or limb threatening, or treating personnel deem to be life or limb threatening, and the individual's condition is such that a delay in treatment poses a threat to the individual's survival or seriously endangers the individual's health, or could result in serious impairment to the individual's bodily functions and/or serious dysfunction of any of the individual's bodily organs or parts;
  • The necessary diagnostic and/or therapeutic services are not available at the facility in which the member is located.
  • The necessary diagnostic and/or therapeutic services are available at the facility to which the member is being transported.
In products with worldwide coverage for emergency care, emergency transport of individuals in a foreign country or in non-U.S. 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 U.S. is not covered.

NONCOVERED EMERGENCY AMBULANCE SERVICES

Emergency ground ambulance services without transportation is considered not covered and, therefore, not eligible for reimbursement consideration.

NONEMERGENCY GROUND TRANSPORTATION

MEDICALLY NECESSARY
Nonemergency ground ambulance services with transportation is considered medically necessary and, therefore, covered when ALL of the following criteria (1) through (5) are met:

(1)BENEFIT

Nonemergency ambulance transport benefit requirements are met when nonemergency ambulance transport is outlined as a benefit according to the member's Evidence of Coverage. A member's Evidence of Coverage may variously limit or exclude the eligibility of the transport origin, transport destination, type of provider or transport (e.g., nonemergency ambulance transport), and/or the participation status of the transport provider. Individual member benefits must be verified.

(2)

TRANSPORT TO OBTAIN COVERED TREATMENTS OR SERVICES

This requirement is met when the nonemergency ambulance transport is requested to obtain a covered treatment or service for an individual or to return an individual from having obtained a covered treatment or service. A treatment or service is considered covered when it is identified in the member's Evidence of Coverage as a benefit and the individual meets the medical necessity criteria required to obtain the treatment or service. When a treatment or service for which an individual has a benefit does not meet medical necessity requirements, nonemergency ambulance transport for that treatment or service is not covered or eligible for reimbursement.

(3)

ORIGIN

The origin (point of ambulance pick-up) is covered when all of the following criteria are met:
  • The origin is not precluded from eligibility in the member's Evidence of Coverage.
  • The origin must be one of the following:
    • An individual's home (refer to the Description section of this policy for the definition of home)
    • An acute care facility (e.g., hospital, rehabilitation hospital)
    • An inpatient hospice
    • A skilled nursing facility
    • A dialysis facility

(4)

DESTINATION

The destination for nonemergency ambulance transport is covered when all of the following criteria are met:
  • The destination is not precluded from eligibility in the member's Evidence of Coverage.
  • The destination has the appropriate facilities to treat the individual’s condition.
  • The destination must be one of the following:
    • The individual's home (when a destination, an individual’s home is exempt from the appropriate facilities requirements)
    • An acute care facility (e.g., hospital, rehabilitation hospital)
    • An inpatient hospice
    • A skilled nursing facility
    • A dialysis facility

In addition to the above, the following destinations are covered when:
  • The transport origin is either a skilled nursing, sub-acute, or acute rehabilitation facility where the individual is being treated at a skilled level of care:
    • A physician's office
    • A free-standing facility
  • The transport origin is a skilled nursing facility where the individual is a resident and is not being treated at a skilled level of care, AND the ambulance transport is to the nearest supplier of medically necessary services (other than a physician's office or hospital) that are not available at the skilled nursing facility, such as the following diagnostic and therapeutic sites:
    • Independent diagnostic testing facility (IDTF)
    • Cancer treatment center
    • Radiation therapy center
    • Wound care center

(5)

MEDICAL NECESSITY

Medical necessity requirements for nonemergency ambulance transport are met when the individual's health condition is such that the use of any other method of transportation (e.g., taxicab, private car, wheelchair coach) would be medically contraindicated (e.g., would endanger the member's medical condition). In addition:
  • If covered, medically necessary services can be otherwise provided quickly, equally as safely, and more cost efficiently to the individual than by nonemergency ambulance transport, the transport is not considered to be reasonable. For example, the transport of an individual to receive wound care is not considered reasonable if the wound care could be provided at the individual's bedside at less cost than transporting the individual to a facility to obtain the services.
  • In products requiring precertification, a medical necessity determination is based on the medical information received at the time of the request for the service.
  • The individual's condition at the time of transport must require the presence of medical personnel who are certified and/or licensed to provide monitoring and/or interventional medical services.

The following are examples of medical conditions that satisfy the medical necessity requirement:
  • The individual is unconscious.
  • The individual has to remain immobile because of a fracture that has not been set or the possibility of a fracture (e.g., hip fracture).
  • The individual is in a body cast or spica cast.
  • The individual is bed-confined before and after transport (refer to the Description section of this policy for a definition of bed-confined).
  • The individual is unable to sit in a chair or wheelchair for the duration of the transport.
  • The individual has lower extremity contractures that are of sufficient degree as to prohibit sitting in a wheelchair (severe fixed contractures at or proximal to the knee).
  • Morbid obesity (as a sole qualifying condition) caused the individual to meet the definition of bed-confined.
  • The individual has a health condition(s) that would be exacerbated by transport in a vehicle other than an ambulance.
  • The individual must remain in a supine/prone position.
  • The individual must be moved by a stretcher because of a specific physical condition or limitation. According to the American Academy of Orthopaedic Surgeons (AAOS):
    • Post-hip replacement individuals may sit in a chair slightly higher than the average seat (e.g., wheelchair). Therefore, in most cases, this condition alone does not satisfy the medical necessity requirement.
    • Post-knee replacement individuals should be able to bend their knee approximately 90 degrees at the time of discharge. Therefore, in most cases, this condition alone does not satisfy the medical necessity requirement.
  • The individual requires maintenance of medical isolation precautions for active infectious processes.
  • The individual requires restraints.
  • The individual requires a skilled service during transport (e.g., ventilator care, nursing).
  • The individual requires continued oxygen therapy and the assistance of medically trained personnel to monitor and/or adjust the oxygen during transport because the individual is not able to self administer oxygen. In addition, clinical documentation must be consistent with a need for continued oxygen therapy.

Acute Care Facility to Acute Care Facility Transport of a Registered Inpatient (Nonemergency)

Nonemergency ground ambulance transport of a registered inpatient from one acute care facility to another acute care facility to obtain specialized necessary therapeutic services is considered medically necessary and, therefore, covered when ALL of the following criteria are met:
  • The above policy requirements (1) through (5) are met;
  • The necessary therapeutic services must be provided in the inpatient setting;
  • The necessary therapeutic services are not available at the facility in which the member is admitted.
  • The necessary therapeutic services are available at the facility to which the member is being transported.
Roundtrip Nonemergency Ambulance Transport

A roundtrip nonemergency transport between an eligible point of origin (as defined above) and an eligible destination (as defined above) to receive eligible medical services not otherwise available at the point of origin is only covered when requirements (1) through (5) in this policy are met. Roundtrip nonemergency ambulance transport must be reported with the appropriate origin and destination modifier for each segment corresponding to the origin and destination of the roundtrip transport.

Repetitive Nonemergency Transport

For repetitive nonemergency transport, the following apply:
  • A letter of medical necessity stating that transport is medically necessary must be signed by the patient’s attending provider.
  • The letter of medical necessity must be dated no later than 60 days in advance of the transport for those individuals who require repetitive ambulance services and whose transportation is scheduled in advance.

A repetitive ambulance service is defined as medically necessary ambulance transportation that is furnished either:
  • Three or more times during a 10-day period
  • At least once per week for at least three weeks

Scheduled Ambulance Transport

All scheduled ground ambulance transports will be considered nonemergency. Transports to nursing homes, places of residence, and ESRD facilities will be considered nonemergency.

SEA AMBULANCE TRANSPORT

Sea ambulance transportation is considered medically necessary and, therefore, covered in either of the following circumstances:
  • A land ambulance cannot reach the scene easily or quickly enough; or,
  • The individual needs to be transported over a distance or terrain that makes water transportation the most practical transport mode.

MISCELLANEOUS ITEMS AND SERVICES

When the ambulance transport is covered, miscellaneous items and services associated with the transport are also covered. However, reimbursement eligibility varies as follows:
  • The transport of multiple individuals in the same ambulance vehicle is eligible for separate reimbursement consideration only when the nonemergency ambulance transport would have otherwise been covered and eligible for reimbursement consideration if provided to each individual separately.
  • 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.

NONCOVERED NONEMERGENCY TRANSPORT SERVICES

Nonemergency ambulance transport is not covered and, therefore, not eligible for reimbursement consideration in any of the following situations:
  • The requirements in this policy are not met, regardless of the individual's condition.
  • The individual is not transported, even if medical services are provided to the individual.
  • The type of vehicle used for the transport or the medical personnel present during transport do not meet local, state, and federal regulatory, certification, and licensing requirements. Examples of vehicles that do not satisfy these requirements include, but are not limited to: public transportation, privately owned vehicles, wheelchair vans, and taxicabs.

Transportation services other than ambulance (e.g., wheelchair vans, taxicabs) and/or ancillary transportation fees (e.g., parking fees, tolls) are not covered by the Company because these services are not covered by Medicare.

For benefit information on nonemergency air ambulance transport, please refer to the Company policy addressing Air Ambulance Services.

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 emergency and nonemergency ambulance transport should meet all applicable local, state, and federal regulatory, certification, and licensing requirements.

If an emergency occurs during a nonemergency ambulance transport, the Company considers it an emergency ambulance transport only if the individual's condition meets the Company's definition of an emergency condition (refer to the Description section of this policy for the definition of emergency).

This policy is consistent with Medicare's coverage criteria. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, emergency and nonemergency ambulance transport is covered under the medical benefits of the Company’s Medicare Advantage plans 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.

Members enrolled in Medicare Advantage Health Maintenance Organization (HMO) products (HMO65) do not have benefits for nonemergency ambulance transport outside of the United States of America (USA), except in limited circumstances as defined by Medicare

In products without an Out-of-Network benefit (HMO), nonemergency ambulance transport may be covered to return the member to the nearest appropriate facility in the service area for required continuing care (when a covered benefit), when such facility care immediately follows an inpatient emergency admission and the member is not able to return to the service area by any other means. This type of transportation is safely provided when the individual's medical condition requires uninterrupted care and attendance by qualified medical staff during transport that cannot be provided by any other means of transportation. Transportation back to the service area will not be covered for family members or companions as it is not covered by Medicare.

In products with an Out-of-Network benefit (PPO and the POS product), nonemergency ambulance transport may be covered from the facility where the member is currently hospitalized to the nearest appropriate facility regardless of whether that facility is within the service area, for required continuing care (when a covered benefit), when such care immediately follows an inpatient emergency admission and the member is not able to be transported by any other means. This type of transportation is safely provided when the individual's medical condition requires uninterrupted care and attendance by qualified medical staff during transport that cannot be provided by any other means of transportation. Transportation back to the service area will not be covered for family members or companions as it is not covered by Medicare.

Description

Ground ambulance transport services may involve ground or sea transport in both emergency and nonemergency situations.

A ground ambulance vehicle is designed and equipped to respond to medical emergencies and for the transport of individuals who are sick or injured. The vehicle must comply with state and local laws governing the licensing and certification of an emergency medical transportation vehicle and is staffed by state certified or qualified staff who are able to provide basic life support or advanced life support services, as appropriate.

A sea ambulance is a watercraft used for emergency medical assistance in situations where either a ground ambulance cannot reach the scene easily or quickly enough, or the individual needs to be transported over a distance or terrain that makes water transportation the most practical transport mode. Sea ambulance crews are supplied with equipment that enables them to monitor and provide medical treatment to an individual during transportation.

DEFINITIONS

Appropriate facilities are generally equipped and staffed to provide the necessary care for the individual's health condition. In the case of an acute care hospital, it also means that a physician or a physician specialist is available to provide the necessary care required to treat the individual's condition.

Bed-confined, which is not synonymous with bed rest or nonambulatory, means that an individual is unable to do all of the following:
  • Get up from bed without assistance
  • Ambulate
  • Sit in a chair or wheelchair
Emergent/emergency is the sudden onset of a medical condition that manifests itself by acute symptoms of sufficient severity or pain such that a prudent layperson possessing an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in any of the following:
  • The health of the individual being placed in serious jeopardy
  • The health of a pregnant woman or her unborn child being placed in serious jeopardy
  • Serious impairment to the individual's bodily functions
  • Serious dysfunction of any of the individual's bodily organs or parts
Emergency response means responding immediately at the basic life support (BLS) or advanced life support (ALS) level of services to a 911 call or the equivalent due to a sudden onset of a medical condition, requiring medical assessment, monitoring, treatment or observation of the individual. An immediate response is one in which the ambulance supplier begins as quickly as possible to take the steps necessary to respond to the call.

Home is defined as the individual's place of residence (e.g., private residence/domicile, assisted living facility, long-term care facility, skilled nursing facility [SNF] at a custodial level of care).

Nonemergency ambulance transport is an ambulance transport provided for an individual who has nonemergent conditions but still requires ambulance transportation because other methods of transportation are contraindicated (e.g., bed confinement status, need for continuous supervision, physical restraint status, and/or dependence on other enabling machines and devices). Nonemergency ambulance transport may be provided at either a basic life support (BLS) or an advanced life support (ALS) level of care.

Nonemergent/nonemergency conditions are conditions that require medical attention, which may be provided or directed by a physician shortly after occurrence, but are not severe enough to meet this policy's definition of emergency.
References

Centers for Medicare & Medicaid Services (CMS). Ambulance Fee Schedule and Medicare Transports. Effective: July 2019. Available at:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Medicare-Ambulance-Transports-Booklet-ICN903194.pdf. Accessed May 29, 2020.

Centers for Medicare & Medicaid Services (CMS). CMS Manual System. Transmittal 243. Pub 100-02: Medicare Benefit Policy. Ambulance transportation for a skilled nursing facility (SNF) resident in a stay not covered by part A. [CMS Web site]. 04/13/18. Available at:https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R243BP.pdf. Accessed May 29, 2020.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual Chapter 15 – Ambulance. (Revision #4407: 10/04/19). Available at:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c15.pdf. Accessed May 29, 2020.

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 10 - Ambulance Services. 30.1. Definition of ambulance services. [CMS Web site].(Revision #243: 04/13/18). Available at:https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c10.pdf.Accessed May 29, 2020.

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 10 - Ambulance services. [CMS Web site]. (Revision #243: 04/13/18). Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c10.pdf.Accessed May 29, 2020.

Centers for Medicare & Medicaid Services (CMS). Medicare Managed Care Manual. Chapter 4 - Benefits and beneficiary protections. 20.2. Definitions of emergency and urgently needed services. [CMS Web site]. (Revision #121: 04/22/16). Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c04.pdf.Accessed May 29, 2020.

Centers for Medicare & Medicaid Services (CMS). MLN Matters. Effective April 1, 2019. MM10955 – Revision of SNF CB Edits for Ambulance Services Rendered to Beneficiaries in a Part A Skilled Nursing Facility Stay . Available at:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10955.pdf. Accessed May 29, 2020.

Evidence of Coverage.

Novitas Solutions Inc. Local Coverage Article: Ambulance Services (Ground Ambulance) - Policy Article (A54574). Revised effective 11/14/2019. Original effective:10/01/2015. Available at:
https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=54574&ver=33&Keyword=ambulance&KeywordSearchType=Or&Date=&PolicyType=Both&ArticleType=BC%7cSAD%7cRTC%7cReg&Cntrctr=323*1&KeyWordLookUp=Doc&SearchType=Advanced&CoverageSelection=Both&kq=true&search_id=&service_date=&bc=IAAAABAAAAAA&. Accessed May 29, 2020.

Novitas Solutions Inc. Local Coverage Determination: L35162 Ambulance Services (Ground Ambulance). Revised effective 01/01/2020. Original effective:10/01/2015. Available at:
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35162&ver=65&Keyword=ambulance&KeywordSearchType=Or&Date=&PolicyType=Both&ArticleType=BC%7cSAD%7cRTC%7cReg&Cntrctr=323*1&KeyWordLookUp=Doc&SearchType=Advanced&CoverageSelection=Both&kq=true&bc=IAAAABAAAAAA&. Accessed May 29, 2020.



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, 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

A0425 Ground mileage, per statute mile

A0426 Ambulance service, advanced life support, nonemergency transport, level 1 (ALS 1)

A0427 Ambulance service, advanced life support, emergency transport, level 1 (ALS 1 - emergency)

A0428 Ambulance service, basic life support, nonemergency transport (BLS)

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

A0433 Advanced life support, level 2 (ALS 2)

A0434 Specialty care transport (SCT)

A0999 Unlisted ambulance service


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); (requires medical review)


NOT COVERED

A0080 Nonemergency transportation, per mile - vehicle provided by volunteer (individual or organization), with no vested interest

A0090 Nonemergency transportation, per mile - vehicle provided by individual (family member, self, neighbor) with vested interest

A0100 Nonemergency transportation; taxi

A0110 Nonemergency transportation and bus, intra- or interstate carrier

A0120 Nonemergency transportation: mini-bus, mountain area transports, or other transportation systems

A0130 Nonemergency transportation: wheelchair van

A0160 Nonemergency transportation: per mile - caseworker or social worker

A0170 Transportation ancillary: parking fees, tolls, other

A0180 Nonemergency transportation: ancillary: lodging - recipient

A0190 Nonemergency transportation: ancillary meals - recipient

A0200 Nonemergency transportation: ancillary: lodging - escort

A0210 Nonemergency transportation: ancillary: meals - escort

A0888 Noncovered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility)

A0998 Ambulance response and treatment, no transport

S0209 Wheelchair van, mileage, per mile

S0215 Nonemergency transportation; mileage, per mile

S9992 Transportation costs to and from trial location and local transportation costs (eg, fares for taxicab or bus) for clinical trial participant and one caregiver/companion



Revenue Code Number(s)



MEDICALLY NECESSARY

0540 Ambulance-General Classification
0542 Ambulance-Medical Transport
0543 Ambulance-Heart Mobile
0546 Ambulance-Neonatal Ambulance Services
0549 Ambulance-Other 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

MA12.002b
07/01/2020The policy has been reviewed and reissued to communicate the Company’s continuing position on Ground Ambulance Transport Services (Emergency and Nonemergency).
01/01/2020
            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

            MEDICALLY NECESSARY
            Emergency ground ambulance services with transportation is considered medically necessary and, therefore, covered when ALL of the following criteria are met:
            • The services provided are medically necessary to stabilize the individual’s medical condition.
            • The responding Emergency Medical Services (EMS) ambulance, in accordance with state regulations, is a specially designed and equipped vehicle used to transport the sick or injured.
            • The responding EMS ambulance, in accordance with state regulations, is staffed by state certified or qualified staff who are able to provide basic life support or advanced life support services, as appropriate, at the treating location during the time of the emergency.
            • The EMS staff is able to provide assessment, monitoring, assistance, treatment and observation during transportation.
            • Transportation of the individual will be from the individual’s home, or the scene of the accident or medical emergency, to the nearest acute care hospital or other Emergency Care Facility, where emergency health services can be provided to the individual.

            Acute Care Facility to Acute Care Facility Transport of a Registered Inpatient (Emergency)

            Emergency ground ambulance transport from one acute care facility of a registered inpatient to another acute care facility to obtain necessary specialized diagnostic and/or therapeutic services, is considered medically necessary and, therefore, covered when ALL of the following criteria are met:
            • There is a medical condition that is life or limb threatening, or treating personnel deem to be life or limb threatening, and the individual's condition is such that a delay in treatment poses a threat to the individual's survival or seriously endangers the individual's health, or could result in serious impairment to the individual's bodily functions and/or serious dysfunction of any of the individual's bodily organs or parts;
            • The necessary diagnostic and/or therapeutic services must be provided in the inpatient setting;
            • The necessary diagnostic and/or therapeutic services are not available at the facility in which the member is admitted.
            • The necessary diagnostic and/or therapeutic services are available at the facility to which the member is being transported to.

            Other Facility to Facility Transport (Emergency)

            Emergency ground ambulance transport from one facility to another facility to obtain necessary specialized diagnostic and/or therapeutic services is considered medically necessary and, therefore, covered when ALL of the following criteria are met:
            • There is a medical condition that is life or limb threatening, or treating personnel deem to be life or limb threatening, and the individual's condition is such that a delay in treatment poses a threat to the individual's survival or seriously endangers the individual's health, or could result in serious impairment to the individual's bodily functions and/or serious dysfunction of any of the individual's bodily organs or parts;
            • The necessary diagnostic and/or therapeutic services are not available at the facility in which the member is located.
            • The necessary diagnostic and/or therapeutic services are available at the facility to which the member is being transported to.


            NONCOVERED EMERGENCY TRANSPORT SERVICES

            Emergency ground ambulance services without transportation of an individual is considered not covered and, therefore, not eligible for reimbursement consideration.

            The following criteria for Nonemergency Ground Transportation was added to the policy:

            Acute Care Facility to Acute Care Facility Transport of a Registered Inpatient (Nonemergency)

            Nonemergency ground ambulance transport of a registered inpatient from one acute care facility to another acute care facility to obtain necessary specialized therapeutic services is considered medically necessary and, therefore, covered when ALL of the following criteria are met:
              • The above policy requirements (1) through (5) are met;
              • The necessary therapeutic services must be provided in the inpatient setting;
              • The necessary therapeutic services are not available at the facility in which the member is admitted.
              • The necessary therapeutic services are available at the facility to which the member is being transported.
              The list for examples of medical conditions that may satisfy the medical necessity requirement for nonemergency ground ambulance transport in individuals requiring oxygen therapy was revised. The following example was added to the policy:
              • The individual requires continued oxygen therapy and the assistance of medically trained personnel to monitor and/or adjust the oxygen during transport because the individual is not able to self-administer oxygen. In addition, clinical documentation must be consistent with a need for continued oxygen therapy.

              The following examples of medical conditions for nonemergency ground ambulance transport in individuals requiring oxygen therapy were deleted from the policy:
              • The individual is not able to self-administer oxygen or requires active assistance with its administration by medical personnel during transport.
              • The individual requires the continuation of oxygen therapy that was initiated during the immediate hospitalization from which the transport is being requested and the individual does not have portable oxygen equipment at the time of the transport request.
              Scheduled Ambulance Transport

              All scheduled ground ambulance transports will be considered nonemergency. Transports to nursing homes, places of residence, and ESRD facilities will be considered nonemergency.

              SEA AMBULANCE TRANSPORT

              Sea ambulance transportation is considered medically necessary and, therefore, covered in either of the following circumstances:
              • A land ambulance cannot reach the scene easily or quickly enough; or,
              • The individual needs to be transported over a distance or terrain that makes water transportation the most practical transport mode.
              The following statement regarding NONCOVERED NONEMERGENCY TRANSPORT SERVICES has been added to the policy:
              • Transportation services other than ambulance (e.g., wheelchair vans, taxicabs) and/or ancillary transportation fees (e.g., parking fees, tolls) are not covered by the Company because these services are not covered by Medicare.

MA12.002a
08/13/2018This version of the policy will become effective 08/13/2018.

The following criteria regarding transport to diagnostic and therapeutic sites has been added to Destination section of this policy:
  • The transport origin is a skilled nursing facility where the individual is a resident and is not being treated at a skilled level of care, AND the ambulance transport is to the nearest supplier of medically necessary services (other than a physician's office or hospital) that are not available at the skilled nursing facility, such as the following diagnostic and therapeutic sites:
    • Independent diagnostic testing facility (IDTF)
    • Cancer treatment center
    • Radiation therapy center
    • Wound care center

MA12.002
11/22/2017This policy has been reissued in accordance with the Company's annual review process.
12/09/2016This policy has been reissued in accordance with the Company’s annual review process
10/14/2015The policy has been reviewed and reissued to communicate the Company’s continuing position on nonemergency ambulance transport.
01/01/2015This is a new policy.





Version Effective Date: 01/01/2020
Version Issued Date: 12/31/2019
Version Reissued Date: 07/01/2020