RETIRED LCD Reference Article Billing and Coding Article

Billing and Coding: Ambulance Services

A56468

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
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Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A56468
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Ambulance Services
Article Type
Billing and Coding
Original Effective Date
04/04/2019
Revision Effective Date
07/01/2021
Revision Ending Date
08/31/2024
Retirement Date
08/31/2024

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CMS National Coverage Policy

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim

Title XVIII of the Social Security Act §1861(s)(7) defines ambulance service where the use of other methods of transportation is contraindicated by the individual's condition, but only to the extent provided in regulations

Title XVIII of the Social Security Act §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member

42 CFR §410.40 addresses the coverage of ambulance services

CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 10, §10 Ambulance Service, §10.2.2 Reasonableness of the Ambulance Trip, §10.2.6 Effect of Beneficiary Death on Medicare Payment for Ground Ambulance Transports, §10.3 The Destination, §10.3.1 Institution of Beneficiary's Home, §10.3.2 Institution of Institution, §10.3.3 Separately Payable Ambulance Transport Under Part B Versus Patient Transportation that is Covered Under a Packaged Institutional Service, §10.3.4 Transports to and from Medical Services for Beneficiaries who are not Inpatients, §10.3.7 Partial Payment, §10.3.8 Ambulance Service to Physician's Office, §10.3.9 Transportation Requested by Home Health Agency, §10.3.10 Multiple Patient Ambulance Transport, §10.4 Air Ambulance Services, §10.1.1 Coverage Requirements, §10.4.4 Hospital to Hospital Transport, §10.4.5 Special Coverage Rule, §10.4.6 Special Payment Limitations, §10.4.8 Air Ambulance Transports Canceled Due to Weather or Other Circumstances Beyond the Pilot's Control, §10.4.9 Effect of Beneficiary Death on Program Payment for Air Ambulance Transports, §10.5 Joint Responses, and §20 Coverage Guidelines for Ambulance Service Claims

CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 15, §10.2 Summary of the Benefit, §10.4 Additional Introductory Guidelines, §20 Payment Rules, §20.1 Payment Under the Ambulance Fee Schedule, §20.1.1 General, §20.1.3 Services Provided, §20.1.4 Components of the Ambulance Fee Schedule, §20.3 Air Ambulance, §20.6 Payment for Non-Emergency BLS Trips to/from ESRD Facilities, §30 General Billing Guidelines, §30.1 Multi-Carrier System (MCS) Guidelines, §30.1.1 MCS Coding Requirements for Suppliers, §30.1.2 Coding Instructions for Paper and Electronic Claim Forms, §30.1.3 Coding Instructions for Form CMS-1491, §30.2 Fiscal Intermediary Shared System (FISS) Guidelines, §30.2.1 A/B MAC (A) Bill Processing Guidelines Effective April 1, 2002, as a Result of Fee Schedule Implementation, §30.2.2 SNF Billing, §30.2.3 Indian Health Services/Tribal Billing, and §30.2.4 Non-covered Charges on Institutional Ambulance Claims

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Ambulance Services L34549.

Physician Certification & Order:

The ambulance supplier is responsible for obtaining the signed written order and certification with the appropriate signatures as expeditiously as possible, and must obtain the signed order before billing for the service.

If the ambulance supplier is unable to obtain the written order and certification with appropriate signatures within 21 calendar days following the date of the service, the supplier may bill only if there is documentation of good faith effort to obtain the order and certification.

When the transport involves a ground ambulance and an air ambulance, both services may be reimbursed if both are medically necessary.

The ambulance provider or supplier must meet all coverage criteria in order for payment to be made.

Medicare requires the signature of the beneficiary, or that of his or her representative, for both the purpose of accepting assignment and submitting a claim to Medicare.

Ambulance services that are not Medicare benefits because some other form of transportation is not contraindicated, is an exclusion from Medicare benefits under the statutory definition of that benefit at §1861(s)(7). An Advance Beneficiary Notice of Noncoverage (ABN) is not needed and should not be used in the following situations: 

  1. Any denial where the patient could be transported safely by other means (these are denials under §1861(s)(7) of the Social Security Act (SSA)).
  2. Any denial that is based on not meeting an origin or destination requirement (these denials are inconsistent with 42 CFR §410.40 and generally also constitute §1861(s)(7) denials).
  3. A denial for mileage that is beyond the nearest appropriate facility (for the same reason as b. above).
  4. A denial where the physician certification statement or accepted alternative (e.g., certified mail) is not obtained (for the same reason as b. above).
  5. A convenience discharge, e.g., where the beneficiary is an inpatient at one hospital that can care for their needs, but wants to be transferred to a second hospital to be closer to family (for the same reason as b. above).

Not obtaining an ABN in these technical denial situations does not prevent the supplier or provider from collecting denied charges from the beneficiary.

CMS developed the Beneficiary Notices Initiative web page to assist suppliers and providers in informing beneficiaries that the services they are receiving are excluded from Medicare benefits. Ambulance suppliers may develop their own process to communicate to beneficiaries that they will be billed for excluded services for which the ABN is not appropriate.

Multiple patient transports - a single payment allowance for mileage will be prorated by the number of beneficiaries onboard.

Downcoding from air to ground is an §1862(a)(1)(A) denial.

Multiple arrivals - when multiple units respond to a call for services the entity that provides the transport for the beneficiary should be the only provider billing the service.

Response To Comments

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Coding Information

Bill Type Codes

Code Description

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Revenue Codes

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

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ICD-10-CM Codes that DO NOT Support Medical Necessity

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ICD-10-PCS Codes

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Additional ICD-10 Information

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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 article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description

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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 article, 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 article should be assumed to apply equally to all Revenue Codes.

Code Description

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Other Coding Information

Group 1

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
08/31/2024 R5

This article is being retired while this contractor reviews clinical evidence.

07/01/2021 R4

Under CMS National Coverage Policy updated section headings for regulations and added the following regulations: Social Security Act §1861(s)(7), Social Security Act §1862(a)(1)(A), and 42 CFR §410.40. Typographical errors were corrected throughout the article.

10/10/2019 R3

This article is being revised in order to adhere to CMS requirements per Chapter 13, Section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs and incorporate into related Billing and Coding Articles. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of the related Ambulance Services L34549 LCD and placed in this article.

05/09/2019 R2

Under Article Text added the subheading “Physician Certification & Order”. The verbiage “The ambulance supplier is responsible for obtaining the signed written order and certification with the appropriate signatures as expeditiously as possible, and must obtain the signed order before billing for the service. If the ambulance supplier is unable to obtain the written order and certification with appropriate signatures within 21 calendar days following the date of the service, the supplier may bill only if there is documentation of good faith effort to obtain the order and certification. When the transport involves a ground ambulance and an air ambulance, both services may be reimbursed if both are medically necessary. The ambulance provider or supplier must meet all coverage criteria in order for payment to be made.” was added to this section.

04/04/2019 R1

All coding located in the Coding Information section has been removed from the related Ambulance Services L34549 LCD and added to this article.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L34549 - Ambulance Services (Retired)
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
08/31/2024 07/01/2021 - 08/31/2024 Retired You are here
06/22/2021 07/01/2021 - N/A Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Ambulance Services