Ambulance Statutory and Billing Requirements
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Ambulance Statutory and Billing Requirements
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Distance and Point of Drop-off (POD) Requirements
ZIP Code/Point of Pickup for Ambulance Services
Ambulance Transportation Coverage Exclusion
Transports During an Inpatient Stay
Assignment for Ambulance Claims
Patient Signature Requirements for Ambulance Claims
Procedure Codes for Ambulance Services
Emergency vs Non-Emergency Ambulance Transports
Non-Covered Ambulance Services
We recognize Medicare ambulance requirements are in multiple locations. This article brings the statutory and billing requirements together. Our article Ambulance Documentation Requirements contains the information Medicare requires in the documentation.
Distance and Point of Drop-off (POD) Requirements
The CMS Internet-Only Manual (IOM) Publication 100-02, Chapter 10 , Section 10.3, provides the Medicare covered PODs.
Medicare covers ambulance transports meeting all other program coverage requirements, to the following PODs:
- Hospital;
- Critical Access Hospital (CAH);
- Skilled Nursing Facility (SNF);
- Beneficiary's home;
- Dialysis facility for ESRD patient who requires dialysis; or
- Physician's office (only under special circumstances)
Medicare covers local transports, meaning mileage coverage is to the nearest appropriate facility equipped to treat the patient. Local refers to:
- Transports within the surrounding area
- Transports to or from facilities where patients expect to receive hospital or skilled nursing care
When taking the beneficiary beyond the local area, Medicare considers full payment to the nearest appropriate facility.
“Nearest appropriate facility" means the institution has a bed and equipment available to treat the patient’s medical condition. Contractors assume the closest facility meets these requirements, unless documented otherwise. Also, a physician or non-physician specialist is available to provide the care required for the patient's condition. For transports to a hospital, Medicare uses the American Hospital Association (AHA) Guide to determine the nearest appropriate facility. You can purchase a copy of the AHA Guide on the AHA’s website.
Medicare does not cover ambulance miles to a more distant hospital, when it is for the following reasons:
- Solely to obtain the services of a specific physician
- Solely to stay in certain facility’s network
- Patient or family preference
- A hospital is better equipped (qualitatively or quantitatively)
Transport coverage
- The discharging institution does not have appropriate facilities
- The admitting institution is the nearest and the most appropriate facility
- The transportation is medically necessary
Coverage of an ambulance service from a hospital or SNF to the beneficiary's home occurs if:
- The home is within the local transportation area
- The discharging institution is the closest appropriate facility
- The trip is medically necessary
When submitting a Part B claim for a payable ambulance mileage beyond the nearest facility, include the following information:
- Facility name being bypassed
- Service(s) or professional specialty not available at the bypassed facility
- On electronic claims provide this item following the reason for transport
- The name, complete address, and facility type for the starting and ending facilities
- Bill all mileage as covered mileage
Ambulance Modifiers
Point of Pickup (POP) and Point of Drop-off (POD) Modifiers
The CMS IOM Publication 100-04, Chapter 15 , Section 30 covers POP and POD modifiers.
Ambulance claims must include POP and POD modifiers. Place the POP character in the first modifier position and the POD character in the second position (e.g., A0428RH). A list of these modifiers with descriptions follows:
- Modifier D: Diagnostic or therapeutic site
- A building or portion of a building providing diagnostic or therapeutic services
- This is the sole purpose of that building or section of a building
- Modifier E: Residential, domiciliary, custodial facility
- The facility providing room, board, and other personal assistance services on a long-term basis
- This facility does not include a medical component
- Modifier G: Hospital-based ESRD facility
- A dialysis unit contained within a hospital, or located adjacent to a hospital
- Modifier H: Hospital
- A building or portion of a building used to treat sick or injured patients
- The building must contain overnight stay medically equipped care rooms
- Modifier I: Site of transfer
- A scheduled location moving from a ground to air transport or vice versa
- Modifier J: Freestanding ESRD facility
- A dialysis facility not located within or adjacent to a hospital
- Modifier N: Skilled Nursing Facility
- A facility providing skilled nursing care and related services to inpatients requiring
- Medical or nursing care, or
- Rehabilitation services to people injured, disabled or sick
- Communicate with the facility for determination if it is an N or E
- A facility providing skilled nursing care and related services to inpatients requiring
- Modifier P: Physician's office
- Physician offices
- Freestanding diagnostic or therapeutic sites
- Clinics
- Urgent care center
- P is not a covered destination
- Modifier R: Residence
- A building where the patient makes his/her home and dwells permanently
- A building where another person makes his/her home permanently and the patient is temporally staying
- Excluding facilities considered residential, domiciliary, or custodial care
- Modifier S: Scene
- The scene of an accident or acute event
- Modifier X:
- Intermediate stop at a physician's office on the way to the hospital
- POD Only
- Physician office used to treat a patient in an emergency setting
- An interim stop when the patient is in such distress requiring a physician's office on the way to the hospital
- Intermediate stop at a physician's office on the way to the hospital
Hospitals
A hospital’s building could include several different types of POP and POD modifiers, including:
- Nursing home beds
- Skilled facility beds
- Observation care beds
- Outpatient service areas
- Emergency rooms
- Inpatient acute care rooms
- Clinics
- Professional offices
A supplier should verify how the facility classifies the patient to determine the appropriate origin and destination modifiers.
Freestanding Emergency Departments (ED)
WPS sought CMS guidance on freestanding EDs POP and POD modifiers. It includes two types of freestanding EDs.
- Hospital-based EDs – Fully owned and operated by a hospital
- Medicare recognizes limited exceptions for joint ventures between hospitals and other medical organizations
- Independent EDs – Owned and operated as a separate legal entity
For transports from a freestanding ED choose from the following modifiers in the origin position:
- Modifier H (Hospital)
- Provider-based freestanding ED (part of the hospital)
- Modifier P (Physician’s office)
- Freestanding ED designated as a clinic
- Modifier D (Diagnostic or therapeutic site other than P or H)
- Freestanding ED designated as an
- Independent diagnostic testing facility
- Cancer treatment center
- Radiation therapy center
- Wound care center, or
- Other diagnostic or therapeutic site
- Freestanding ED designated as an
To determine the correct POP modifier, suppliers need to ask the freestanding ED its correct designation.
Medicare covers a freestanding ED as POD when it is 100% owned and operated as a hospital off-campus department. This means the freestanding ED is a hospital’s provider-based department. Code the modifier POD position as a hospital (H).
If a facility is an independent ED, it does not meet the provider-based regulations in 42 CFR 413.65 . As it does not meet the regulations, it is not a Medicare payable ambulance transport. There is not a POD modifier for this.
Facility Modifiers for Ambulance Services
Institutional based ambulance suppliers report one of the following modifiers with every HCPCS code.
- QM: provided under arrangement by a provider of services
- QN: ambulance service furnished directly by a provider of services
Hospice Modifier
The ambulance supplier must document if a transport relates to the hospice condition and bill accordingly.
If the transport relates to the hospice condition, bill the hospice.
Bill Medicare for transports:
- Not relating to the hospice condition
- On the day of admission, but before the hospice admission occurs
- On the day of discharge
The GW modifier allows the Medicare system to consider the transport form the patient’s Hospice stay. Append the modifier to both the base rate and mileage procedure code lines.
ZIP Code/Point of Pickup for Ambulance Services
Medicare bases payment on the POP ZIP Code under the ambulance fee schedule. Report it as a 5-digit ZIP Code. It determines the applicable geographic practice cost index (GPCI) and whether a rural adjustment applies. Report the POP ZIP Code on every claim.
The CMS IOM Publication 100-04, Chapter 15 , Section 20.1.5 contains the POP ZIP Code requirements.
For Part A claims, report value code A0 with POP ZIP Code in the Value Code field. Bill multiple transports on the same day:
- With the same POP ZIP Code on one claim
- With different POP ZIP Codes on different claims
Section 30.2 C of the IOM reference above contains information on reporting ambulance claims with value codes.
For Part B use Box 23 of the CMS 1500 form or ANSI version X-12N837 (5010) loop 2310E.
The claims processing system reports the POP ZIP Code to the Common Working File (CWF). CWF reports it to the national claims history file, along with the rest of the ambulance claims record.
ZIP Code/Point of Pickup Claims outside the US
For the POP outside the United States (US) or its territorial waters, report the POP ZIP Code as follows:
- Ground or air transport with a pick-up outside the US, use the closest POP’s US ZIP Code
- Valid for Canada or Mexico
- Water transport from US territorial waters, use the port of entry ZIP Code
For ground transport from Canada or Mexico to the US
- Use the US border ZIP Code from the point of entry
- Ground mileage payment is from the point of entry ZIP Code
For air transport from areas outside the United States to the US
- Use the ZIP Code at the border at the point of crossing into the US
- Air transports can pay fees associated with the US border port of entry ZIP Codes
The CMS IOM Publication 100-04, Chapter 15 , Section 20.1.5 D, addresses claims outside the US.
Suppliers must determine the accurate POP ZIP Code. For areas without assigned ZIP Codes
- Verify with the United States Postal Service or other authoritative source that no ZIP Code exists
- Use the nearest ZIP Code to the point of pickup
- Annotate the claim with "Surrogate ZIP Code: POP in No-ZIP."
Ambulance Transportation Coverage Exclusion
Medicare does not pay for ambulance transportation under the following circumstances:
- Medi-Car, Medi-Van, or wheelchair ambulance services
- Trips to a funeral home
- Trips for services where the service is safe to perform at the patient’s location
- Example: blood draws and catheterization
- Dispatch to the scene of a beneficiary pronounced dead
- Ambulance service to a physician's office not meeting the emergency exception
- Non-transport - If no transport occurs, then Medicare does cover the service
- This applies to situations where the beneficiary refuses transport, including the on-scene services
If a supplier provides one of the above exclusions, it is optional to submit a claim to Medicare. The only required situation is at a patient’s request. If submitting the service, include modifier GY to indicate it’s a statutory exclusion. The patient is responsible for the non-covered services.
An Advance Beneficiary Notice of Non-Coverage (ABN Form CMS-R-131) is optional. It helps inform the patient services are a Medicare benefit exclusion.
Transports During an Inpatient Stay
Transports during a Hospital Stay
When Medicare is paying for an inpatient hospital stay, Medicare does not pay separately for ambulance transports. The payment for the revenue code of the procedure at the destination includes the transport’s payment.
Medicare defines inpatient round trips as
- A transport to and from another facility
- On the same day
- For the same patient not discharged from the first facility
Use the following to help you bill inpatient round trips correctly
- Charges are the inpatient hospital’s responsibility
- The hospital includes the charge on the claim
- Not with Revenue Code 54x
- With the Revenue Code for the procedure at the destination
- Critical Access Hospitals are the only hospital separately reimbursed
Transports during a Skilled Nursing Facility (SNF) Stay
SNF Consolidated Billing (CB) applies to all services while the patient is in a Part A stay. An exception occurs for those services outside the SNF scope of practice. The ambulance suppliers must determine if the service at the destination meets the exception.
A Part A stay means Medicare is covering the room and board, nursing services, and other inpatient care. The basis for the decision is medical necessity and the service at the destination.
Ambulance suppliers follow these options for billings:
- If a transport is not medically necessary, then bill the patient
- If the transport is medically necessary and:
- Is not subject to SNF CB, bill the SNF when Part A is covering the stay
- Is subject to SNF CB, bill Medicare when Part A is covering the stay
- If Medicare Part A is not covering the stay, then bill Medicare Part B
- If the transport relates to outpatient rehabilitation services, bill the SNF
- This applies regardless of if Medicare Part A is paying
- The SNF is responsible for these charges
To determine who to bill, view
- Our Quick Reference: Skilled Nursing Facility (SNF) Consolidated Billing (CB) Who to Bill
- The CMS SNF Consolidated Billing web page for details on SNF CB
Assignment for Ambulance Claims
Ambulance suppliers who furnish a Medicare-covered ambulance service to a Medicare beneficiary must submit a claim. This is from the CMS IOM Publication 100-02, Chapter 10 , Section 20.1.
Ambulance providers must accept assignment on all claims for Medicare covered services. This is from the CMS IOM Publication 100-04, Chapter 1 , Section 30.3. The assignment agreement is binding. Ambulance suppliers may collect coinsurance and/or deductible, in non-emergent situations, at the time of transport. If you do not know the patient’s liability, consider waiting for the Remittance Advice before collecting from the patient.
Patient Signature Requirements for Ambulance Claims
The CMS IOM Publication 100-02, Chapter 10 , Section 20.1.2, explains the patient signature requirements. It indicates to use the signature to accept assignment and allow for claims filing.
A beneficiary is always able to sign on his/her own behalf. If he/she is unable to sign, the following can sign on his/her behalf:
- Beneficiary's legal guardian
- A relative or other person
- Receiving Social Security or other governmental benefits on his/her behalf
- Arranging the beneficiary’s treatment or exercising responsibilities for his/her affairs
- An agency representative from an institution not furnishing the services on the claim
- Furnishing other care, services, or assistance to the beneficiary
- A supplier is unable to have the claim signed in accordance with 42 CFR 424.36(b) (1 - 4) (C)
- A representative of the ambulance supplier
- Present during an emergency and/or nonemergency transport
After transport, an ambulance supplier may obtain a signature. Always have a signature before submitting a claim. Guidance is available in the CMS article "Guidance on Beneficiary Signature Requirements for Ambulance Claims ".
Beneficiaries refusing to sign for claim submission to Medicare for payment are responsible for the full bill. CMS allows ambulance suppliers to refuse services.
Ambulance Claims Jurisdiction
Privately owned suppliers use the garage or hanger location to determine which Medicare Administrative Contractor (MAC) receives the claim. For institutionally owned ambulance suppliers, the institution’s primary location establishes the MAC to submit a claim to for transports.
To locate jurisdiction information, use the CMS IOM Publication 100-04, Chapter 15 , Section 20.1.2.
Ambulance Mileage
Medicare covers only loaded mileage or patient on board mileage. The CMS IOM Publication 100-04, Chapter 15 , Section 20.2 contains this information.
The ground mileage submission is in CMS IOM Publication 100-04, Chapter 15 , Section 30.1.2. Submit ground miles on a Form CMS-1500 paper claim, 837P and 837I electronic claim as follows:
- Whole numbers for trips 100 miles or over
- Always round up
- One line of services up to 999 miles
- To the tenth of a mile for 99.9 miles and under
- For example, 10.4, 20.5, 40.4, or 99.9
- Trips under 1 mile to the fractional mile with a zero in front of the decimal
- For example, 0.1, 0.5, and 0.8
Submit mileage on a Form CMS-1450 in whole miles.
Procedure Codes for Ambulance Services
Seven categories of ground ambulance services fall under the fee schedule. "Ground" refers to both land and water transports.
The patient’s condition determines the level of service, not the transport vehicle.
A0428 - Ambulance service, basic life support, non-emergency transport (BLS non-emergent)
BLS means medically necessary transportation by ground ambulance vehicle. This transport includes all supplies and services when the meeting the state license provision of BLS ambulance services.
A0429 - Ambulance service, basic life support, emergency transport (BLS emergency)
BLS means medically necessary transport by ground ambulance vehicle. This includes:
- All supplies and services
- State license provision of a BLS ambulance services
Emergency response means:
- The nature of the call requires immediate response acting as quickly as possible to respond to an emergent situation
- Dispatch protocols show the need for an emergency response versus a standard response
A0426 - Ambulance service, advanced life support, non-emergency transport, level 1 (ALS1 non-emergent)
ALS means medically necessary transport by ground ambulance vehicle
- Includes all supplies and services
- State license provision of an ALS ambulance services above the BLS level of state license
- Patient’s medical condition requires the Emergency Medical Technician (EMT) Intermediate (EMT-I) or EMT Paramedic (EMT-P) to complete an assessment
- Unsuccessful ALS procedures can qualify for ALS billing
A0427 - Ambulance service, advanced life support, emergency transport, level 1 (ALS1 emergency)
ALS means medically necessary transport by ground ambulance vehicle
- Includes all supplies and services
- State license provision of an ALS ambulance services above the BLS level of state license
- Patient’s medical condition requires the EMT-I or EMT-P to complete an ALS assessment
- Unsuccessful ALS procedures can qualify for ALS billing
Emergency response means:
- The nature of the call requires immediate response acting as quickly as possible to respond to an emergent situation
- Dispatch protocols show the need for an emergency response versus a standard response
The ALS1 emergency response category uses the provision of ALS1 services as specified above. It includes the context of an emergency response.
A0433 - Advanced Life Support, Level 2 (ALS2)
The ALS2 category is:
Ground transportation, medically necessary supplies, and services with one of two following items:
- Three or more different medication administrations by intravenous push/bolus or by continuous infusion
- Excludes crystalloid, hypotonic, isotonic, and hypertonic solutions (Dextrose, Normal Saline, Ringer's Lactate)
- Excludes the same medication with three or more different protocol pushes
- At least one of the following ALS procedures:
- Manual defibrillation/cardioversion endotracheal intubation (or monitoring and maintenance of an endotracheal tube previously inserted)
- Central venous line
- Cardiac pacing
- Chest decompression
- Surgical airway
- Intraosseous line
A0434 - Specialty Care Transport (SCT)
- Ground transportation, including medically necessary supplies and services
- Requires inter facility transport of a critically ill or injured person
- Requires services beyond the state scope of an EMT-P. This includes:
- EMT-P with training above the state requirement to be an EMT-P
- Other medical professionals, such as:
- Registered nurse
- Respiratory therapist
- Other medical professionals
A0425 - Ground Mileage, per statute mile
Bill ground mileage for both ground and water ambulances. Record mileage with an odometer or mapping software to the nearest appropriate facility.
A0430 - Ambulance service, conventional air service, transport, one-way (Fixed Wing (FW) Air Ambulance)
A0431 - Ambulance service, conventional air service, transport, one-way (Rotary Wing (RW) Air Ambulance)
Medicare covers both fixed and rotary wing air transports. Air transport coverage occurs when the beneficiary's medical condition makes ground ambulance transport inappropriate. Generally, this type of transport is necessary when the beneficiary's condition requires rapid transport to a treatment facility. Examples include:
- Great distances or other obstacles preclude rapid delivery to the nearest appropriate facility
- The beneficiary is inaccessible by a land or water ambulance
A0435 - Fixed wing air mileage, per statute mile
A0436 - Rotary wing air mileage, per statute mile
A0888 - Non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility)
Emergency vs Non-Emergency Ambulance Transports
CMS defines an emergency response as the immediate response, at any level, to a 911 call or the equivalent. An ambulance supplier begins to respond to the call as quickly as possible. This does not include:
- When a patient condition is non-emergent and stable
- Scheduled transports
Information received during the call for dispatch drives if a transport is an emergency response. Medicare considers the 911 or internal supplier protocol. Calls do not have to come through a 911 system even in areas with a 911 call system.
Scheduled transports are non-emergency. Examples of scheduled transports include those to
- Nursing homes
- Patient homes
- Dialysis facilities
Medicare requires suppliers to verify if a transport is emergent or non-emergent and code the claim accordingly.
Non-Covered Ambulance Services
Ambulance providers can bill procedure codes A0021 - A0424 and A0998 for non-covered ambulance services. Bill each code separately. Submit all codes with a GY modifier. Medicare does not consider payment for the services, and they will deny with the patient liable for payment.
Base rates for covered transports include all supplies associated with the transport. Do not bill the supplies separately. This information is in the CMS IOM Publication 100-04, Chapter 15 , Section 30.1.
global-tags: J8A,J5A,Ambulance,Claim Submission,J8B,J5B,Coding Guidelines,Claims
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