Article - Billing and Coding: Ambulance Services (A56468)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claimTitle 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 regulationsTitle 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 member42 CFR 410.40 addresses the coverage of ambulance servicesCMS 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 ClaimsCMS 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 ClaimsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forAmbulance 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.