(Medicare Claims Processing Manual)

Providers must report an origin and destination modifier for each ambulance trip provided and either a QM (Ambulance service provided under arrangement by a provider of services) or QN (Ambulance service furnished directly by a provider of services) modifi er in FL 44 HCPCS/Rates".   D. Service Units Reporting   For line items reflecting HCPCS codes  A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434, providers are required to report in Service Units for each ambulance trip provided.  Therefore, the service units for each occurrence of these HCPCS codes are always equal to one. In addition, for line items reflecting HCPCS code  A0425, A0435, or  A0436, providers must also report the number of loaded miles.  E. Total Charges Reporting  For line items reflecting HCPCS codes  A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434, providers are required to report in Total Charges the actual charge for the ambulance service including all supplies used for the ambulance trip, but excluding the charge for mileage.   For line items reflecting HCPCS codes  A0425, A0435, or A0436, providers are to report the actual charge for mileage.   NOTE :  There are instances where the provider does not incur any cost for mileage, e.g., if the beneficiary is pronounced dead after the ambulance is called but before the ambulance arrives at the scene.  In these situations, providers report the base rate ambulance trip and mileage as separate revenue code lines.  Providers report the base rate ambulance trip in accordance with current billing requirements.  For purposes of reporting mileage, they must report the a ppropriate HCPCS code, modifiers, and units.  For the related charges, providers report $1.00 in non-covered charges.  A/B MACs (A) should assign remittance adjustment Group Code OA to the $1.00 non- covered mileage line, which in turn informs the beneficia ries and providers that they each have no liability.   F. Edits (A/B MAC (A) Claims with Dates of Service On or After 4/1/02)   For claims with dates of service on or after April 1, 2002, FISS performs the following edits to assure proper reporting:    Edit to assure each pair of revenue codes 540 have one of the following ambulance HCPCS codes -  A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434; and one of the following mileage HCPCS codes -  A0425, A0435, or A0436.    Edit to assure the presence of an origin, destination modifier, and a QM or QN modifier for every line item containing revenue code 540;    Edit to assure that the units field is completed for every line item containing revenue code 540;    Edit to assure that service units for line items containing HCPCS codes A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434 always equal 1"; and   Edit to assure on every claim that revenue code 540, a value code of A0 (zero), and a corresponding ZIP Code are reported. If the ZIP Code is not a valid ZIP Code in accordance with the USPS assigned ZIP Codes, A/B MACs (A) verify the ZIP Code to determine  if the ZIP Code is a coding error on the claim or a new ZIP Code from the USPS not on the CMS supplied ZIP Code File.    Beginning with dates of service on or after April 1, 2012, edit to assure that only non-emergency trips (i.e., HCPCS A0426, A0428 [when A0428 is billed without modifier QL]) require an NPI in the Attending Physician field.  Emergency trips do not require an NPI in the Attending Physician field (i.e., A0427, A0429, A0430, A0431, A0432, A0433, A0434 and A0428 [when A0428 is billed with modifier QL])   G. CWF (A/B MACs (A))   A/B MACs (A) report the procedure codes in the financial data section.  They include revenue code, HCPCS code, units, and covered charges in the record.  Where more than one HCPCS code procedure is applicable to a single revenue code, the provider reports each HCPCS code and related charge on a separate line, and the A/B MAC (A) reports this to CWF.  Report the payment amount before adjustment for beneficiary liability in Rate and the actual charge in Covered Charges.   30.2.2 - SNF Billing (Rev.4021; Issued: 04- 13-18; Effective: 07 -16-18; Implementation: 07 -16-18)  When billing for ambulance transports of SNF residents, suppliers should indicate whether the transport was part of a SNF Part A covered stay, using the appropriate origin/destination modifier (e.g., NH for a transport from a SNF to a hospital). The following ambulance transportat ion and related ambulance services for residents in Part A stays are not included in the PPS rate.  For additional information, see Chapter 6, SNF Inpatient Part A Billing and SNF Consolidated Billing,  20.3.1, Ambulance Services.  They may be billed as P art B services by the supplier only in the following situations:   The ambulance trip is to the SNF for admission (the second character (destination) of any ambulance HCPCS code modifier is N (SNF) other than modifier QN, and the date of service is the same as the SNF 21X admission date.)    The ambulance trip is from the SNF to home (the first character (origin) of any HCPCS code ambulance modifier is N (SNF)), and date of ambulance service is the same date as the SNF through date, and the SNF patient status (FL 22) is other than 30.)   The ambulance trip is to or from a hospital based or non- hospital based ESRD facility (either one of any HCPCS code ambulance modifiers is G (Hospital based dialysis facility) or J (Non -hospital based dialysis facility) and the other modifier is N (SNF)).   The ambulance trip is from the SNF to another SNF (the first and second character (origin and destination) of any ambulance HCPCS code modifier is N (SNF)) and the beneficiary is not in a Part A stay.  Ambulance payment associated with the following outpatient hospital service exclusions is paid under the ambulance fee schedule:   Cardiac catheterization;   Computerized axial tomography (CT) scans;   Magnetic resonance imaging (MRIs);   Ambulatory surgery involving the use of an operating room, including the insertion, removal, or replacement of a percutaneous esophageal gastrostomy (PEG) tube in the hospitals gastrointestinal (GI) or endoscopy suite;   Emergency services;   Angiography;   Lymphatic and Venous Procedures; and   Radiation therapy.  See  Chapter 6,  20.1.2, Other Excluded Services Beyond the Scope of a SNF Part A Benefit, for further information pertaining to the list of services that are excluded from SNF Part A payment referenced above.  The following ambulance transportation and related ambulance services for residents in a Part A stay are included in the SNF PPS rate and may not  be billed as Part B services by the supplier.  For additional information, see Chapter 6,  20.3.1, In these scenarios, the services provided are subject to SNF CB and the first SNF is responsible for billing the services to the A/B MAC (A):   Suppliers should bill with an NN origin/destination modifier when a SNF -to-SNF transport occurs.  A transport between two SNFs (that is, a beneficiarys same -day transfer from one SNF to another) is not separately payable when a beneficiary is in a Part A covered SNF stay, and will result in a denial of a Part B claim for such a transport.   Ambulance transports to or from a diagnostic or therapeutic site other than a hospital or renal dialysis facility (e.g., an independent diagnostic testing facility (IDTF), cancer treatment center, radiation therapy center, wound care center, etc.).  The fi rst or second character (origin or destination) of any HCPCS code ambulance modifier is D (Diagnostic or therapeutic site other than P or H), and the other modifier (origin or destination) is N (SNF). Exception: An ambulance transport from a SNF to the  nearest supplier of medically necessary services not available at the SNF where the beneficiary is a resident and not in a covered Part A stay, including the return trip, is covered under Part B provided that the ambulance transportation was medically reasonable and necessary and all other coverage requirements are met.   30.2.3 - Indian Health Service (IHS)/Tribal Billing  (Rev. 2102, Issued: 11- 19-10, Effective: 04 -01-11, Implementation: 04- 04-11)  Ambulance services furnished by IHS/Tribal hospitals including Critical Access Hospitals (CAHs) will be paid according to the appropriate payment methodology.  For dates of service on or after December 21, 2000 and prior to January 1, 2004, medically necessary ambulance services furnished by an IHS/Tribal CAH or by an entity that is owned and operated by an IHS/Tribal CAH are paid based on 100 percent of the reas onable cost if the 35 mile rule for cost- based payment is met.  In order for the 35 mile rule to be met, the IHS/Tribal CAH or the entity that is owned and operated by the IHS/Tribal CAH, must be the only provider or supplier of ambulance services that is located within a 35 mile drive of the IHS/Tribal CAH or the entity.  Those CAHs that meet the 35 mile rule for cost -based payment shall report condition code B2 (CAH ambulance attestation) on their bills.   For dates of service on or after January 1, 2004, ambulance services furnished by an IHS/Tribal CAH or by an entity that is owned and operated by an IHS/Tribal CAH are paid based on 101 percent of the reasonable cost if the 35 mile rule for cost -based paym ent is met.   When the 35 mile rule for cost -based payment is not met, the IHS/Tribal CAH ambulance service or the ambulance service furnished by the entity that is owned and operated by the IHS/Tribal CAH is paid based on the ambulance fee schedule.   Other IHS/Tribal hospital based ambulance services are reimbursed based on the ambulance fee schedule.   30.2.4 - Non-covered Charges on Institutional Ambulance Claims  (Rev. 1921, Issued: 02- 19-10, Effective: 04 -01-10, Implementation: 04- 05-10)  Medicare law contains a restriction that miles beyond the closest available facility cannot be billed to Medicare.  Non -covered miles beyond the closest facility are billed with HCPCS procedure code A0888 (non- covered ambulance mileage per mile, e.g., for  miles traveled beyond the closest appropriate facility).  These non- covered line items can be billed on claims also containing covered charges.  Ambulance claims may use the - GY modifier on line items for such non- covered mileage, and liability for the s ervice will be assigned correctly to the beneficiary.   The method of billing all miles for the same trip, with covered and non- covered portions, on the same claim is preferable in this scenario.  However, billing the non- covered mileage using condition code 21 claims is also permitted, if desired, as long as a ll line items on the claims are non-covered and the beneficiary is liable.  Additionally, unless requested by the beneficiary or required by specific Medicare policy, services excluded by statute do not have to be billed to Medicare.   When the scenario is point of pick up outside the United States, including U.S. territories but excepting some points in Canada and Mexico in some cases, mileage is also statutorily excluded from Medicare coverage.  Such billings are more likely to be subm itted on entirely non- covered claims using condition code 21.  This scenario requires the use of a different message on the Medicare Summary Notice (MSN) sent to beneficiaries.   Another scenario in which billing non- covered mileage to Medicare may occur is when the beneficiary dies after the ambulance has been called but before the ambulance arrives.  The -QL modifier should be used on the base rate line in this scenario, in place  of origin and destination modifiers, and the line is submitted with covered charges.  The -QL modifier should also be used on the accompanying mileage line, if submitted, with non- covered charges.  Submitting this non-covered mileage line is optional for providers.