Ambulance Services (Ground Ambulance) CPT code - A0425,A0426,A0433,A0888


Emergency Ambulance Services
Medicare will cover emergency ambulance services when the services are medically necessary, meet the destination limits of closest appropriate facilities and are provided by an ambulance service that is licensed by the state. Emergency response means responding immediately at the Basic Life Support (BLS) or Advanced Life Support 1 (ALS1) level of service to a 911 call or the equivalent. 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.
The patient’s condition is an emergency that renders the patient unable to go safely to the hospital by other means. Emergency ambulance services are services provided after the sudden onset of a medical condition. For the purposes of this LCD, acute signs and/or symptoms of sufficient severity must manifest the emergency medical condition such that the absence of immediate medical attention could reasonably be expected to result in one or more of the following:
  • Place the patient’s health in serious jeopardy.
  • Cause serious impairment to bodily functions.
  • Cause serious dysfunction of any body organ or part.

Non-Emergency Ambulance Service
Medical necessity is established for non-emergency ambulance services when the patient’s condition at the time of transport is such that the use of any other method of transportation (such as taxi, private car, wheelchair van or other type of vehicle) is contraindicated.
For conditions that do not fit the definitions given above for emergency ambulance services, Medicare covers ambulance transportation if the beneficiary is bed-confined or if the patient’s medical condition at the time of transport is such that transportation by ambulance is medically required whether or not he is bed-confined.
For the purposes of this LCD, “bed-confined” means the patient must meet all of the following three criteria:
  • Unable to get up from bed without assistance.
  • Unable to ambulate.
  • Unable to sit in a chair (including a wheelchair).
Non-emergency ambulance transportation is not covered for patients who are restricted to bed rest by a physicians instructions but who do not meet the above three criteria. If some means of transportation other than an ambulance (i.e., private car, wheelchair van, etc.) could be utilized without endangering the individuals health, whether such other transportation is actually available, no payment may be made for ambulance service.
Non-emergency ambulance services may be those that are scheduled in advance – scheduled services being either repetitive or non-repeating.
Non-emergency ambulance transportation is not covered if transportation is provided for the patient who is transported to receive a service that could have been safely and effectively provided in the point of origin (residence, Skilled Nursing Facility (SNF), hospital, etc.). Such transportation is not covered even if the patient could only have gone for the service by ambulance.
Ambulance transportation for services excluded from SNF consolidated billing must meet the criteria as reasonable and necessary indicated above.
Ambulance transports to or from an Independent Diagnostic Testing Facility (IDTF) are considered paid in the SNF Prospective Payment System (PPS) rate when the beneficiary is in a covered Part A stay and may not be paid separately as Part B services. The ambulance transport is included in the SNF PPS rate if the first or second character (origin or destination) of any HCPCS code ambulance modifier is “D” (diagnostic or therapeutic site other than “P” or “H”), and the other modifier (origin or destination) is “N” (SNF). In this instance, the SNF is responsible for the costs of the transport. The “D” origin/destination modifier includes cancer treatment centers, wound care centers, radiation therapy centers, and all other diagnostic or therapeutic sites.
Destination
For ambulance services to be a covered benefit, the transport must be to the nearest institution with appropriate facilities for the treatment of the illness or injury involved. The term “appropriate facilities” means that the institution is generally equipped to provide hospital care necessary to manage the illness or injury involved. It is the institution, its equipment, its personnel and its capability to provide the services necessary to support the required medical care that determine whether it has appropriate facilities. The fact that a more distant institution may be better equipped (either subjectively or quantitatively) does not mean that the closer institution does not have “appropriate facilities.” In the case of a hospital, it also means that a physician or a physician specialist is available to provide the necessary care required to treat the patient’s condition. However, the fact that a particular physician does or does not have staff privileges in a hospital is not a consideration in determining whether the hospital has appropriate facilities. Thus, ambulance service to a more distant hospital solely to avail a patient of the service of a specific physician or physician specialist does not make the hospital in which the physician has staff privileges the nearest hospital with appropriate facilities. However, a legal impediment that bars the patient’s admission would preclude that institution from having “appropriate facilities.” For example, if the nearest appropriate specialty hospital is in another state and that state’s law precludes admission of non-residents, that facility is not an “appropriate facility.”
An institution is also not considered an appropriate facility if there is no bed available. The carrier, however, will presume there are beds available at the local institutions unless the claimant furnished evidence that none of these institutions had a bed available at the time the ambulance service was provided.
In the case of ambulance services to a facility other than the closest appropriate facility, only those miles to the closest facility are eligible for coverage.
Covered destinations for emergency ambulance services include:
  • Hospitals.
  • Physician’s office only if during an emergency transportation to a hospital the ambulance stops at a physician’s office en route due to a dire need for professional attention and thereafter continues to the hospital. In such cases, the patient is deemed not to have been transported to the physician’s office and payment may be made for the entire trip.
Covered destinations for “non-emergency” transports include:
  • Hospitals (“appropriate facility”).
  • Skilled nursing facilities.
  • Dialysis facilities – Ambulance services furnished to a maintenance dialysis patient only when the patient’s condition at the time of transport requires ambulance services.
  • From an SNF to the nearest supplier of medically necessary services not available at the SNF where the beneficiary is a resident, including the return trip (for instance, cardiac catheterization; specialized diagnostic imaging procedures such as computerized axial tomography or magnetic resonance imaging; surgery performed in an operating room; specialized wound care; cancer treatments) when the patient’s condition at the time of transport requires ambulance services.
  • The patient’s residence only if the transport is to return from an “appropriate facility” and the patient’s condition at the time of transport requires ambulance services.
Physician Certification Statement (PCS)
For scheduled and non-scheduled non-emergency ambulance transports, providers of ambulance transportation must obtain a written statement (PCS) from the patient’s attending physician certifying that medical necessity requirements for ambulance transportation are met. A PCS is not required for emergency transports or for non-scheduled non-emergency transports of patients residing at home or in facilities where they are not under the direct care of a physician. It is important to note that the mere presence of the signed physician certification statement does not, by itself, demonstrate that the transport was medically necessary and does not absolve the ambulance provider from meeting all other coverage and documentation criteria.
For non-repetitive non-emergency transports, the following apply:
  • The PCS must be obtained from the attending physician within 48 hours after the transport.
  • If the ambulance provider is unable to obtain the PCS from the attending physician within 48 hours of transport, the provider may submit a claim if a certification has been obtained from a Physician Assistant (PA), Nurse Practitioner (NP), Clinical Nurse Specialist (CNS), Registered Nurse (RN) or discharge planner who is knowledgeable about the patient’s condition and who is employed by either the attending physician or the facility in which the patient is admitted.
  • Alternatively, the provider may submit the claim after 21 days if there is documentation of a good faith effort to obtain the order and certification. The ambulance supplier must document efforts to obtain certification. When the PCS cannot be obtained in accordance with 42 CFR 410.40, the provider/supplier may send a letter via U.S. Postal Service certified mail with return receipt and/or proof of mailing or other similar service demonstrating delivery of the letter as evidence of the attempt to obtain the PCS.
For repetitive non-emergency transports, the following apply:
  • A PCS for repetitive transports must be signed by the patient’s attending physician.
  • The PCS must be dated no earlier than 60 days in advance of the transport for those patients who require repetitive ambulance services and whose transportation is scheduled in advance.
Tables of Medical Conditions
The following tables illustrate Medicares expectations with respect to the severity of the patient’s condition to justify payment for ambulance transportation services when all other coverage and payment conditions are met. Though not all-inclusive, the following table lists medical conditions for which ambulance transportation is commonly required and can be used to judge relative severity of conditions not listed.
Medicare requires the run report to include a description of the patient’s symptoms and physical findings in sufficient detail as to demonstrate conditions such as those described in the tables.
Special Note Regarding Patients Transported to and From Hemodialysis Centers:
Only a fraction (approximately 10 percent) ESRD patients on chronic hemodialysis requires ambulance transportation to and from hemodialysis sessions. The presence of ESRD and the requirement for hemodialysis do not alone qualify a patient for ambulance transportation. Medicare payment requires patients transported to and from hemodialysis centers to have other conditions such as those described in the tables below and requires adequate documentation of those conditions in the ambulance supplier’s run reports and in the medical records of other providers involved with the patient’s care.

I. Medical Conditions
Complaint or Symptom
Condition Requirement
Comments Regarding Conditions and Examples
Abdominal pain
Accompanied by other signs or symptoms
Associated symptoms include nausea, vomiting, fainting. Associated signs include tender or pulsatile mass, distention, rigidity, rebound tenderness on exam, guarding.
Abnormal cardiac rhythm/cardiac dysrhythmia
Symptomatic or potentially life-threatening arrhythmia
Symptoms include syncope or near syncope, chest pain and dyspnea. Signs include severe bradycardia or tachycardia (rate < 60 or > 120), signs of congestive heart failure. Examples include junctional and ventricular rhythms, non-sinus tachycardias, PVCs > 6/min, bi- and trigeminy, ventricular tachyarrhythmias, PEA, asystole. Patients are expected to have conditions that require monitoring during and after transportation.
Abnormal skin signs
Includes diaphorhesis, cyanosis, delayed capillary refill, diminished skin turgor, mottled skin. Presence of other emergency conditions
Alcohol or drug intoxication
Severe intoxication
Unable to care for self. Unable to ambulate. Altered level of consciousness. Airway may or may not be at risk.
Allergic reaction
Potentially life-threatening manifestations
Includes rapidly progressive symptoms, prior history of anaphylaxis, wheezing, oral/facial/laryngeal edema
Animal bites/sting/ envenomation
Potentially life- or limb- threatening
Symptoms of specific envenomation, significant face, neck, trunk and extremity involvement. Special handling and/or monitoring required. Presence of other emergency conditions.
Sexual assault
With significant external and/or internal injuries
Blood glucose
Abnormal <80 or >250 with symptoms
Signs include altered mental status (altered beyond baseline function), vomiting, significant volume contraction, significant cardiac dysfunction.
Back pain (see general pain listing below)
Sudden onset, severe non-traumatic pain suggestive of cardiac or vascular origin or requiring special positioning only available by ambulance
7–10 on 10-point severity scale. Neurologic symptoms and/or signs, absent leg pulses, pulsatile abdominal mass, concurrent chest or abdominal pain
Respiratory arrest
Includes apnea or hypoventilation requiring ventilatory assistance and airway management
Respiratory distress
Objective evidence of abnormal respiratory function
Includes tachypnea, labored respiration, hypoxemia requiring oxygen administration. Includes patients who require advanced airway management such as ventilator management, apnea monitoring for possible intubation and deep airway suctioning. Includes patients who require positioning not possible in other conveyance vehicles. Note that oxygen administration absent signs or symptoms of respiratory distress is, by itself, inadequate reason to justify ambulance transportation in a patient capable of self-administration of oxygen. Patient must require oxygen therapy and be so frail as to require assistance of medically trained personnel.
Cardiac arrest with resuscitation in progress
Chest pain (non-traumatic)
Cardiac origin suspected. Obvious non-emergent cause not identified
Pain characterized as severe, tight, dull or crushing, substernal, epigastric, left-sided chest pain. Especially with associated pain of the jaw, left arm, neck, back, GI symptoms (such as nausea, vomiting), arrhythmias, palpitations, difficulty breathing, pallor, diaphoresis, alteration of consciousness. Atypical pain accompanied by nausea and vomiting, severe weakness, feeling of impending doom or abnormal vital signs.
Choking episode
Respiratory or neurologic impairment
Cold exposure
Potentially life- or limb- threatening
Findings include temperature < 95º F, signs of deep frost bite or presence of other emergency conditions.
Altered level of consciousness (non-traumatic)
Neurologic dysfunction in addition to any baseline abnormality
Acute condition with Glasgow Coma Scale <15 or transient symptoms of dizziness associated with neurologic or cardiovascular symptoms and/or signs or abnormal vital signs
Convulsions/seizures
Active seizing or immediate post-seizure at risk of repeated seizure and requires medical monitoring/observation
Conditions include new onset or untreated seizures or history of significant change in baseline control of seizure activity. Findings include ongoing seizure activity, post-ictal neurologic dysfunction.
Non-traumatic headache
Associated neurologic signs and/or symptoms or abnormal vital signs
Heat exposure
Potentially life-threatening
Findings include hot and dry skin, core temperature >105º, neurologic dysfunction, muscle cramps, profuse sweating, severe fatigue.
Hemorrhage
Potentially life-threatening
Includes uncontrolled bleeding with signs of shock and active severe bleeding (quantity identified) ongoing or recent with potential for immediate rebleeding.
Infectious diseases requiring isolation procedures/public health risk
The nature of the infection or the behavior of the patient must be such that failure to isolate poses significant risk of spread of a contagious disease.
Infections in this category are limited to those infections for which isolation is provided both before and after transportation.
Hazardous substance exposure
The nature of the exposure should be such that potential injury is likely.
Toxic fume or liquid exposure via inhalation, absorption, oral, radiation, smoke inhalation
Medical device failure
Life- or limb-threatening malfunction, failure or complication
Malfunction of ventilator, internal pacemaker, internal defibrillator, implanted drug delivery device, O2 supply malfunction, orthopedic device failure
Neurologic dysfunction
Acute or unexplained neurologic dysfunction in addition to any baseline abnormality
Signs include facial drooping, loss of vision without ophthalmologic explanation, aphasia, dysphasia, difficulty swallowing, numbness, tingling extremity, stupor, delirium, confusion, hallucinations, paralysis, paresis (focal weakness), abnormal movements, vertigo, unsteady gait/balance.
Pain not otherwise specified in this table
Pain is the reason for the transport. Acute onset or bed-confining.
Pain is severity of 7–10 on 10-point severity scale despite pharmacologic intervention. Patient needs specialized handling to be moved. Other emergency conditions are present or reasonably suspected. Signs of other life- or limb-threatening conditions are present. Associated cardiopulmonary, neurologic, or peripheral vascular signs and symptoms are present.
Poisons ingested, injected, inhaled or absorbed, alcohol or drug intoxication
Potentially life-threatening
Requires cardiopulmonary and/or neurologic monitoring and support and/or urgent pharmacologic intervention. Includes circumstances in which quantity and identity of agent known to be life-threatening; instances in which quantity and identity of agent are not known but there are signs and symptoms of neurologic dysfunction, abnormal vital signs, or abnormal cardiopulmonary function. Also, includes circumstances in which quantity and identity of agent are not known but life-threatening poisoning reasonably suspected.
Complication of pregnancy/childbirth and postoperative procedure complications
Requires special handling for transport
Includes major wound dehiscence, evisceration, organ prolapse, hemorrhage or orthopedic appliance failure
Psychiatric/behavioral
Is expressing active signs and/or symptoms of uncontrolled psychiatric condition or acute substance withdrawal. Is a threat to self or others requiring restraint (chemical or physical) or monitoring and/or intervention of trained medical personnel during transport for patient and crew safety. Transport is required by state law/court order.
Includes disorientation, suicidal ideations, attempts and gestures, homicidal behavior, hallucinations, violent or disruptive behavior, sign/symptoms or DTs, drug withdrawal signs/symptoms, severe anxiety, acute episode or exacerbation of paranoia. Refer to definition of restraints in the CFR, Section 482.13(e). For behavioral or cognitive risk such that patient requires attendant to assure patient does not try to exit the ambulance prematurely, see CFR, Section 482.13(f)(2) for definition.
Fever
Significantly high fever unresponsive to pharmacologic intervention or fever with associated symptoms
Temperature after pharmacologic intervention >102º (adult)
Temperature after pharmacologic intervention >104º (child)
Associated neurologic or cardiovascular symptoms/signs, other abnormal vital signs
Gastrointestinal distress
Accompanied by other signs or symptoms
Severe nausea and vomiting or severe, incapacitating diarrhea with evidence of volume depletion, abnormal vital signs or neurologic dysfunction
General mobility issues
Patient’s physical condition is such that patient risks injury during vehicle movement despite restraints or positioning and/or record demonstrates specialized handling required and provided
This may be due to any or multiple of the conditions listed above. All conditions that contribute to general mobility issues must be adequately described. Includes conditions such as:
  • Decubitus ulcers on sacrum or buttocks that are grade 3 or greater for transfers requiring more than 60 minutes of sitting.
  • Lower extremity contractures that are of sufficient degree as to prohibit sitting in a wheelchair (severe fixed contractures at or proximal to the knee).
  • Unstable joints. Includes flail weight-bearing joints following joint surgery. Includes other patients who, in the expressed opinion of the operating surgeon, must absolutely bear no weight on a postoperative joint or patients who are incapable of protecting the joint without the assistance of the trained medical ambulance personnel. Patients who have undergone successful weight bearing joint repair/replacement and those who have successfully undergone long-bone fracture repair (and who are not otherwise immobilized in casts that prohibit sitting) will generally not be included.
  • Severely debilitating chronic neurological conditions such as degenerative conditions or strokes with severe sequelae.
  • Morbid obesity (as a sole qualifying condition) causing the patient to meet the regulatory definition of bed-confined. Medicare does not expect this to occur with persons whose BMI is <80.
II. Conditions – Trauma
On-Scene Condition (General)
On-Scene Condition (Specific)
Comments and Examples (Not All-Inclusive)
Major trauma
As defined by ACS Field Triage Decision Scheme
Trauma with one of the following: Glasgow < 14; systolic BP < 90; RR < 10 or > 29; all penetrating injuries to head, neck, torso, extremities proximal to elbow or knee; flail chest; combination of trauma and burns; pelvic fracture; two or more long-bone fractures; open or depressed skull fracture; paralysis; severe mechanism of injury including: ejection, death of another passenger in same patient compartment, falls > 20 feet, 20-inch deformity in vehicle or 12-inch deformity of patient compartment, auto pedestrian/bike, pedestrian thrown/run over, motorcycle accident at speeds > 20 miles per hour and rider separated from vehicle
Other trauma
Need to monitor or maintain airway or immobilize head/neck
Decreased level of consciousness, bleeding into airway, significant trauma to head, face or neck
Hemorrhage
Potentially life-threatening hemorrhage
Includes uncontrolled bleeding with signs of shock and active severe bleeding (quantity identified), ongoing or recent, with potential for immediate rebleeding
Suspected fractures/dislocations
Suspected fracture or dislocation requires splinting/immobilization and renders patient unable to be transported by another vehicle
Includes suspected fractures or dislocations of spine and long bones and joints proximal to knee and elbow. The record will demonstrate history of significant trauma and or findings to support such suspicions.
Penetrating extremity injuries
Life-or limb-threatening injury
Uncontrolled hemorrhage, compromised neurovascular supply, uncontrollable pain requiring pharmacologic intervention
Traumatic amputations
Life-threatening injury or reattachment opportunity exists
Suspected internal, head, chest or abdominal injuries
Signs of closed head injury, open head injury, pneumothorax, hemothorax, abdominal bruising, positive abdominal signs on exam, internal bleeding criteria, evisceration
Burns
Major: per American Burn Association (ABA)
Partial thickness burns > 10 percent Total Body Surface Area (TBSA); involvement of face, hands, feet, genitalia, perineum or major joints; third-degree burns; electrical, chemical, inhalation burns with pre-existing medical disorders; burns and trauma
Lightning
Electrocution
Near-drowning
Eye injuries
Acute vision loss or blurring, severe pain or chemical exposure, penetrating, severe lid lacerations
Special Considerations Regarding Beneficiary Death
Payment for ambulance services in circumstances in which the beneficiary dies is based on the time of the beneficiary’s death related to the time of the call for service and transport.
In cases where the beneficiary is pronounced dead after the ambulance is called but before the ambulance arrives at the scene, payment may be made for a BLS service. Neither mileage nor a rural adjustment would be paid. The blended rate amount will otherwise apply. In cases where the beneficiary is pronounced dead after being loaded into the ambulance (regardless of whether the pronouncement is made during or subsequent to the transport), payment is made following the usual rules of payment as if the beneficiary had not died. This scenario includes a determination of Dead on Arrival (DOA) at the facility to which the beneficiary was transported.

Limitations
Medicare does not cover the following services:
  • Transportation in Ambi-buses, ambulettes (Mobility Assistance Vehicle (MAV)), Medi-cabs, vans, privately owned vehicles, taxicabs.
  • Transportation via Mobile Intensive Care Unit (MICU) (if billed under Medicare Part A).
  • Parking fees.
  • Tolls for bridges, tunnels and highways.
  • Medicare does not provide payment for “Ambulance response and treatment, no transport (A0998).”
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.

Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
12X, 13X, 22X, 23X, 83X, 85X
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/orRevenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual Publication 100-04, Claims Processing Manual, for further guidance.
054X
CPT/HCPCS Codes
Note:
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
A0425
Ground mileage, per statute mile
A0426
Ambulance service, ALS, non-emergency transport, level 1
A0427
Ambulance service, ALS, emergency transport, level 1
A0428
Ambulance service, BLS, non-emergency transport
A0429
Ambulance service, BLS, emergency transport
A0433
Advanced life support, level 2 (ALS2)
A0434
Specialty Care Transport (SCT)
A0888
Non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility)
A0999
Unlisted ambulance service


Billing and Coding Guidelines

Payment for ambulance transports, including items and services furnished in association with such transports, are based on the AFS and includes a base rate payment plus a separate payment for mileage. The payment reduction for non-emergency BLS transports to and from renal dialysis treatment applies to both the base rate and the mileage reimbursement. The payment reduction will be applied to HCPCS code A0425 when billed with HCPCS code A0428 and origin/destination modifier code “G” or “J” is present.

For ambulance services, suppliers and hospital-based ambulance providers must report an accurate origin and destination modifier for each ambulance trip provided. Origin and destination modifiers used for ambulance services are created by combining two alpha characters. Each alpha character, with the exception of “X”, represents an origin code or a destination code. The pair of alpha codes creates a modifier. The first position alpha code equals origin; the second position alpha code equals destination. The reduction will be applied on claim lines containing HCPCS code A0428 with modifier code “G” or “J” in either the first position (origin code) or second position (destination code) within the two-digit ambulance modifier code and HCPCS code A0425, which reflects the mileage associated with the transport.

 Edits

FISS edits to assure proper reporting as follows:

• For claims with dates of service on or after January 1, 2001, each pair of revenue codes 0540 must have one of the following ambulance HCPCS codes - A0426, A0427, A0428,A0429, A0430, A0431, A0432, A0433, or A0434; and one of the following mileage HCPCS codes - A0435, A0436 or for claims with dates of service on or after April 1, 2002, A0425;

• For claims with dates of service on or after January 1, 2001, the presence of an origin and destination modifier and a QM or QN modifier for every line item containing revenue code 0540;

• The units field is completed for every line item containing revenue code 0540;

• For claims with dates of service on or after January 1, 2001, the units field is completed for every line item containing revenue code 0540;

• Service units for line items containing HCPCS codes A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434 always equal “1"


In addition, providers must report one of HCPCS mileage codes:

A0425;

A0435; or


A0436.



 Service Units Reporting

For line items reflecting HCPCS codes A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434, providers are required to report in “Service Units” for each ambulance trip provided. Therefore, the service units for each occurrence of these HCPCS codes are always equal to one. In addition, for line items reflecting HCPCS code A0425, A0435, or A0436, providers must also report the number of loaded miles.


Total Charges Reporting

For line items reflecting HCPCS codes A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434, providers are required to report in Total Charges the actual charge for the ambulance service including all supplies used for the ambulance trip, but excluding the charge for mileage.


For line items reflecting HCPCS codes A0425, A0435, or A0436, providers are to report the actual charge for mileage.

VA insurance Guidelines


Ambulance HCPCS Codes HCPCS Code Description

A0425 Ground mileage, per statute mile

Benefits, Limitations, and Authorization Requirements

Emergency ambulance transport services may be reimbursed if the client’s condition meets the definition of an emergency. The CSHCN Services Program defines an emergency as the “sudden onset of a life-threatening situation in which a severe debilitating condition or death would result if immediate medical care is not provided.” When the condition of the client is life-threatening and requires use of special equipment, life support systems, and close monitoring by trained attendants while en route to the nearest appropriate facility, the ambulance transport is considered an emergency service. 

The following procedure codes are considered for reimbursement for emergency ground ambulance transportation:

Service Procedure Codes


Mileage and transport A0425 with modifier ET A0429'


Ambulance providers must use an appropriate International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code on the claim form to document the client’s condition and the reason for the transport. Emergency ambulance claims submitted without the ICD-9-CM diagnosis code are denied. If a diagnosis is not known at the time of the transport, providers must use the diagnosis code that most closely represents the client’s physical signs and symptoms at the time of the transport.

If the above documentation does not indicate an emergency, the claim is denied.


If procedure code A0425 with the ET modifier is billed on the claim for emergency ambulance services, the claim must include the number of loaded miles traveled (i.e., the number of miles traveled between the time the client is loaded on to the ambulance and the time the client is unloaded from the ambulance). If mileage (procedure code A0425 with ET modifier) is not indicated on the claim, only the base rate (procedure code A0429) may be reimbursed. 



ICD-9-CM Codes that Support Medical Necessity
Medical necessity and coverage of ambulance services are not based solely on the presence of a specific diagnosis. Medicare payment for ambulance transportation may be made only for those patients whose condition at the time of transport is such that ambulance transportation is necessary. For example, it is insufficient that a patient merely has a diagnosis such as pneumonia, stroke or fracture to justify ambulance transportation. In each of those instances, the condition of the patient must be such that transportation by any other means is medically contraindicated. In the case of ambulance transportation, the condition necessitating transportation is often that an accident or injury has occurred giving rise to a clinical suspicion that a specific condition exists (for instance, fractures may be strongly suspected based on clinical examination and history of a specific injury).
It is the providers responsibility to supply the contractor with information describing the condition of the patient that necessitated ambulance transportation. Medicare recognizes limitations of usual ambulance personnel for establishing a diagnosis and recognizes, therefore, that diagnosis coding of a patient’s condition using ICD-9-CM codes when reporting ambulance services may be less specific than for services reported by other professional providers. Also, selected ICD-9-CM diagnosis codes from the CMS condition code list are included with instructions to use them in a manner that is contrary to usual ICD-9-CM coding conventions. Providers who submit ICD-9-CM diagnosis codes should choose the code that best describes the patient’s condition at the time of transport. As a reminder to providers of ambulance services, “rule out” or “suspected” diagnoses should not be reported using specific ICD-9-CM codes. In such instances where a diagnosis is not confirmed, it is more correct to use a symptom, finding or injury code.
Reporting ambulance services using a code from the list below certifies to Medicare that the ambulance provider believes the code description reasonably reflects the condition of the patient at the time of transport and that the patient’s condition was consistent with the requirements of the Medicare ambulance transportation benefit.
TrailBlazer recognizes that ambulance suppliers are not required to submit ICD-9-CM codes on their claims though their doing so facilitates timely claim adjudication. The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a claim contains one or more ICD-9-CM diagnoses but a covered diagnosis code is not on the claim, the edit will automatically deny the service as not medically necessary. Claims without an ICD-9-CM diagnosis code are adjudicated manually utilizing the information contained in the claim’s narrative field and/or medical records (the trip report and any other records supplied to Medicare by the provider upon our request).
Medicare is establishing the following limited coverage for HCPCS codes A0425, A0426, A0427, A0428, A0429, A0433 and A0434:
Table 1 – Covered for Ambulance Transportation Services to the Site of Medical Care:
041.9
Bacterial infection, unspecified
Note: Use code 041.9 to denote special handling in route – isolation.
191.9
Brain tumor
199.1-199.2
Malignant neoplasm without specification of site
250.02–250.03
Diabetes mellitus, uncontrolled (without mention of complication)
250.12–250.13
Diabetes mellitus, uncontrolled (with ketoacidosis)
250.22–250.23
Diabetes mellitus, uncontrolled (with hyperosmolar coma)
250.32–250.33
Diabetes mellitus, uncontrolled (with other coma)
250.42–250.43
Diabetes mellitus, uncontrolled (with renal manifestations)
250.52–250.53
Diabetes mellitus, uncontrolled (with ophthalmologic manifestations)
250.62–250.63
Diabetes mellitus, uncontrolled (with neurologic manifestations)
250.72–250.73
Diabetes mellitus, uncontrolled (with peripheral circulatory manifestations)
250.80–250.83
Diabetes mellitus, with other specified manifestations
251.0–251.1
Other disorders of pancreatic secretions
276.50–276.52
Disorders of fluid, electrolytes, and acid-base balance
291.0
Delirium tremens
291.81
Alcohol withdrawal psychosis
292.0
Drug withdrawal
292.2
Pathologic drug intoxication
293.0
Delirium due to conditions classified elsewhere
Note: Use code 293.0 to denote chemical restraint.
293.1
Subacute delirium
Note: Use code 293.1 to denote patient safety: danger to self and others – monitoring other and unspecified reactive psychosis.
298.8
Other and unspecified reactive psychosis
Note: Use code 298.8 to denote patient safety: danger to self and others – seclusion (flight risk).
305.00-305.92
Drunkenness and other drug intoxicated states
312.39
Combativeness
Note: Use code 312.39 if behavior is such that restraints were required to ensure patient safety.
410.00–410.02
Acute myocardial infarction of anterolateral wall
410.10–410.12
Acute myocardial infarction of other anterior wall
410.20–410.22
Acute myocardial infarction of inferolateral wall
410.30–410.32
Acute myocardial infarction of inferoposterior wall
410.40–410.42
Acute myocardial infarction of other inferior wall
410.50–410.52
Acute myocardial infarction of other lateral wall
410.60–410.62
Acute myocardial infarction, true posterior wall infarction
410.70–410.72
Acute myocardial infarction, subendocardial infarction
410.80–410.82
Acute myocardial infarction of other specified site
410.90–410.92
Acute myocardial infarction of unspecified site
413.1
Angina pectoris
415.11
Iatrogenic pulmonary embolism and infarction
415.19
Pulmonary embolism, other
423.3
Cardiac tamponade
426.0
Atrioventricular block, complete
426.3
Left bundle branch block
426.4
Right bundle branch block
426.51–426.54
Bundle branch block, other and unspecified
427.0–427.1
Paroxysmal tachycardia, supraventricular and ventricular
427.31–427.32
Atrial fibrillation and flutter
427.41–427.42
Ventricular fibrillation and flutter
427.5
Cardiac or cardiopulmonary arrest
427.69
Ventricular premature beats
427.81
Bradycardia
428.0–428.1
Heart failure, congestive and left heart
428.20–428.23
Systolic heart failure
428.30–428.33
Diastolic heart failure
428.40–428.43
Combined systolic and diastolic heart failure
428.9
Heart failure, unspecified
Note: Use code 428.9 to denote cardiac/hemodynamic monitoring required en route.
431
Intracerebral hemorrhage
434.00–434.01
Cerebral thrombosis
434.10–434.11
Cerebral embolism
434.90–434.91
Cerebral artery occlusion, unspecified
435.9
Transient cerebral ischemia
436
Stroke
438.0
Late effects of cerebrovascular disease, cognitive deficits
438.20–438.22
Late effects of cerebrovascular disease, hemiplegia/hemiparesis
438.40–438.42
Late effects of cerebrovascular disease, monoplegia of lower limb
451.11
Phlebitis and thrombophlebitis, femoral vein (deep)(superficial)
451.19
Phlebitis and thrombophlebitis of deep vessels of lower extremities, other
458.9
Hypotension
459.0
Hemorrhage, unspecified
493.91–493.92
Asthma, unspecified, with status asthmaticus/acute exacerbation
496
Chronic obstructive pulmonary disease, not elsewhere classified
Note: Use code 496 to denote suctioning required en route, need for titrated oxygen therapy or IV fluid(s).
514
Pulmonary congestion and hypostasis
518.4
Acute pulmonary edema, acute
518.7
Transfusion related acute lung injury (TRALI)
530.3
Stricture and stenosis of esophagus, esophageal obstruction
560.81
Intestinal or peritoneal adhesions with obstruction (postoperative)(postinfection)
560.89
Intestinal or peritoneal adhesions with obstruction, other
578.9
Hemorrhage of gastrointestinal tract, unspecified
646.80
Other specified complications of pregnancy, unspecified as to episode of care or not applicable
707.03–707.05
Pressure ulcer
707.23–707.24
Pressure ulcer
718.40–718.49
Contracture of joints
719.49
Pain in joint, multiple sites
Note: Use code 719.49 to denote specialized handling en route – position requires specialized handling.
724.1
Pain in thoracic spine
724.2
Lumbago
724.5
Backache unspecified
729.81
Swelling of limb
780.01–780.03
Alterations of consciousness
780.09
Alterations of consciousness
780.1–780.2
General symptoms
780.32
Complex febrile convulsions
780.33
Post traumatic seizures
780.39
Other convulsions (seizures)
780.60–780.62
Fever
780.65
Hypothermia not associated with low environmental temperature
Note: Use of diagnosis codes 780.60–780.62 and 780.65 alone will not be sufficient to allow ambulance transportation. Use an additional diagnosis to indicate the associated condition of the patient that necessitates ambulance transportation of a febrile person.
780.72
Functional quadriplegia
780.97
Altered mental status
781.2–781.4
Symptoms involving nervous and musculoskeletal systems
Note: Use code 781.3 to denote patient safety – risk of falling off wheelchair or stretcher while in motion.
781.6
Meningismus
782.5
Cyanosis
784.0
Headache
784.3
Aphasia
785.0–785.1
Symptoms involving cardiovascular system
785.4
Gangrene
785.50–785.52
Shock without mention of trauma
785.59
Shock without mention of trauma, other
786.09
Dyspnea and respiratory abnormalities (respiratory distress), other
Note: Use code 786.09 to denote airway control/positioning required en route.
786.50–786.52
Chest pain
787.01
Nausea with vomiting
787.03
Vomiting
789.01–789.07
Abdominal pain
789.09
Abdominal pain, other specified site
789.30–789.37
Abdominal or pelvic swelling, mass or lump
789.39
Abdominal or pelvic swelling, mass or lump
789.40–789.47
Abdominal rigidity
789.49
Abdominal rigidity
789.60–789.67
Abdominal tenderness (rebound tenderness)
789.69
Abdominal tenderness (rebound tenderness)
796.2
Elevated blood pressure reading without diagnosis of hypertension
799.01–799.02
Other ill-defined and unknown causes of morbidity and mortality, asphyxia (hypoxemia)
799.1
Respiratory arrest
799.82
Apparent life threatening event in infant
803.00–803.06
Closed skull fracture without mention of intracranial injury
803.09
Closed skull fracture without mention of intracranial injury
803.10–803.16
Closed skull fracture with cerebral laceration and contusion
803.19
Closed skull fracture with cerebral laceration and contusion
803.20–803.26
Closed skull fracture with subarachnoid, subdural and extradural hemorrhage
803.29
Closed skull fracture with subarachnoid, subdural and extradural hemorrhage
803.30–803.36
Closed skull fracture with other and unspecified intracranial hemorrhage
803.39
Closed skull fracture with other and unspecified intracranial hemorrhage
803.40–803.46
Closed skull fracture with intracranial injury of other and unspecified nature
803.49
Closed skull fracture with intracranial injury of other and unspecified nature
803.50–803.56
Open skull fracture without mention of intracranial injury
803.59
Open skull fracture without mention of intracranial injury
803.60–803.66
Open skull fracture with cerebral laceration and contusion
803.69
Open skull fracture with cerebral laceration and contusion
803.70–803.76
Open skull fracture with subarachnoid, subdural and extradural hemorrhage
803.79
Open skull fracture with subarachnoid, subdural and extradural hemorrhage
803.80–803.86
Open skull fracture with other and unspecified intracranial hemorrhage
803.89
Open skull fracture with other and unspecified intracranial hemorrhage
803.90–803.96
Open skull fracture with intracranial injury of other and unspecified nature
803.99
Open skull fracture with intracranial injury of other and unspecified nature
805.00–805.08
Fracture, closed, cervical spine, without mention of spinal cord injury
805.10–805.18
Fracture, open, cervical spine, without mention of spinal cord injury
805.2–805.9
Fracture of vertebral column without mention of spinal cord injury, open/closed
806.00–806.09
Fracture, cervical spine, with spinal cord injury, closed
806.10–806.19
Fracture, cervical spine, with spinal cord injury, open
806.20–806.29
Fracture, dorsal (thoracic) spine, with spinal cord injury, closed
806.30–806.39
Fracture, dorsal (thoracic) spine, with spinal cord injury, open
806.4–806.5
Fracture, lumbar spine, with spinal cord injury, closed/open
806.60–806.62
Fracture, sacrum and coccyx, with spinal cord injury, closed
806.69
Fracture, sacrum and coccyx, with spinal cord injury, closed
806.70–806.72
Fracture, sacrum and coccyx, with spinal cord injury, open
806.79
Fracture, sacrum and coccyx, with spinal cord injury, open
806.8–806.9
Fracture, unspecified vertebral, with spinal cord injury, closed/open
808.0–808.3
Fracture, pelvis (acetabulum/pubis), closed/open
808.41–808.43
Fracture, pelvis (other specified part), closed
808.49
Fracture, pelvis (other specified part), closed
808.51–808.53
Fracture, pelvis (other specified part), open
808.59
Fracture, pelvis (other specified part), open
808.8–808.9
Fracture, pelvis (unspecified part), closed/open
810.10–810.13
Fracture, clavicle, open
812.10–812.13
Fracture of humerus, upper end, open
812.19
Fracture of humerus, upper end, open
812.20–812.21
Fracture of humerus, shaft or unspecified part, closed
812.30–812.31
Fracture of humerus, shaft or unspecified part, open
812.50–812.54
Fracture of humerus, lower end, open
812.59
Fracture of humerus, lower end, open
818.1
Ill-defined fractures of upper limb, open
819.0–819.1
Multiple fractures involving both upper limbs, and upper limb with rib(s) and sternum
820.00–820.03
Fracture of neck of femur, transcervical, closed
820.09
Fracture of neck of femur, transcervical, closed
820.10–820.13
Fracture of neck of femur, transcervical, open
820.19
Fracture of neck of femur, transcervical, open
820.20–820.22
Fracture of neck of femur, pertrochanteric, closed
820.30–820.32
Fracture of neck of femur, pertrochanteric, open
820.8–820.9
Fracture of neck of femur, unspecified part, closed/open
821.00–821.01
Fracture of shaft or unspecified part of femur, open
821.10–821.11
Fracture of shaft or unspecified part of femur, open
821.20–821.23
Fracture of lower end of femur, closed
821.29
Fracture of lower end of femur, closed
821.30–821.33
Fracture of lower end of femur, open
821.39
Fracture of lower end of femur, open
822.1
Fracture of patella, open
823.00–823.02
Fracture of tibia and fibula, upper end, closed
823.10–823.12
Fracture of tibia and fibula, upper end, open
823.30–823.32
Fracture of tibia and fibula, shaft, open
823.90–823.92
Fracture of tibia and fibula, unspecified part, open
835.00–835.03
Dislocation of hip, closed dislocation
835.10–835.13
Dislocation of hip, open dislocation
836.50–836.54
Dislocation, other, of knee, closed
836.59
Dislocation, other, of knee, closed
836.60–836.64
Dislocation, other, of knee, open
836.69
Dislocation, other, of knee, open
839.00–839.08
Dislocation, closed, cervical spine
839.10–839.18
Dislocation, open, cervical spine
839.20–839.21
Dislocation, closed, thoracic and lumbar spine
839.30–839.31
Dislocation, open, thoracic and lumbar spine
839.40
Dislocation, closed, unspecified vertebra
839.42
Dislocation, closed, sacrum
839.50–839.52
Dislocation, other vertebra, open
839.69
Dislocation, closed, other location (pelvis)
839.71
Dislocation, open, other location (sternum)
839.79
Dislocation, open, other location
839.8–839.9
Multiple and ill-defined dislocations
854.00–854.06
Intracranial injury of other and unspecified nature, without mention of open intracranial wound (closed head injury)
854.09
Intracranial injury of other and unspecified nature, without mention of open intracranial wound (closed head injury)
854.10–854.16
Intracranial injury of other and unspecified nature, with open intracranial wound (open head injury)
854.19
Intracranial injury of other and unspecified nature, with open intracranial wound (open head injury)
870.1–870.4
Open wound of ocular adnexa
871.0–871.7
Open wound of eyeball
871.9
Open wound of eyeball
907.2
Late effect of spinal cord injury
Note: Use code 907.2 to denote special handling en route to reduce pain.
933.1
Foreign body in larynx (choking)
934.9
Foreign body in respiratory tree
949.0–949.5
Burn, unspecified
959.01
Head injury, unspecified
959.09
Injury of face and neck
959.11–959.12
Other injury of trunk
959.19
Other injury of other sites of trunk
959.6–959.9
Injury to hip/thigh, knee/leg/ankle/foot, other specified/multiple, and unspecified site
Note: Use code 959.9 to report a fall with injuries and other multiple injury conditions such as injuries sustained in motor vehicle accidents.
977.9
Poisoning by unspecified drugs and medicinal substances (drug overdose)
991.6
Effects of reduced temperature (hypothermia)
994.0–994.1
Effects of other external causes
994.7–994.8
Effects of other external causes
995.0
Anaphylactic shock, not otherwise specified
995.27
Other drug allergy
995.29
Unspecified adverse effect of other drug, medicinal and biological substance
995.3
Allergy, unspecified
995.80
Adult maltreatment, unspecified (This code may be used to report assaults.)
998.30
Disruption of wound, unspecified
998.32
Disruption of external operation (surgical) wound
998.33
Disruption of traumatic injury wound repair
V07.0
Isolation (need for)
V15.6
Personal history of poisoning
V15.89
Other specified personal history presenting hazards to health
V45.88
Status post-administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility
V46.11– V46.12
Dependence on respirator (ventilator)
V46.14
Mechanical complication of respirator (ventilator)
V46.2
Other dependence on machines, supplemental oxygen
Note: Use code V46.2 to indicate that transportation was necessary due to administration of medically necessary oxygen or required IV medications when the patient is incapable of self-administration.
V49.75–V49.76
Lower limb amputation status
V49.84
Cannot sit in a chair and cannot stand and cannot get up from bed without assistance
V49.87
Physical restraints status
Table 2 – Covered for Ambulance Services for Return Transportation Following Receipt of Medical Care:
191.9
Brain tumor
199.1-199.2
Malignant neoplasm without specification of site
312.39
Combativeness
Note: Use code 312.39 if behavior is such that restraints were required to ensure patient safety.
436
Acute, but ill-defined, cerebrovascular disease (stroke)
438.0
Late effects of cerebrovascular disease, cognitive deficits
438.20–438.22
Late effects of cerebrovascular disease, hemiplegia/hemiparesis
438.40–438.42
Late effects of cerebrovascular disease, monoplegia of lower limb
707.03–707.05
Pressure ulcer
707.23–707.24
Pressure ulcer
718.40–718.49
Contracture of joints
780.01–780.03
Alterations of consciousness
780.09
Alterations of consciousness
806.00–806.09
Fracture, cervical spine, with spinal cord injury, closed
806.10–806.19
Fracture, cervical spine, with spinal cord injury, open
806.20–806.29
Fracture, dorsal (thoracic) spine, with spinal cord injury, closed
806.30–806.39
Fracture, dorsal (thoracic) spine, with spinal cord injury, open
806.4–806.5
Fracture, lumbar spine, with spinal cord injury, closed/open
806.60–806.62
Fracture, sacrum and coccyx, with spinal cord injury, closed
806.69
Fracture, sacrum and coccyx, with spinal cord injury, closed
806.70–806.72
Fracture, sacrum and coccyx, with spinal cord injury, open
806.79
Fracture, sacrum and coccyx, with spinal cord injury, open
806.8–806.9
Fracture, unspecified vertebral, with spinal cord injury, closed/open
808.0-808.3
Fracture, pelvis (acetabulum/pubis), closed/open
808.41–808.43
Fracture, pelvis (other specified part), closed
808.49
Fracture, pelvis (other specified part), closed
808.51–808.53
Fracture, pelvis (other specified part), open
808.59
Fracture, pelvis (other specified part), open
808.8–808.9
Fracture, pelvis (unspecified part), closed/open
820.00–820.03
Fracture of neck of femur, transcervical, closed
820.09
Fracture of neck of femur, transcervical, closed
820.10–820.13
Fracture of neck of femur, transcervical, open
820.19
Fracture of neck of femur, transcervical, open
820.20–820.22
Fracture of neck of femur, pertrochanteric, closed
820.30–820.32
Fracture of neck of femur, pertrochanteric, open
820.8-820.9
Fracture of neck of femur, unspecified part, closed/open
821.00–821.01
Fracture of shaft or unspecified part of femur, closed
821.10–821.11
Fracture of shaft or unspecified part of femur, open
821.20–821.23
Fracture of lower end of femur, closed
821.29
Fracture of lower end of femur, closed
821.30–821.33
Fracture of lower end of femur, open
821.39
Fracture of lower end of femur, open
959.01
Head injury, unspecified
959.11–959.12
Other injury of trunk
959.19
Other injury of other sites of trunk
V46.11–V46.12
Dependence on respirator (ventilator)
V46.14
Mechanical complication of respirator (ventilator)
V46.2
Other dependence on machines, supplemental oxygen
Note: Use code V46.2 to indicate that transportation was necessary due to administration of medically necessary oxygen when the patient is incapable of self-administration.
V49.75–V49.76
Lower limb amputation status
V49.84
Cannot sit in a chair and cannot stand and cannot get up from bed without assistance
V49.87
Physical restraints status

Documentation Requirements
It is the responsibility of the ambulance supplier to maintain (and furnish to Medicare upon demand) complete and accurate documentation of the beneficiary’s condition to demonstrate the ambulance service being furnished meets the medical necessity criteria. Documentation must be legible. The documents required for this Medicare purpose include the following:
  • A PCS (for those services for which the physician certification is required - see Physician’s Certification Statement section). The certification itself is not the sole factor used in determining whether payment for ambulance services will be allowed:
    • The PCS may be completed and signed by the following medical professionals: the patient’s attending physician (MD or DO), or for instances in which the physician signature is not available, a PA, NP, CNS, Registered Nurse (RN), or discharge planner employed by the hospital or facility where the beneficiary is treated with knowledge of the beneficiary’s condition at the time the transport was ordered or the service was rendered.
    • A particular form or format is not required for the certification. Suppliers and physicians may develop their own certification form.
    • Ambulance company employees should not complete forms on behalf of these individuals.
    • For repetitive services, the PCS may include the expected length of time ambulance transport would be required but may not exceed 60 days.
  • Trip record must include:
    • A detailed description of the patient’s condition at the time of transport. Coverage will not be allowed if the trip record contains an insufficient description of the patient’s condition at the time of transfer for Medicare to reasonably determine that other means of transportation are contraindicated. Coverage will not be allowed if the description of the patient’s condition is limited to conclusory opinions, such as the following:
      • “Patient is non-ambulatory.”
      • “Patient moved by drawsheet.”
      • “Patient could only be moved by stretcher.”
      • “Patient is bed-confined.”
      • “Patient is unable to sit, stand or walk.”
    • The trip record must “paint a picture” of the patient’s condition and must be consistent with documentation found in other supporting medical record documentation (including the physician’s certification). The trip record must include the following:
      • A concise explanation of symptoms reported by the patient and/or other observers and details of the patient’s physical assessments that clearly demonstrate that the patient requires ambulance transportation and cannot be safely transported by an alternate mode.
      • A description of the patient’s physical condition in sufficient detail to demonstrate that the patient’s condition or functional status at the time of transport meets Medicare limitation of coverage for ambulance services.
      • Description of the traumatic event when trauma is the basis for suspected injuries.
      • A detailed description of existing safety issues.
      • A detailed description of special precautions taken (if any) and explanation of the need for such precautions.
      • A description of specific monitoring and treatments ordered and performed/administered. That a treatment (such as oxygen) and/or monitoring (such as cardiac rhythm monitoring) were performed absent sufficient description of the patient’s condition (to demonstrate that the treatment and/or monitoring was medically necessary) is inadequate on its own merit to justify payment for the ambulance service.
    • Point of pick-up (identify place and complete address).
    • Number of loaded miles/cost per mile/mileage charge.
    • Minimal or base charge and charge for special items or services with an explanation.
    • For hospital-to-hospital transports, the trip record must clearly indicate the precise treatment or procedure (or medical specialist) that is available only at the receiving hospital. Non-specific or vague statements such as “needs cardiac care” or “needs higher level of care” are insufficient.
  • Any additional available documentation that supports medical necessity of ambulance transport (for example, emergency room report, SNF record, End Stage Renal Disease (ESRD) facility record, hospital record).
  • Dispatch record

Utilization Guidelines
Most patients who require ambulance transportation have a short-term need due to an acute illness or injury. Longer term repetitive or frequent ambulance transportation is medically necessary for relatively few patients. Medicare expects that more than eight covered ambulance trips per year will rarely be medically necessary for an individual beneficiary and will cover no more than 12 ambulance trips per beneficiary per year without review of the patient’s medical record.
Notice: This LCD imposes utilization guideline limitations that support automated frequency denials. Despite Medicare’s allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services.

1 comment:

Martin Stromberg said...

There is two type of medical transportation, Emergency and non-emergency and Medicaid covered like first aid, medicine, oxygen pump therapy in emergency medical transportation but it is not in non-emergency medical transportation.
Now there are some private companies in Scottsdale, USA, which are engaged with these Non-emergency medical transportation services provides Medicaid and non-Medicaid facilities with wheelchair and stretcher.

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