RETIRED Local Coverage Determination (LCD)

Ambulance Services

L34549

Expand All | Collapse All

Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
Palmetto GBA	A and B MAC	10111 - MAC A	J - J	Alabama
Palmetto GBA	A and B MAC	10211 - MAC A	J - J	Georgia
Palmetto GBA	A and B MAC	10311 - MAC A	J - J	Tennessee
Palmetto GBA	A and B and HHH MAC	11201 - MAC A	J - M	South Carolina
Palmetto GBA	A and B and HHH MAC	11301 - MAC A	J - M	Virginia
Palmetto GBA	A and B and HHH MAC	11401 - MAC A	J - M	West Virginia
Palmetto GBA	A and B and HHH MAC	11501 - MAC A	J - M	North Carolina

LCD Information

Document Information

LCD ID
L34549

LCD Title
Ambulance Services

Proposed LCD in Comment Period
N/A

Source Proposed LCD
N/A

Original Effective Date
For services performed on or after 10/01/2015

Revision Effective Date
For services performed on or after 07/29/2021

Revision Ending Date
08/31/2024

Retirement Date
08/31/2024

Notice Period Start Date
N/A

Notice Period End Date
N/A

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Copyright © 2024, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution, or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

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

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 §1861(v)(1)(K)(ii) defines emergency services

42 CFR §410.40 addresses the coverage of ambulance services

42 CFR §424.36 (a)-(e) addresses signature requirements

Federal Register, Vol. 66, No. 233, December 4, 2001, Rules and Regulations, pp.62980, Ambulance Restocking and the Anti-Kickback Statute

Federal Register, Vol. 67, No. 39, February 27, 2002, Rules and Regulations, pp. 9102, 9106, and 9108

CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 10, §10.1 Vehicle and Crew Requirement, §10.1.1 The Vehicle, §10.1.2 Vehicle Requirements for Basic Life Support and Advanced Life Support, §10.1.3 Verification of Compliance, §10.1.4 Ambulance Services Furnished by Providers of Services, §10.1.5 Equipment and Supplies, §10.2 Necessity and Reasonableness, §10.2.1 Necessity for the Service, §10.2.3 Medicare Policy Concerning Bed-Confinement, §10.2.4 Documentation Requirements, §10.2.5 Transport of Persons Other Than the Beneficiary, §10.3.5 Locality, §10.3.6 Appropriate Facilities, §10.4.2 Medical Reasonableness, §10.4.3 Time Needed for Ground Transport. §10.4.7 Documentation, §20.1 Mandatory Assignment Requirements, §20.1.1 Managed Care Providers/Suppliers, §20.1.2 Beneficiary Signature Requirements, §30 Implementation of the Ambulance Fee Schedule, §30.1 Definition of Ambulance Services, §30.1.1 Ground Ambulance Services, and §30.1.2 Air Ambulance Services

CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 15, §10 Overview, §10.1 Authorities, §10.1.1 Statutes and Regulations, §10.1.2 Other References to Ambulance Related Policies in the CMS Internet Only Manuals, §10.3 Definitions, §20.1.2 Jurisdiction, §20.1.5 ZIP Code Determines Fee Schedule Amounts, §20.1.5.1 CMS Supplied National ZIP Code File and National Ambulance Fee Schedule File, §20.1.6 Contractor Determination of Fee Schedule Amounts, §20.2 Payment for Mileage Charges, §20.4 Ambulance Inflation Factor (AIF), §20.5 Documentation Requirements, §30.1.4 CWF Editing of Ambulance Claims for Inpatients, and §40 Medical Conditions List and Instructions

CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 6, §6.4 Medical Review of Rural Air Ambulance Services, §6.4.1 "Reasonable" Requests, §6.4.2 Emergency Medical Services (EMS) Protocols, §6.4.3 Prohibited Air Ambulance Relationships, §6.4.4 Reasonable and Necessary Services, and §6.4.5 Definition of Rural Air Ambulance Services

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Medicare covers ambulance services, only if they are furnished to a beneficiary whose medical condition is such that use of any other means of transportation is contraindicated. A beneficiary whose condition permits transport in any type of vehicle, other than an ambulance, would not qualify for services under Medicare. The beneficiary's condition at the time of the transport is the determining factor in whether medical necessity is met.

A. Emergency Ambulance Services (Ground):

Emergency response means responding immediately at the Basic Life Support (BLS) or Advanced Life Support, Level 1 (ALS1) level of service to a 911 call or the equivalent in areas without a 911 call system. Medicare will cover emergency ambulance services when the services are medically necessary, meet the destination limits of the closest appropriate facilities, and are provided by an ambulance service that is licensed by the state.

Medical Reasonableness:

Medical reasonableness is established if the beneficiary's condition is an emergency, and the beneficiary is unable to go to the hospital by other means. An emergency means services provided after the sudden onset of a medical condition, manifesting itself by acute signs or symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in the following: placing the beneficiary's health in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part.

Examples of emergency situations are: (Note: this list is not all inclusive)

1. Injury resulting from an accident, or illness with acute symptoms. Examples are hemorrhage, shock, chest pain, acute neurological symptoms or respiratory distress.

2. The beneficiary requires restraints by a professionally trained ambulance attendant as a means of preventing injury either to the beneficiary or to another person. A description of why restraints are necessary is required. Such descriptions may include narrative describing specific violent or psychotic acts, frequency/severity/predictability of seizure activity, or a precise description of the risk to safety that unrestrained and unsupervised transport would create. A sole diagnosis of senility, forgetfulness, or Alzheimer's does not qualify.

3. Oxygen is required by the beneficiary during transport. The administration of oxygen itself does not satisfy the requirement that the beneficiary needed oxygen. Documentation should reflect the need for oxygen administration, such as hypoxemia, syncope, airway obstruction, and chest pain. Ambulance transport is not medically necessary if the only reason for the ambulance service is to provide oxygen during transport, and the beneficiary has a portable oxygen system available.

4. Immobilization of the beneficiary is necessary because of a suspected fracture, a compound fracture, severe pain, the need for pain medication, or suspicion of neurological injury.

5. A transfer is made of a beneficiary between institutions for necessary services not available at the transferring institution and the beneficiary meets any of the criteria 1-4 above. Examples are beneficiaries with cardiac disease requiring cardiac catheterization or coronary bypass not available at the transferring institution.

B. Non-Emergency (Scheduled) Ambulance Service (Ground):

Three criteria determine whether a beneficiary has Medicare coverage for non-emergency (scheduled) ambulance services:

* Only when transportation by any other means of transportation is contraindicated by the medical condition of the beneficiary;

* Only to specific destinations; and

* Only when certified as medically necessary by a physician directly responsible for the beneficiary's care

NOTE: All 3 of the above criteria must be met.

Medical Reasonableness:

Ambulance transport in non-emergency situations must meet medical necessity guidelines.

1. Medical reasonableness is established for non-emergency ambulance services when the beneficiary's condition is such that the use of any other method of transportation (e.g., taxi, private car, wheelchair van, or other type of vehicle) is contraindicated.

NOTE: Bed confinement does not include a beneficiary who is restricted to bed rest on a physician's instructions due to a short-term illness. Bed confinement, by itself, is neither sufficient nor is it necessary to determine the coverage for Medicare ambulance benefits. It is simply 1 element of the beneficiary's condition that may be taken into account in the A/B MAC determination of whether means of transport, other than an ambulance, were contraindicated. Examples of situations in which beneficiaries are bed-confined and cannot be moved by wheelchair, but must be moved by stretcher include:

a. Contractures creating non-ambulatory status and the beneficiary cannot sit

b. Severe generalized weakness

c. Severe vertigo causing inability to remain upright

d. Immobility of lower extremities (beneficiary is in a spica cast, fixed hip joints, or lower extremity paralysis) and unable to be moved by wheelchair

2. If some means of transportation other than an ambulance (e.g., private car, wheelchair van, etc.) could be utilized without endangering the individual's health, whether or not such other transportation is actually available, no payment may be made for ambulance service.

3. If transportation is for the purpose of receiving an excluded service (e.g., a routine dental examination) then the transportation is also excluded even if the beneficiary could only have gone by ambulance.

4. If transportation is for the purpose of receiving a service that could have been safely and effectively provided at the point of origin, then the transport is not covered even if the beneficiary could only have gone by ambulance. Examples include: (a) A transport from a residence to a hospital for a service that can be performed more economically in the beneficiary's home, and (b) A transport of a Skilled Nursing Facility (SNF) beneficiary to a hospital or to another SNF for a service that can be performed more economically in the first SNF.

5. Ambulance transportation for services excluded from SNF consolidated billing must meet the criteria as reasonable and necessary (i.e., other means contraindicated).

C. Emergency Air Ambulance Transportation:

Emergency response means responding immediately at the BLS or ALS1 level of service to a 911 call or the equivalent in areas without a 911 call system. 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. Medically appropriate air ambulance transportation, either by means of a helicopter or fixed wing aircraft, is a covered service, regardless of the state or region in which it is rendered, only if the beneficiary's medical condition required immediate and rapid ambulance transportation that could not have been provided by land ambulance, or either:

A. The point of pick-up is inaccessible by land vehicle (this condition could be met in Hawaii, Alaska, and in other remote or sparsely populated areas of the continental United States), or

B. Great distances or other obstacles (i.e., heavy traffic) are involved in getting the patient to the nearest hospital with appropriate facilities as described in this policy.

NOTE: If the transport is for the purpose of receiving a non-covered service, then the transport is also non-covered, even if the destination is an appropriate facility.

Physician Certification & Order:

Ambulance transport providers or suppliers must obtain a written order from the attending physician for all non-emergency, scheduled repetitive ambulance services and a written statement from the physician certifying the medical necessity of the ambulance services. Requirements for non-emergency ambulance transportation include:

1. The order and certification must be dated no earlier than 60 days in advance of the transport, for repetitive beneficiaries whose transportation is scheduled in advance.

2. For residents in facilities who are under the direct care of a physician, written orders from the patient's attending physician certifying medical necessity can be obtained within 48 hours after the transport.

3. The physician order may be signed by a physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS) (where all applicable state licensure or certification requirements are met).

4. For unscheduled non-emergency transports, a registered nurse (RN) or discharge planner, who is employed by the beneficiary's attending physician or the hospital or facility where the patient is being treated, may sign a physician certification statement on oral orders from the physician or other qualified practitioner (i.e., PA, NP, CNS).

5. A physician order is not required prior to emergency transports or unscheduled transports of a beneficiary residing at home or in a facility, who is not under the direct care of a physician.

NOTE: It is important to note that the presence of the signed physician certification statement does not necessarily demonstrate that the transport was medically necessary.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes

Changes	Fields Changed
	N/A

Associated Information

Sources of Information

Bibliography

Open Meetings

Contractor Advisory Committee (CAC) Meetings

MAC Meeting Information URLs

Proposed LCD Posting Date

Comment Period Start Date

Comment Period End Date

Reason for Proposed LCD

Requestor Name	Requestor Letter
	View Letter

Requestor Information

Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code	Description
Please accept the License to see the codes.

Revenue Codes

Code	Description
Please accept the License to see the codes.

ICD-10-CM Codes that Support Medical Necessity

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

Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements- For non-emergent transport:

It is the responsibility of the ambulance supplier to furnish complete and accurate documentation of the beneficiary's condition to demonstrate that the ambulance service being furnished meets the medical necessity criteria.

Documentation should include a physicians written order for transport.

Trip record to include:

Detailed statement of the condition necessitating the ambulance service
Name and address of the certifying physician
Name and address of the physician ordering the service, if other than the certifying physician
Point of pick-up (identify place and complete address)
Destination (identify place and complete address)
Number of loaded miles (the number of miles traveled when the beneficiary was in the ambulance)
Cost per mile
Mileage charge
Minimal or base charge
Charge for special items or services with an explanation
Rationale for the condition (bed confined if applicable) and any further documentation that supports the medical necessity of ambulance transport (i.e., emergency room report).

Documentation Requirements- For emergent transport:

It is the responsibility of the ambulance supplier to furnish complete and accurate documentation of the beneficiary's condition to demonstrate that the ambulance service being furnished meets the medical necessity criteria.

Documentation should include a physicians written order for transport.

Trip record to include:

Detailed statement of the condition necessitating the ambulance service

Name and address of the certifying physician

Name and address of the physician ordering the service, if other than the certifying physician

Point of pick-up (identify place and complete address)

Destination (identify place and complete address)

Number of loaded miles (the number of miles traveled when the beneficiary was in the ambulance)

Cost per mile

Mileage charge

Minimal or base charge

Charge for special items or services with an explanation
Rationale for the condition (bed confined if applicable) and any further documentation that supports the medical necessity of ambulance transport (i.e., emergency room report).

Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, and must be made available to the A/B MAC upon request.

Utilization Guidelines

Aspirin alone does not qualify to validate as an indicator that an ALS2 level has been supplied. Oxygen alone, even at high flow rates, does not qualify to validate as an indication that an ALS2 level has been supplied. Administration of IV fluids, even with a fluid challenge, does not qualify to validate as an indication that an ALS2 level has been supplied.

Nitroglycerin administered as an assist to the beneficiary's own nitroglycerin does not qualify to validate as an indication that an ALS2 level has been supplied. Nitroglycerin administered intravenously from the ambulance stock under a physician's telephonic order, or standing orders does qualify as an indication (as 1 of 3 medications) that an ALS2 level has been supplied.

Sources of Information
N/A

Bibliography

N/A

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation	Reasons for Change
08/31/2024	R15	This LCD is being retired while this contractor reviews clinical evidence.	LCD Being Retired
07/29/2021	R14	Under *CMS National Coverage Policy* updated section headings for regulations. Typographical errors were corrected throughout the LCD.	Provider Education/Guidance
10/10/2019	R13	This LCD 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. There has been no change in coverage with this LCD revision. Regulations regarding billing and coding were removed from the *CMS National Coverage Policy* section of this LCD and placed in the related Billing and Coding: Ambulance Services A56468 article. Under *CMS National Coverage Policy* removed sentence “CMS National Coverage Policy Language quoted from the Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy.” At this time 21^stCentury Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance
05/09/2019	R12	All verbiage regarding billing and coding under the *Coverage Indications, Limitations and/or Medical Necessity* section has been removed and is included in the related Billing and Coding: Ambulance Services A56468 article. Formatting and typographical errors were corrected throughout this section. At this time 21^stCentury Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance
04/04/2019	R11	All coding located in the *Coding Information* section has been moved into the related Billing and Coding: Ambulance Services A56468 article and removed from the LCD. Under *Coverage Indications, Limitations and/or Medical Necessity* removed all quoted Internet Only Manual (IOM) text. Under the subheading *B. Non Emergency (Scheduled) Ambulance Service (Ground) - Medical Reasonableness:* the verbiage “If the condition contraindicating other means of transportation is “bed confined” the beneficiary must meet the following criteria of “bed confined”. The beneficiary is:” and the verbiage “All three components must be met in order for the beneficiary to be considered “bed-confined” was deleted. The word “It” was replaced by the words “Bed confinement” in first sentence of the *NOTE* section. Under *Associated Information* moved verbiage regarding billing and coding to the associated Article A56468. Formatting, punctuation and typographical errors were corrected and acronyms were inserted where appropriate throughout the LCD. At this time 21^stCentury Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance
05/31/2018	R10	Under *CMS National Coverage Policy* deleted the verbiage “NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860 (b) and 42 CFR 426 (Subpart D)). In addition, an administrative law judge may not review a NCD. See section 1869(f)(1)(A)(l) of the Social Security Act” from the first paragraph. The verbiage “Code of Federal Regulations-" was deleted from the fifth and sixth regulation. The section range was revised for the ninth regulation and now reads “10-30.1.2”. The section range was revised for the tenth regulation and now reads “10.1.1-40”. The last regulation was deleted from this section as it has been added to the CMS Internet-Only Manual. Under *Coverage Indications, Limitations and/or Medical Necessity – A. Emergency Ambulance Services (Ground):* added the word “the” before the word “closest”. Under *B. Non Emergency (Scheduled) Ambulance Service (Ground):* deleted the word “and” at the end of the third sentence. Under *Medical Reasonableness:* replaced the verbiage “such as:” with “e.g.” in the paragraphs numbered 1, 2 and 3. Under *C. Emergency Air Ambulance Transportation:* replaced the verbiage “for example,” with “i.e.” in the third paragraph. Under *Medical Reasonableness for Emergency Air Ambulance Transportation:* changed numbered sentences to bullet points. Under *Destination* the numbers at the beginning of the second and third paragraph were removed and the paragraphs were combined. The words “beneficiary” was changed to the word “patient” throughout this paragraph. The verbiage “specialized medical” and “but are not limited to:” were added, and the word “and” was deleted in the second sentence. The verbiage “A patient transported from one hospital to another hospital is covered only if” was added at the beginning of the third sentence. The word “an” was deleted from the fourth paragraph. Under *Ambulance Service to a Physician’s Office:* bullets were added at the beginning of the second and third sentences, the word “and” was added after the second sentence, a new paragraph was formed starting with the verbiage “In such cases”, and the word “beneficiary” was replaced with the word “patient”. Under *CPT/HCPCS Codes – Group 1: Paragraph – Basic Life Support* deleted the verbiage “(as defined in section 10.1, above)” and “(as defined in section 10.2 above)”, and formed a new paragraph starting with the second sentence in the paragraph. Under *Basic Life Support (BLS) Emergency* added the word “Definition:” at the beginning of the paragraph, deleted the verbiage “as specified above” and “(as specified below)”, and formed a new paragraph starting with the second sentence in the paragraph. Under *Advanced Life Support, Level 1 (ALS1)* deleted the verbiage “(as defined in section 10.1, above)” and “(as defined in section 10.2, above)” from the first paragraph, and deleted the verbiage “(as defined below)”, “as defined below”, and “as defined in section 10.2 above” from the second paragraph. Under *Advanced Life Support, Level 1 (ASL1) – Emergency* deleted the verbiage “as specified above” and “as defined below”. Under *Advanced Life Support, Level 2 (ASL2)* added lettered bullets after the paragraph. Under *Specialty Care Transport (SCT)* deleted the verbiage “(as defined below)”. Under *Associated Information – Documentation Requirements – For non-emergent transport and For emergent transport:* added the word “the” in three places in the third bullet. The word “the” was added before the word “condition” in the last bullet. The words “Advance Beneficiary Notice of Noncoverage” was added before the acronym “ABN” and parentheses were placed around the acronym in the third paragraph after the bullets. Throughout the LCD, text quoted from the CMS NCDs and interpretive manuals was italicized, typographical and punctuation errors were corrected, and acronyms were inserted where appropriate. At this time 21^stCentury Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance Typographical Error
01/29/2018	R9	The Jurisdiction "J" Part A Contracts for Alabama (10111), Georgia (10211) and Tennessee (10311) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 01/28/18. Effective 01/29/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part A contract numbers) have been completed in this revision.	Change in Affiliated Contract Numbers
09/18/2017	R8	Under *CMS National Coverage Policy* added the first paragraph and Change Request 10110. Under *Coverage Indications, Limitations, and/or Medical Necessity* added the heading *Locality. Under CPT/HCPCS Codes Group 1: Paragraph Definition of Level of Service- Advanced Life Support, Level 1, (ALS1)* revised “may” in the third sentence of the second paragraph to now read “shall” and added verbiage to the end of the sentence.	Provider Education/Guidance Other
06/01/2017	R7	Under *CPT/HCPCS Codes* – updated the definitions of Basic Life Support, Basic Life Support (BLS) Emergency, Advanced Life Support, Level 1 (ALS1), Advance Life Support, Level 1 (ALS1) – Emergency, Advanced Life Support, Level 2 (ALS2), Specialty Care Transport (SCT), Paramedic Intercept (PI) and Rural Air Ambulance Services	Provider Education/Guidance Typographical Error
06/09/2016	R6	Under *CMS National Coverage Policy* added an “s” to the word “service” to Title XVIII of the Social Security Act, §1861 (v)(1)(k)(ii). Section 10.1 was deleted from CMS Internet-Only Manual, PUB 100-02, Medicare Benefit Policy Manual, Chapter 10. Sections 10, 10.1 and 20.1 were deleted from CMS Internet-Only Manual, PUB 100-04, Medicare Claims Processing Manual, Chapter 15. Under Coverage Indications, Limitations and/or Medical Necessity-Emergency Ambulance Services (Ground) in the first paragraph added “Basic Life Support” and placed BLS in parenthesis, added “Advanced Life Support, Level 1” and placed ALS1 in parenthesis and placed a forward slash and removed the “or” between the word provider and supplier. Under *Destination* added the word “or” after the word "dialysis" in the second paragraph. Under Medical Reasonableness in subsection “a” in the first paragraph the word “and” was removed after the word “assistance”. In subsection “d” verbiage was revised to read “beneficiary is in a spica cast..." and in section four replaced the word “in” with “at”. Under Medical Reasonableness for Emergency Air Ambulance Transportation the word “land” was removed twice and replaced with the word “ground”. Under *Physician Certification & Order* the last sentence in item number four “The physician must later countersign the written order.” was deleted due to a Reconsideration Request. Under *Beneficiary Signature Requirement* the “s” was deleted from the word “claims” in item number five and verbiage was added to the last sentence of the second to the last paragraph in item number six to read “ (Note: there is a 12 month period for filing a Medicare claim, depending upon the date of service.)”. Under CPT/HCPCS Codes -Basic Life Support the word “technical” was deleted and replaced with the word “technician”, under *Advanced Life Support, Level 1 (ALS1)* the words “beneficiary’s/beneficiary” were removed and replaced with the words “patient’s”/patient, under *Specialty Care Transport (SCT)* the word “not” in the last paragraph is bolded and the “s” in “Paramedics” is removed and under *Paramedic Intercept (PI)* the word “Federal Register” in the last paragraph is bolded and the underlining is removed. UnderAssociated Information – Documentation Requirements-For non-emergent transport-Trip Record the verbiage “Statement indicating the beneficiary was admitted as an inpatient including the name and address of the facility” was deleted. Throughout the entire policy punctuation was corrected.	Provider Education/Guidance Typographical Error Reconsideration Request
01/01/2016	R5	The description changed for HCPCS code A0427 under the CPT/HCPCS Codes section.	Revisions Due To CPT/HCPCS Code Changes
10/01/2015	R4	Under CMS National Policy corrected the citation for Pub 11-02, Chapter 10, sections 10-30.1.1 to include new section 30.1.2. Under Coverage Indications, Limitations and/or Medical Necessity made several grammatical and punctuation corrections, under Medical Reasonableness number 3 added “for oxygen administration” to the second sentence, under Destination to clarify transfer site added the verbiage “when a beneficiary is transported by ground ambulance and transferred to an air ambulance, the ground ambulance may bill Medicare for the level of service provided and mileage from the point of pick up to the point of transfer to the air ambulance”. Under Associated Information added “Documentation should include a” to the Physician written order statement.	Provider Education/Guidance Other (Annual Validation)
10/01/2015	R3	Per CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 13, §13.1.3 LCDs consist of only “reasonable and necessary” information. All bill type and revenue codes have been removed.	Other (Bill type and/or revenue code removal)
10/01/2015	R2	Under *CMS National Coverage Policy* added the entire signature requirements for 42 CFR 424.36(a)-(e).	Provider Education/Guidance Other (Expanded signature requirements citation.)
10/01/2015	R1	Under *CMS National Coverage Policy* revised “CMS Manual System” to now read “CMS Internet-Only Manual” Under *Associated Information –Documentation Requirements* added the following verbiage to the heading: “for non-emergent transports” and deleted the following verbiage that was previously located after Physician written order for transport- “if non-emergency physician ordered”. An additional heading was added to now read: Documentation Requirements for Emergent Transports. This revision becomes effective May 1, 2014.	Provider Education/Guidance Other

Associated Documents

Attachments
N/A

Related Local Coverage Documents
Articles
A56468 - Billing and Coding: Ambulance Services (Retired)

Updated On	Effective Dates	Status
08/31/2024	07/29/2021 - 08/31/2024	Retired	You are here
07/23/2021	07/29/2021 - N/A	Superseded	View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

Ambulance Services

Read the LCD Disclaimer

License Agreements
American Medical Association Current Procedural Terminology
American Dental Association Current Dental Terminology
American Hospital Association NUBC UB-04

Please review the licensing information below and indicate your agreement and acceptance.

License for Use of Current Procedural Terminology (CPT)

End User Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the American Medical Association (AMA).

You, your employees, and agents are authorized to use CPT only as agreed upon with the AMA internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid or other programs administered by the Centers for Medicare and Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, AMA Plaza, 330 Wabash Ave., Suite 39300, Chicago, IL 60611-5885. Applications are available at the AMA Web site, http://www.ama-assn.org/go/cpt http://www.ama-assn.org/go/cpt.

Applicable FARS\DFARS Restrictions Apply to Government Use.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, AMA Plaza, 330 N. Wabash Ave., Suite 39300, Chicago, IL 60611-5885. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of FAR 52.227-14 (December 2007) and/or subject to the restricted rights provisions of FAR 52.227-14 (December 2007) and FAR 52.227-19 (December 2007), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT should be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS disclaims responsibility for any liability attributable to end user use of the CPT. CMS will not be liable for any claims attributable to any errors, omissions, or other inaccuracies in the information or material contained on this page. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

License For Use of Current Dental Terminology (CDT^TM)

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. By clicking below on the button labeled "I accept", you hereby acknowledge that you have read, understood, and agreed to all terms and conditions set forth in this agreement.

If you do not agree with all terms and conditions set forth herein, click below on the button labeled "I do not accept" and exit from this computer screen.

If you are acting on behalf of an organization, you represent that you are authorized to act on behalf of such organization and that your acceptance of the terms of this agreement creates a legally enforceable obligation of the organization. As used herein, "you" and "your" refer to you and any organization on behalf of which you are acting.

Subject to the terms and conditions contained in this Agreement, you, your employees and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association web site, http://www.ADA.org/ http://www.ADA.org/.

Applicable Federal Acquisition Regulation Clauses (FARS)/Department of Defense Federal Acquisition Regulation supplement (DFARS) Restrictions Apply to Government Use.

Organizations who contract with CMS acknowledge that they may have a commercial CDT license with the ADA, and that use of CDT codes as permitted herein for the administration of CMS programs does not extend to any other programs or services the organization may administer and royalties dues for the use of the CDT codes are governed by their commercial license.

ADA DISCLAIMER OF WARRANTIES AND LIABILITIES

CDT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values, or related listings are included in CDT. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for software, including any CDT and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third-party beneficiary to this Agreement.

CMS DISCLAIMER

The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT should be addressed to the ADA. End Users do not act for or on behalf of the CMS. CMS disclaims responsibility for any liability attributable to end user use of the CDT. CMS will not be liable for any claims attributable to any errors, omissions, or other inaccuracies in the information or material covered by this license. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I Accept". If you do not agree to the terms and conditions, you may not access or use software. Instead, you must click below on the button labeled "I Do Not Accept" and exit from this computer screen.

License For Use of National Uniform Billing Committee (NUBC) UB-04

These materials contain NUBC Official UB-04 Specifications (UB-04 Data), which is copyrighted by the American Hospital Association (AHA).

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "I DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN. IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use UB-04 Data only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of UB-04 Data is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this Agreement. You acknowledge that the AHA holds all copyright, trademark, and other rights in UB-04 Data. You shall not remove, alter, or obscure any AHA copyright notices or other proprietary rights notices included in the materials.
Any use not authorized herein is prohibited, including, by way of illustration and not by way of limitation, making copies of UB-04 Data for resale and/or license, transferring copies of UB-04 Data to any party not bound by this agreement, creating any modified or derivative work of UB-04 Data, or making any commercial use of UB-04 Data. License to use UB-04 Data for any use not authorized herein must be obtained through the American Hospital Association, 155 N. Wacker Drive, Suite 400, Chicago, Illinois, 60606. Applications are available at the NUBC website, http://www.nubc.org/ http://www.nubc.org/.
The UB-04 Data included in this product is commercial technical data and/or computer databases and/or commercial computer software and/or commercial computer software documentation, as applicable, which was developed exclusively at private expense by the American Hospital Association, 155 N. Wacker Drive, Suite 400, Chicago, Illinois 60606. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (November 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (December 2007) and FAR 52.227-19 (December 2007), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.
AHA DISCLAIMER OF WARRANTIES AND LIABILITIES. UB-04 Data is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. The sole responsibility for the software, including any UB-04 Data and other content contained therein, is with the Medicare/Medicaid Contractor or the CMS; and no endorsement by the AHA is intended or implied. The AHA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The AHA is a third-party beneficiary to this Agreement.
CMS DISCLAIMER. The scope of this license is determined by the AHA, the copyright holder. Any questions pertaining to the license or use of the UB-04 Data should be addressed to the AHA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE UB-04 DATA. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

Submit Feedback/Ask a Question

Ambulance Services

Document Note

Note History

Contractor Information

LCD Information

Document Information

Issue

CMS National Coverage Policy

Coverage Guidance

Proposed Process Information

Coding Information

Bill Type Codes

Please accept the License to see the codes.

Revenue Codes

Please accept the License to see the codes.

CPT/HCPCS Codes

Please accept the License to see the codes.

ICD-10-CM Codes that Support Medical Necessity

Group 1

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

Group 1

Additional ICD-10 Information

General Information

Revision History Information

Associated Documents

Keywords

Page Help for LCD - Ambulance Services (L34549)

Introduction

More information

Tracking Sheet

Printing a Document to PDF

Get email updates

CMS & HHS WEBSITES

HELPFUL LINKS

RSS FEEDS