Notification

Ground Ambulance Transport Services (Emergency and Nonemergency)


Notification Issue Date: 11/02/2018

This version of the policy will become effective 01/01/2019.

This policy was updated to revise policy coverage criteria regarding Ground Ambulance Services



Medical Policy Bulletin


Title:Ground Ambulance Transport Services (Emergency and Nonemergency)

Policy #:12.04.02h

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


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. 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.

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 Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

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.

Miscellaneous Items and Services

Supplies that are needed to stabilize an individual’s medical condition are considered medically necessary and, therefore, covered when the emergency ambulance service with transport is medically necessary.

BENEFIT EXCLUSION
Emergency ground ambulance services without transportation of an individual to an emergency facility is considered a benefit contract exclusion for all products of the Company 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 contract. Member contracts 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 contract 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 considered not medically necessary and, therefore, not covered.

(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 contract.
  • 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 contract.
  • The destination has the 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 only 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

(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 considered to be not medically necessary. 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 list includes, but is not limited to, examples of medical conditions that may 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 because of 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 oxygen therapy in one of the following circumstances:
    • 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.

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 diagnostic and/or 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 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.

Roundtrip Nonemergency Transport

A roundtrip nonemergency ground ambulance transport between an eligible point of origin (as defined above) and an eligible destination (as defined above) for an individual to receive eligible medical services not otherwise available at the point of origin is considered medically necessary and therefore covered, when requirements (1) through (5) in this policy are met. Roundtrip nonemergency ground 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

Repetitive nonemergency ground ambulance transports, that is three or more round trips (or six one-way trips) within a ten-day period OR at least one trip per week for at least three weeks, is considered medically necessary and, therefore, covered when ALL of the following criteria are met:
  • The above policy requirements (1) through (5) are met;
  • 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.

Miscellaneous Items and Services

When the nonemergency ground ambulance transport is medically necessary, miscellaneous items and services associated with the transport may also be 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.
  • The use of extra attendants is eligible for reimbursement consideration when all of the following conditions are met:
    • The use of extra attendants has been prearranged with the Company.
    • The attendants are state certified or qualified staff who are able to provide basic life support or advanced life support services, as appropriate.
    • The nonemergency ambulance transport record indicates that unusual circumstances existed to necessitate the presence of extra attendants.
  • Disposable supplies (e.g., gauze, dressings, cervical collars) that are utilized in excess of the amount that would be considered appropriate in the treatment of the individual's medical condition are eligible for separate reimbursement consideration only when the nonemergency ambulance transport record indicates that unusual circumstances existed and when the applicable provider contract has a provision for such services.

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.

BENEFIT EXCLUSION
Nonemergency ground ambulance services without transportation of an individual, even if medical services are provided to the individual, is considered a benefit contract exclusion for all products of the Company and, therefore, not eligible for reimbursement consideration.

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.

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.

BILLING REQUIREMENTS

Reusable devices and equipment (e.g., backboards, neck boards, inflatable splints) are not eligible for separate reimbursement, regardless of the provider's participation status with the Company, because they are included in the reimbursement for the transport.

Waiting time is not eligible for separate reimbursement because it is always integral to the primary nonemergency ambulance transport code with which it is reported.

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

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, ground ambulance services are covered under the medical benefits of the Company’s products when the criteria listed in this policy are met.

Subject to the terms and conditions of the applicable benefit contract, ground ambulance services that do not satisfy the criteria listed in this policy are considered not medically necessary.

The application of benefits may vary by product and/or group; therefore, individual member benefits must be verified.

In products without an Out-of-Network benefit (HMO), non-emergency ground transport may be covered to transport the member back to an In-Network Facility Provider in the member's service area as determined by the [(Fully-Insured) Health Benefit Plan or (Self-Insured) Claims Administrator], when the transfer is medically necessary (as determined by the company’s definition of medical necessity); AND the member's medical condition requires uninterrupted care and attendance by qualified medical staff during ground transport. Transportation back to the member's service area is not covered for family members or companions as it is a benefit contract exclusion.

In products with an Out-of-Network benefit (PPO and the POS product) non-emergency ground transport may be covered to transport the Member back to an In-Network Facility Provider as determined by the [(Fully-Insured) Health Benefit Plan or (Self-Insured) Claims Administrator] when the transfer is medically necessary (as determined by the company’s definition of medical necessity); AND the member's medical condition requires uninterrupted care and attendance by qualified medical staff during ground transport. Transportation back to the member's service area is not covered for family members or companions as it is a benefit contract exclusion.

MANDATES

This policy is in compliance with federal, state, and local mandates.

Description

Ground ambulance transport services may involve ground or water 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

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).

Emergent/emergency refers to 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, for the transportation of an individual 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.

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


American College of Emergency Physicians (ACEP). Policy Statements. Appropriate interfacility patient transfer. [ACEP Web site]. Original: 09/1989. (Revised 01/2016). Available at:https://www.acep.org/patient-care/policy-statements/appropriate-interfacility-patient-transfer/#sm.00006vg9fr1bakdtbz9sgovgpzj01. Accessed September 12, 2018.

Centers for Medicare & Medicaid Services (CMS). Medicare Learning Network (MLN) Matters. SE1514: Overview of the repetitive scheduled non-emergent ambulance prior authorization model. [CMS Web site]. Original:05/04/2015. (Revised 02/14/2018). Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1514.pdf. Accessed August 8, 2018.

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 August 8, 2018.

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 August 8, 2018.

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 August 8, 2018.

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 August 8, 2018.

Commonwealth of Pennsylvania. PA Code 28, Ch 9, 9.602. Definitions. [The Pennsylvania Code Web site]. Available at: https://www.pacode.com/secure/data/028/chapter9/s9.602.html. Accessed August 8, 2018.

Company Benefit Contracts.

New Jersey (NJ) Administrative Code. Office of Emergency Medical Services. Title 8, Ch 40, Subchapter 1, 8:40-1.3. Mobility assistance vehicle and basic life support ambulance services. [State of NJ Department of Health and Senior Services Web site]. Available at: http://www.state.nj.us/health/ems/documents/reg-enforcement/njac840ar.pdf. Accessed August 8, 2018.

New Jersey (NJ) Administrative Code. Office of Emergency Medical Services. Title 8, Ch 41, Subchapter 1, 8:41-1.3. Advanced life support services; mobile intensive care programs, specialty care transport services and air medical services. [State of NJ Department of Health and Senior Services Web site]. Available at: http://www.state.nj.us/health/ems/documents/reg-enforcement/njac841r.pdf. Accessed August 8, 2018.

New Jersey (NJ) Administrative Code. Office of Emergency Medical Services. Title 8, Ch 41a, Subchapter 1, 8:41a-1.3. Emergency Medical Technicians - Paramedic: training and certification. [NJ Department of Health and Senior Services Web site]. Available at: http://www.state.nj.us/health/ems/documents/reg-enforcement/njac841r.pdf. Accessed August 8, 2018.

Novitas Solutions Inc. LCD L35162 Ambulance Services (Ground Ambulance). Revised effective 07/16/2018. Original effective:10/01/2015. Available at:
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35162&ver=51&Keyword=ambulance&KeywordSearchType=Or&Date=&PolicyType=Both&ArticleType=SAD%7cEd&Cntrctr=323*1&KeyWordLookUp=Doc&SearchType=Advanced&CoverageSelection=Both&kq=true&bc=IAAAACAAAAAA&. Accessed September 10, 2018.

Pennsylvania Department of Health. Bureau of Emergency Medical Services. EMS Information Bulletin 2012-08. 05/03/12. Available at:http://www.health.pa.gov/My%20Health/Emergency%20Medical%20Services/EMS%20in%20PA/Documents/2012/EMSIB%202012-008-Stretcher%20Vans.pdf. Accessed August 8, 2018.




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)

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 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)



AMBULANCE SERVICE CODES

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

A0225 Ambulance service, neonatal transport, base rate, emergency transport, one way


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


MISCELLANEOUS AMBULANCE CODES

A0380 BLS mileage (per mile)

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)

A0390 ALS mileage (per mile)

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

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)

A0425 Ground mileage, per statute mile

A0999 Unlisted ambulance service

S0215 Nonemergency transportation; mileage, per mile


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

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


BENEFIT EXCLUSION

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



Revenue Code Number(s)



0540 Ambulance - General Classification

0541 Ambulance - Supplies

0542 Ambulance - Medical Transport

0543 Ambulance - Heart Mobile

0544 Ambulance - Oxygen

0546 Ambulance - Neonatal Ambulance Services

0547 Ambulance - Pharmacy

0548 Ambulance - EKG Transmission

0549 Ambulance - Other Ambulance

Coding and Billing Requirements


Cross References


Policy History

12.04.02h
01/01/2019This version of the policy will become effective 01/01/2019.

This policy was updated to revise policy coverage criteria regarding Ground Ambulance Services.

12.04.02g
08/13/2018Effective 08/13/2018, this policy has been reviewed and reissued to communicate the Company’s continuing position on Nonemergency Ambulance Transport Services.

12.04.02f
11/22/2017This policy has been reissued in accordance with the Company's annual review process.


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 01/01/2019
Version Issued Date: 01/02/2019
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.