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:
- 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)).
- 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).
- A denial for mileage that is beyond the nearest appropriate facility (for the same reason as b. above).
- A denial where the physician certification statement or accepted alternative (e.g., certified mail) is not obtained (for the same reason as b. above).
- 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.
