(Medicare Claims Processing Manual)

Effective January 1, 2006, items and services which include but are not limited to oxygen, drugs, extra attendants, supplies, EKG, and night differential are no longer paid separately for ambulance services.  This occurred when CMS fully implemented the Ambulance Fee Schedule, and therefore, payment is based solely on the ambulance fee schedule.  Effective for claims on or after October 1, 2007, if ambulance claims submitted with a code(s) that is/are not separately billable the payment for the code(s) is included in the base rate.   Contractors 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 Four.   Group Code: CO  CARC: 97  RARC: N390  MSN: 1.6  This is true whether the primary transportation service is allowed or denied.  When the service is denied, the services are not separately billable to the beneficiaries as they are already part of the base rate.  Payment for ambulance services may be made only on an assignment related basis. Prospective payment systems, including the Ambulance Fee Schedule, are exempt from Inherent Reasonableness provisions.  20 - Payment Rules (Rev. 1696; Issued:  03- 06-09; Effective/Implementation Date:  04 -06-09) B3-4115, 5116, PM AB -02-131  Medicare covered ambulance services are paid based on the Medicare ambulance fee schedule.   The following subsections describe how contractors calculate the payment amount. Section 20.1 and its subsections describe how the payment amount is calculated for the fee schedule. The other subsections in 20 provide information on certain components of the payment amount (e.g., mileage) or specialized payment amounts (e.g., air ambulance).   20.1 - Payment Under the Ambulance Fee Schedule  (Rev. 1696; Issued:  03- 06-09; Effective/Implementation Date:  04 -06-09)  20.1.1 - General  (Rev. 1696; Issued:  03- 06-09; Effective/Implementation Date:  04 -06-09)  Payment under the fee schedule for ambulance services:    Includes a base rate payment plus a separate 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    Does not include 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 (e.g., ancillary services) - but only when such items and services are both medically necessary and covered by Medicare under the ambulance benefit.   For additional information on the fee schedule, contractors may refer to the Ambulance Services Center on the CMS Web site at http://www.cms.gov/Medicare/Medicare -Fee-for-Service- Payment/AmbulanceFeeSchedule/index.html   20.1.2 - Jurisdiction  (Rev. 1696; Issued:  03- 06-09; Effective/Implementation Date:  04 -06-09)  Claims jurisdiction for suppliers is considered to be where the ambulance vehicle is garaged or hangared.  Claims jurisdiction for institutional based providers is based on the primary location of the institution.   20.1.3 - Services Provided  (Rev. 1696; Issued:  03- 06-09; Effective/Implementation Date:  04 -06-09) AB-03-106  Payment is based on the level of service provided, not on the vehicle used. Occasionally, local jurisdictions require the dispatch of an ambulance that is above the level of service that ends up being provided to the Medicare beneficiary.  In this, as in m ost instances, Medicare pays only for the level of service provided, and then only when the service provided is medically necessary.   20.1.4 - Components of the Ambulance Fee Schedule  (Rev. 3800, Issued: 06- 23-17, Effective: 07 -25-17, Implementation: 07- 25-17)  The mileage rates provided in this section are the base rates that are adjusted by the yearly ambulance inflation factor (AIF).  The payment amount under the fee schedule is determined as follows:    For ground ambulance services , the fee schedule amount includes:   1. A money amount that serves as a nationally uniform base rate, called a conversion factor (CF), for all ground ambulance services;   2. A relative value unit (RVU) assigned to each type of ground ambulance service;   3. A geographic adjustment factor (GAF) for each ambulance fee schedule locality area (geographic practice cost index (GPCI));   4. A nationally uniform loaded mileage rate;   5. An additional amount for certain mileage for a rural point -of-pickup; and   6. For specified temporary periods, certain additional payment amounts as described in section 20.1.4A, below.    For air ambulance services , the fee schedule amount includes:   1. A nationally uniform base rate for fixed wing and a nationally uniform base rate for rotary wing;   2. A geographic adjustment factor (GAF) for each ambulance fee schedule locality area (GPCI);   3. A nationally uniform loaded mileage rate for each type of air service; and  4. A rural adjustment to the base rate and mileage for services furnished for a rural point -of-pickup.   A. Ground Ambulance Services   1. Conversion Factor   The conversion factor (CF) is a money amount used to develop a base rate for each category of ground ambulance service. The CF is updated annually by the ambulance inflation factor and for other reasons as necessary.   2. Relative Value Units   Relative value units (RVUs) set a numeric value for ambulance services relative to the value of a base level ambulance service. Since there are marked differences in resources necessary to furnish the various levels of ground ambulance services, different levels of payment are appropriate for the various levels of service.  The different payment amounts are based on level of service.  An RVU expresses the constant multiplier for a particular type of service (including, where appropriate, an emergency response).  An RVU of 1.00 is assigned to the BLS of ground service, e.g., BLS has an RVU of 1; higher RVU values are assigned to the other types of ground ambulance services, which require more service than BLS.  The RVUs are as follows:   Service Level  RVU  BLS 1.00 BLS - Emergency  1.60 ALS1  1.20 ALS1 - Emergency  1.90 ALS2  2.75 SCT 3.25 PI 1.75  3. Geographic Adjustment Factor (GAF)   The GAF is one of two factors intended to address regional differences in the cost of furnishing ambulance services.  The GAF for the ambulance FS uses the non- facility practice expense (PE) of the geographic practice cost index (GPCI) of the Medicare physician fee schedule to adjust payment to account for regional differences.  Thus, the geographic areas applicable to the ambulance FS are the same as those u sed for the physician fee schedule.   The location where the beneficiary was put into the ambulance (POP) establishes which GPCI applies.  For multiple vehicle transports, each leg of the transport is separately evaluated for the applicable GPCI.  Thus, for the second (or any subsequent) leg of a transport, the POP establishes the applicable GPCI for that portion of the ambulance transport.   For ground ambulance services, the applicable GPCI is multiplied by 70 percent of the base rate. Again, the base rate for each category of ground ambulance services is the CF multiplied by the applicable RVU.  The GPCI is not applied to the ground mileage rate.   4. Mileage   In the context of all payment instructions, the term mileage refers to loaded mileage.  The ambulance FS provides a separate payment amount for mileage.  The mileage rate per statute mile applies for all types of ground ambulance services, except Paramedic Intercept, and is provided to all Medicare contractors electronically by CMS as part of the ambulance FS. Providers and suppliers must report all medically necessary mileage, including the mileage subject to a rural adjustment, in a single line item.   5. Adjustment for Certain Ground Mileage for Rural Points of Pickup (POP)   The payment rate is greater for certain mileage where the POP is in a rural area to account for the higher costs per ambulance trip that are typical of rural operations where fewer trips are made in any given period.   If the POP is a rural ZIP Code, the following calculations should be used to determine the rural adjustment portion of the payment allowance.  For loaded miles 1- 17, the rural adjustment for ground mileage is 1.5 times the rural mileage allowance.   For services furnished during the period July 1, 2004 through December 31, 2008, a 25 percent increase is applied to the appropriate ambulance FS mileage rate to each mile of a transport (both urban and rural POP) that exceeds 50 miles (i.e., mile 51 and greater).   The following chart summarizes the above information:   Service  Dates of Service  Bonus  Calculation  Loaded miles 1 -17, Rural POP  Beginning 4/1/02  50% FS Rural mileage * 1.5 Loaded miles 18 -50, Rural POP  4/1/02 - 12/31/03  25% FS Rural mileage * 1.25 All loaded miles (Urban or Rural POP) 51+  7/1/04 - 12/31/08  25% FS Urban or Rural mileage * 1.25   The POP, as identified by ZIP Code, establishes whether a rural adjustment applies to a particular service.  Each leg of a multi -leg transport is separately evaluated for a rural adjustment application.  Thus, for the second (or any subsequent) leg of a tr ansport, the ZIP Code of the POP establishes whether a rural adjustment applies to such second (or subsequent) transport.  For the purpose of all categories of ground ambulance services except paramedic intercept, a rural area is defined as a U.S. Postal Service (USPS) ZIP Code that is located, in whole or in part, outside of either a Metropolitan Statistical Area (MSA) or in New England, a New England County Metropolitan Area (NECMA), or is an area wholly within an MSA or NECMA that has been identified as rural under the Goldsmith modification.  (The Goldsmith modification establishes an operational definition of rural areas within large counties that contain one or more metropolitan areas. Th e Goldsmith areas are so isolated by distance or physical features that they are more rural than urban in character and lack easy geographic access to health services.)   For Paramedic Intercept, an area is a rural area if:    It is designated as a rural area by any law or regulation of a State;   It is located outside of an MSA or NECMA; or   It is located in a rural census tract of an MSA as determined under the most recent Goldsmith modification.   See IOM Pub. 100- 02, Medicare Benefit Policy Manual, chapter 10 -  Ambulance Services, section 30.1.1 -  Ground Ambulance Services for coverage requirements for the Paramedic Intercept benefit.  Presently, only the State of New York meets these requirements.   Although a transport with a POP located in a rural area is subject to a rural adjustment for mileage, Medicare still pays the lesser of the billed charge or the applicable FS amount for mileage.  Thus, when rural mileage is involved, the contractor compare s the calculated FS rural mileage payment rate to the providers/suppliers actual charge for mileage and pays the lesser amount.  The CMS furnishes the ambulance FS files to claims processing contractors electronically.  A version of the Ambulance Fee Schedule is also posted to the CMS website (http://www.cms.gov/Medicare/Medicare -Fee-for-Service-Payment/AmbulanceFeeSchedule/afspuf.html  ) for public consumption.  To clarify whether a particular ZIP Code is rural or urban, please refer to the most recent version of the Medicare supplied ZIP Code file.   6. Regional Ambulance FS Payment Rate Floor for Ground Ambulance Transports   For services furnished during the period July 1, 2004 through December 31, 2009, the base rate portion of the payment under the ambulance FS for ground ambulance transports is subject to a minimum amount.  This minimum amount depends upon the area of the c ountry in which the service is furnished.  The country is divided into 9 census divisions and each of the census divisions has a regional FS that is constructed using the same methodology as the national FS.  Where the regional FS is greater than the natio nal FS, the base rates for ground ambulance transports are determined by a blend of the national rate and the regional rate in accordance with the following schedule:   Year  National FS Percentage  Regional FS Percentage  7/1/04 - 12/31/04  20% 80% CY 2005  40% 60% CY 2006  60% 40% CY 2007 - CY 2009  80% 20% CY 2010 and thereafter  100%  0%