(Medicare Claims Processing Manual)

D = Diagnostic or therapeutic site other than P or H when these are used as origin codes;  E = Residential, domiciliary, custodial facility (other than 1819 facility); G = Hospital based ESRD facility; H = Hospital; I = Site of transfer (e.g. airport or helicopter pad) between modes of ambulance transport;  J = Freestanding ESRD facility;  N = Skilled nursing facility; P = Physicians office;  R = Residence;  S = Scene of accident or acute event;  X = Intermediate stop at physicians office on way to hospital (destination code only)   In addition, institutional -based providers must report one of the following modifiers with every HCPCS code to describe whether the service was provided under arrangement or directly:   QM -  Ambulance service provided under arrangement by a provider of services; or  QN -  Ambulance service furnished directly by a provider of services.   While combinations of these items may duplicate other HCPCS modifiers, when billed with an ambulance transportation code, the reported modifiers can only indicate origin/destination.   B. HCPCS Codes   The following codes and definitions are effective for billing ambulance services on or after January 1, 2001.   AMBULANCE HCPCS CODES AND DEFINITIONS   HCPCS Code  Description of HCPCS Codes  A0425  BLS mileage (per mile)  A0425  ALS mileage (per mile)  A0426  Ambulance service, Advanced Life Support (ALS), non -emergency transport, Level 1  A0427  Ambulance service, ALS, emergency transport, Level 1  A0428  Ambulance service, Basic Life Support (BLS), non -emergency transport  A0429  Ambulance service, basic life support (BLS), emergency transport  A0430  Ambulance service, conventional air services, transport, one way, fixed wing (FW)  A0431  Ambulance service, conventional air services, transport, one way, rotary wing (RW)  A0432  Paramedic ALS intercept (PI), rural area transport furnished by a volunteer ambulance company, which is prohibited by state law from billing third party payers.  A0433  Ambulance service, advanced life support, level 2 (ALS2)  A0434  Ambulance service, specialty care transport (SCT)  A0435  Air mileage; FW, (per statute mile)  A0436  Air mileage; RW, (per statute mile)   NOTE:  PI, ALS2, SCT, FW, and RW assume an emergency condition and do not require an emergency designator.   Refer to IOM Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 10 - Ambulance Service, section 30.1 -  Definitions of Ambulance Services, for the definitions of levels of ambulance services under the fee schedule.   30.1 - Multi -Carrier System (MCS) Guidelines (Rev. 1696; Issued:  03- 06-09; Effective/Implementation Date:  04 -06-09) B3-5116  Payment under the fee schedule for ambulance services:    Includes a base rate payment plus a payment for mileage;    Covers both the transport of the beneficiary to the nearest appropriate facility and all items and services associated with such transport; and    Precludes a separate payment for items and services furnished under the ambulance benefit.   Payment for items and services is included in the fee schedule payment.  Such items and services include but are not limited to oxygen, drugs, extra attendants, and EKG testing -  but only when such items and services are both medically necessary and covered by Medicare under the ambulance benefit.   30.1.1 - MCS Coding Requirements for Suppliers  (Rev. 1696; Issued:  03- 06-09; Effective/Implementation Date:  04 -06-09) PM AB -00-88  The ambulance fee schedule contains the following HCPCS coding logic:    Seven categories of ground ambulance services;   Two categories of air ambulance services;   Payment based on the condition of the beneficiary, not on the type of vehicle used;   Payment is determined by the point of pickup (as reported by the 5 -digit ZIP Code);   Increased payment for rural services; and   Services and supplies included in base rate.   30.1.2 - Coding Instructions for Paper and Electronic Claim Forms  (Rev. 4205, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medica re Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   Except as otherwise noted, beginning with dates of service on or after January 1, 2001, the following coding instructions must be used.  Origin   Electronic billers should refer to the Implementation Guide to determine how to report the origin information (e.g., the ZIP Code of the point of pickup).  Beginning with the early implementation of version 5010 of the ASC X12 837 professional claim format  on January 1, 2011, electronic billers are required to submit, in addition to the loaded ambulance trips origin information (e.g., the ZIP Code of the point of pickup), the loaded ambulance trips destination information (e.g., the ZIP code of the point of drop -off).  Refer to the appropriate Implementation Guide to determine how to report the destination information.  Only the ZIP Code of the point of pickup will be used to adjudicate and price the ambulance claim, not the point of drop- off.  However, the point of drop- off is an additional reporting requirement on version 5010 of the ASC X12 837 professional claim format.  Where the CMS -1500 Form is used the ZIP code is reported in item 23.  Since the ZIP Code is used for pricing, more than one ambulance service may be reported on the same paper claim for a beneficiary if all points of pickup have the same ZIP Code.  Supplie rs must prepare a separate paper claim for each trip if the points of pickup are located in different ZIP Codes.  Claims without a ZIP Code in item 23 on the CMS -1500 Form item 23, or with multiple ZIP Codes in item 23, must be returned as unprocessable.    The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two.   Group Code: CO  CARC: 16  RARC: N53  MSN: N/A  ZIP Codes must be edited for validity.  The format for a ZIP Code is five numerics.  If a nine -digit ZIP Code is submitted, the last four digits are ignored.  If the data submitted in the required field does not match that format, the claim is rejected.   Mileage  Generally, each ambulance trip will require two lines of coding, e.g., one line for the service and one line for the mileage.  Suppliers who do not bill mileage would have one line of code for the service.  Beginning with dates of service on or after January 1, 2011, mileage billed must be reported as fractional units in the following situations:    Where billing is by ASC X12 claims transaction (professional or institutional), and   Where billing is by CMS -1500 paper form.  Electronic billers should see the appropriate Implementation Guide to determine where to report the fractional units.  Item 24G of the Form CMS -1500 paper claim is used. Fractional units are not required on Form CMS -1450. For trips totaling up to 100 covered miles suppliers must round the total miles up to the nearest tenth of a mile and report the resulting number with the appropriate HCPCS code for ambulance mileage.  The decimal must be used in the appropriate place (e.g., 99.9).  For trips totaling 100 covered miles and greater, suppliers must report mileage rounded up to the next whole number mile without the use of a decimal (e.g., 998.5 miles should be reported as 999). For trips totaling less than 1 mile, enter a 0 before the decimal (e.g., 0.9).   For mileage HCPCS billed on the ASC X12 837 professional transaction or the CMS -1500 paper form only, contractors shall automatically default to 0.1 units when the total mileage units are missing.   Multiple Patients on One Trip  Ambulance suppliers submitting a claim using the ASC X12 professional format or the CMS -1500 paper form for an ambulance transport with more than one patient onboard must use the GM modifier (Multiple Patients on One Ambulance Trip) for each service li ne item. In addition, suppliers are required to submit documentation to A/B MACs (Part B) to specify the particulars of a multiple patient transport. The documentation must include the total number of patients transported in the vehicle at the same time an d the Medicare beneficiary identifiers for each Medicare beneficiary. A/B/MACs (Part B) shall calculate payment amounts based on policy instructions found in Pub.100- 02, Medicare Benefit Policy Manual, Chapter 10  Ambulance Services, Section 10.3.10  Mul tiple Patient Ambulance Transport.  Ambulance claims submitted on or after January 1, 2011, in version 5010 of the ASC X12 837 professional claim format require the presence of a diagnosis code and the absence of diagnosis code will cause the ambulance claim to not be accepted into the claim s processing system. The presence of a diagnosis code on an ambulance claim is not required as a condition of ambulance payment policy. The adjudicative process does not take into account the presence (or absence) of a diagnosis code, but a diagnosis code is required on the ASC X12 837 professional claim format.   30.1.3 - Coding Instructions for Form CMS -1491 (Rev. 1696; Issued:  03- 06-09; Effective/Implementation Date:  04 -06-09)  Effective April 2, 2007, Form CMS -1491 will no longer be a valid format for submitting claims.  Suppliers who wish to submit a paper claim must use CMS -1500 Form.   30.1.4 - CWF Editing of Ambulance Claims for Inpatients  (Rev. 1696; Issued:  03- 06-09; Effective/Implementation Date:  04 -06-09)  Hospital bundling rules exclude payment to independent suppliers of ambulance services for beneficiaries in a hospital inpatient stay (see IOM Pub. 100- 04, Medicare Claims Processing, chapter 3 - Inpatient Hospital Billing, Section 10.4 -  Payment of Nonphysician Services for Inpatients).  CWF performs reject edits to incoming claims from suppliers of ambulance services.   Upon receipt of a hospital inpatient claim at the CWF, CWF searches paid claim history and compares the period between the hospital inpatient admission and discharge dates to the line item service date on an ambulance claim billed by a supplier.  The CWF w ill generate an unsolicited response when the line item service date falls within the admission and discharge dates of the hospital inpatient claim.   Upon receipt of an unsolicited response, the A/B MAC (B) will adjust the ambulance claim and recoup the payment.   Ambulance services with a date of service that are the same as an admission or discharge date on an inpatient claim are separately payable and not subject to the bundling rules.  30.2 - Fiscal Intermediary Shared System (FISS) Guidelines  (Rev. 11365; Issued: 04 -28-22; Effective: 05 -31-22; Implementation: 05 -31-22)  For SNF Part A, the cost of medically necessary ambulance t ransport ation to re ceive most service s inclu ded in  the RUG rate is inclu ded in the c ost for the ser vice. Pay ment for the SNF claim  is based on the R UGs, which takes into account the cost of such transpor tation to re ceive the an cillary  servi ces.  Refer to Pub. 100- 04, Medicare Cla ims Processing Manual, chapter 6 -  SNF Inpatient Part A Billing, Section 20.3.1 - Ambulance Services,  for additional information on SNF consolidated billing and ambulance transportation.  Refer to Pub. 100- 04, Medicare Claims Processing Manual, chapter 3 -  Inpatient Hospital Billing, section 10.5 -  Hospital Inpatient Bundling, f or additional infor mation on hospital inpatient bundling of a mbulance services.   In general, the A/B MAC (A) processes clai ms for Part B  ambulance services provided by an ambulance supplier under arrange ments with hos pitals or SNFs.  These providers bill A/B MACs (A) using only Method 2.  The provider m ust furnish the following data in accordance with A/B MAC (A) instructions. The A/B MAC  (A) will make arrangem ents for the m ethod and m edia for sub mitting the data:   A detailed state ment of the condition necessitati ng the a mbulance service;