Medicare Advantage

Ground Ambulance Transport Services (Emergency and Nonemergency) for Medicare Advantage Members (Updated May 20, 2021)


Policy Impacted



Purpose


The purpose of this communication is to provide advance notice regarding the temporary expansion of the list of allowable destinations for ground ambulance transports AND to convey coverage criteria for medically necessary ground ambulance services without a transport in response to the Public Health Emergency (PHE) for the COVID-19 pandemic. 


This communication addressing ground ambulance transport services (Emergency and Nonemergency) is effective for the duration of the Federal Public Health Emergency.


  • This document replaces the version published on 03/25/2021.
  • This document has been updated to convey coverage criteria for medically necessary ground ambulance services without a transport in response to the Public Health Emergency (PHE) for the COVID-19 pandemic. It is based on a Medicare-implemented waiver for ground ambulance services without a transport as a result of community wide emergency medical service protocols during the PHE.
  • Billing Requirements have been incorporated to convey the required inclusion of specific HCPCS codes based on the level of service provided, a valid origin/destination modifier combination, and use of the CR modifier when submitting a claim for ground ambulance services without a transport.  ​




Background


There is currently an outbreak of respiratory disease caused by a novel coronavirus, which has now been detected internationally. The virus has been named “SARS-CoV-2” and the disease it causes has been named “Coronavirus Disease 2019” (COVID-19). The SARS-CoV-2 virus has demonstrated the capability to rapidly spread, leading to significant impacts on healthcare systems and causing societal disruption. The potential public health threat posed by COVID-19 is high globally. To effectively respond to the COVID-19 outbreak, rapid detection of cases and contacts, appropriate clinical management and infection control, and implementation of community mitigation efforts are critical.


Coverage Statement


Coverage Statement for temporary expansion of the list of allowable destinations for ground ambulance transports:

In accordance with the Centers for Medicare & Medicaid Services (CMS), the list of covered destinations for medically necessary ground ambulance transportation (emergency and nonemergency) from any point of origin will be expanded to include, but not limited to, any of the following:

  • any location that is an alternative site determined to be part of a hospital, critical access hospital (CAH), or skilled nursing facility (SNF)
  • community mental health centers
  • federally qualified health centers (FQHCs)
  • rural health clinics (RHCs)
  • physician offices
  • urgent care facilities
  • ambulatory surgical centers (ASCs)
  • any location furnishing dialysis services outside of an end stage renal disease (ESRD) facility when an ESRD facility is not available
  • an individual's home

​​​Coverage Statement for ground ambulance services without a transport:
 
In accordance with the Centers for Medicare & Medicaid Services (CMS), medically necessary ground ambulance services without transport will be covered when ALL of the following criteria are met:
  • The ground ambulance service was furnished in response to a 911 call (or the equivalent in areas without a 911 call system); and
  • The individual would have been transported to a destination permitted under Medicare regulations, but the transport did not occur as a result of community-wide emergency medical service protocols due to the COVID-19 PHE; and
  • The individual's condition required the level of service provided and would normally require transport by ambulance, absent the community-wide EMS protocols (in other words, any other means of transportation would have been contraindicated).
  • Documentation establishes the community-wide EMS protocol was in effect for the area at the time ambulance services were provided to the individual.​


​BILLING REQUIREMENTS (for ground ambulance services without a transport)


Based on the level of service provided, claims should include one of the following HCPCS codes:
• A0429 (Ambulance service, basic life support, emergency transport (BLS-emergency))
• A0427 (Ambulance service, advanced life support, emergency transport, level 1 (ALS1)) AND
• A valid origin/destination modifier combination (in the first modifier position) that would have been appropriate if the individual had been transported
• The CR modifier to distinguish these waiver claims from other claims


 Note: HCPCS codes for mileage should not be reported because no transport occurred. 


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.


Coding


HCPCS CODES FOR AMBULANCE SERVICES:

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)


REVENUE CODES FOR AMBULANCE SERVICES:

0540 Ambulance-General Classification

0542 Ambulance-Medical Transport

0543 Ambulance-Heart Mobile

0546 Ambulance-Neonatal Ambulance Services

0549 Ambulance-Other Ambulance


MODIFIERS


CR  (catastrophe/disaster related)



ORIGIN AND DESTINATION MODIFIERS:

D Diagnostic or therapeutic site other than P or H when these are used as origin codes; community mental health center, FQHC, RHC, urgent care facility, non-provider-based ASC or freestanding emergency center, location furnishing dialysis services and not affiliated with ESRD facility

E Residential, domiciliary, custodial facility (other than 1819 facility); residential, domiciliary, custodial facility (other than 1819 facility) if the facility is the beneficiary's home

G Hospital based ESRD facility

H Hospital; alternative care site for hospital, including CAH, provider-based ASC, or freestanding emergency center

I Site of transfer (e.g. airport or helicopter pad) between modes of ambulance transport

J Freestanding ESRD facility

N Skilled nursing facility; alternative care site for SNF

P Physician's office

R Residence; beneficiary's home

S Scene of accident or acute event

X Intermediate stop at physician's office on way to hospital (This is a destination code only)



4/14/2020