(Medicare Claims Processing Manual)

o For services furnished on or after July 1, 2004, for rural miles 1- 17, the rate equals 1.5 times the rural ground mileage rate per mile. Therefore, multiply 1.5 times the rural mileage rate amount on the FS to derive the appropriate FS rate per mile;  o For services furnished during the period July 1, 2004 through December 31, 2008, for all ground miles greater than 50 (i.e., miles 51+), the FS rate equals 1.25 times the applicable mileage rate (urban or rural). Therefore, multiply 1.25 times the urban or rural, as appropriate, mileage rate amount on the FS  to derive the appropriate FS rate per mile.    If a rural ZIP Code is reported with an air HCPCS code, the contractor determines the FS amount for the service by using the FS amount for rural air base rate.  To determine the amount allowable for the mileage, multiply the number of loaded miles by the r ural air mileage rate.   20.2 - Payment for Mileage Charges  (Rev. 1696; Issued:  03- 06-09; Effective/Implementation Date:  04 -06-09) B3-5116.3, PM AB -00-131  Charges for mileage must be based on loaded mileage only, e.g., from the pickup of a patient to his/her arrival at destination.  It is presumed that all unloaded mileage costs are taken into account when a supplier establishes his basic charge for ambulanc e services and his rate for loaded mileage.  Suppliers should be notified that separate charges for unloaded mileage will be denied.   Instructions on billing mileage are found in 30.    20.3 - Air Ambulance  (Rev. 3380, Issued: 10- 23-15, Effective: 01 -01-16, Implementation: 01- 04-16)  Refer to IOM Pub. 100- 02, Medicare Benefit Policy Manual, chapter 10 -  Ambulance Services, section 10.4  Air Ambulance Services, and section 30.1.2  Definitions of Air Ambulance Services for additional information on the coverage and definitions of air ambulance services.  Under certain circumstances, transportation by airplane or helicopter may qualify as covered ambulance services.  If the conditions of coverage are met, payment may be made for the air ambulance services .  Air ambulance services are paid at different rates according to two air ambulance categories:    AIR ambulance service, conventional air services, transport, one way, fixed wing (FW) (HCPCS code A0430)    AIR ambulance service, conventional air services, transport, one way, rotary wing  (RW) (HCPCS code A0431)   Covered air ambulance mileage services are paid when the appropriate HCPCS code is reported on the claim:   HCPCS code A0435 identifies FIXED WING AIR MILEAGE    HCPCS code A0436 identifies ROTARY WING AIR MILEAGE   Effective for claims with dates of service on or after January 1, 2011, air mileage must be reported in fractional numbers of loaded statute miles flown.  Contractors must ensure that the appropriate air transport code is used with the appropriate mileage code.   Air ambulance services may be paid only for ambulance services to a hospital.  Other destinations e.g., skilled nursing facility, a physicians office, or a patients home may not be paid air ambulance.  The destination is identified by the use of an appropriate modifier as defined in Section 30(A) of this chapter.   Claims for air transports may account for all mileage from the point of pickup, including where applicable:  ramp to taxiway, taxiway to runway, takeoff run, air miles, roll out upon landing, and taxiing after landing.  Additional air mileage may be allowe d by the contractor in situations where additional mileage is incurred, due to circumstances beyond the pilots control.  These circumstances include, but are not limited to, the following:    Military base and other restricted zones, air -defense zones, and similar FAA restrictions and prohibitions;    Hazardous weather; or    Variances in departure patterns and clearance routes required by an air traffic controller.   If the air transport meets the criteria for medical necessity, Medicare pays the actual miles flown for legitimate reasons as determined by the Medicare contractor, once the Medicare beneficiary is loaded onto the air ambulance.   IOM Pub. 100- 08, Medicare Program Integrity Manual, chapter 6  Intermediary MR Guidelines for Specific Services contains instructions for Medical Review of Air Ambulance Services.   20.4 - Ambulance Inflation Factor ( AIF)  (Rev. 12414; Issued:12- 19-23; Effective: 01 -01-24; Implementation:01- 02-24)  Section 1834(l)(3)(B) of the Social Security Act (the Act) provides the basis for an update to the payment limits for ambulance services that is equal to the percentage increase in the consumer price  index  for all urban consumers (CPI -U) for the 12-month period ending with June of the previous year. Section  3401  of  the Affordable Care Act amended Section 1834(l)(3) of the Act to apply a productivity adjustment to this update equal to the 10-year moving average of changes in economy- wide private nonfarm business multi-  factor productivity beginning January 1, 2011. The resulting update percentage is referred to as the Ambulance Inflation Factor (AIF). These updated percentages are issued via Recurring Update Notifications.   Part B coinsurance and deductible requirements apply to payments under the ambulance fee schedule. Following is a chart tracking the history of the AIF:   CY AIF 2003  1.1 2004  2.1 2005  3.3 2006  2.5 2007  4.3 2008  2.7 2009  5.0 2010  0.0 2011  -0.1 2012  2.4 2013  0.8 2014  1.0 2015  1.5 2016  -0.4 2017  0.7 2018  1.1 2019  2.3 2020  0.9 2021  0.2  2022   5.1     2023       8.7   2024   2.6                                                                20.5 - Documentation Requirements  (Rev. 1696; Issued:  03- 06-09; Effective/Implementation Date:  04 -06-09)  In all cases, the appropriate documentation must be kept on file and, upon request, presented to the contractor.  It is important to note that the presence (or absence) of a physicians order for a transport by ambulance does not necessarily prove (or disprove) whether the transport was medically necessary.  The ambulance service must meet all program coverage criteria in order for payment to be made.   IOM Pub 100- 01, Medicare General Information, Eligibility, and Entitlement Manual, chapter 4 - Physician Certifications and Recertification of Services, contains specific information on supplier requirements for ambulance certification.  IOM Pub. 100- 08, Medicare Program Integrity Manual, chapter 6 - Medicare Contractor Medical Review Guidelines for Specific Services  contains information on medical review instructions of ambulance services.   20.6 - Payment for Non -Emergency Trips to/from ESRD Facilities  (Rev. 4017; Issued: 04- 06-18; Effective: 10 -01-18; Implementation: 10 -01-18)  Section 637 of the American Taxpayer Relief Act of 2012 requires that, effective for transports occurring on and after October 1, 2013, fee schedule payments for non- emergency basic life support (BLS) transports of individuals with end- stage renal disease (ESRD) to and from renal dialysis treatment be reduced by 10%.  The payment reduction affects transports  (base rate and mileage) to and from hospital -based and freestanding renal dialysis treatment facilities for dialysis services provided on a non- emergen cy basis.  Non- emergency BLS ground transports are identified by Healthcare Common Procedure Code System (HCPCS) code A0428.  Ambulance transports to and from renal dialysis treatment are identified by modifier codes G (hospital -based ESRD) and J (freestanding ESRD facility) in either the first position (origin code) or second position (destination code) within the two- digit ambulance modifier.  (See Section 30 (A) for information regarding modifiers specific to ambulance.)   Effective for claims with dates of service on and after October 1, 2013 through September 30, 2018, the 10% reduction will be calculated and applied to HCPCS code A0428 when billed with modifier code G or J.  The reduction will also be applied to any m ileage billed in association with a non- emergency transport of a beneficiary with ESRD to and from renal dialysis treatment.  BLS mileage is identified by HCPCS code A0425.  The 10% reduction will be taken after  calculation of the normal fee schedule payment amount, including any add- on or bonus payments, and will apply to transports in rural and urban areas as well as areas designated as super rural.   Payment for emergency transports is not affected by this reduction.  Payment for non- emergency BLS transports to other destinations is also not affected. This reduction does not affect or change the Ambulance Fee Schedule.   Note:  The 10% reduction applies to beneficiaries with ESRD that are receiving non- emergency BLS transport to and from renal dialysis treatment.  While it is possible that a beneficiary who is not diagnosed with ESRD will require routine transport to and f rom renal dialysis treatment, it is highly unlikely.  However, contractors have discretion to override or reverse the reduction on appeal if they deem it appropriate based on supporting documentation.  Section 53108 of the Bipartisan Budget Act of 2018 increased the amount of the reduction described above to 23% for transports occurring on and after October 1, 2018.   30 - General Billing Guidelines  (Rev. 3076, Issued: 09- 24-14, Effective: Upon Implementation of ICD -10 ASC X12: 01- 01-12, Implementation: ICD -10: Upon Implementation of ICD -10 ASC X12: 09- 16-14)  Independent ambulance suppliers may bill on the ASC X12 837 professional claim transaction or the CMS -1500 form.  These claims are processed using the MCS system.   Institution based ambulance providers may bill on the ASC X12 837 institutional claim transaction or Form CMS 1450.  These claims are processed using the FISS system.   A. Modifiers Specific to Ambulance Service Claims   For ambulance service claims, institutional- based providers and suppliers must report an origin and destination modifier for each ambulance trip provided in HCPCS/Rates.  Origin and destination modifiers used for ambulance services are created by combining two alpha characters.  Each alpha character, with the exception of X, represents an origin code or a destination code.  The pair of alpha codes creates  one modifier.  The first position alpha code equals origin; the second position alpha code equals des tination.  Origin and destination codes and their descriptions are listed below:   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