(Medicare Benefit Policy Manual)

30.1 - Definition of Ambulance Services  (Rev. 226, Issued: 09- 12-16, Effective: 01- 01-16, Implementation: 12- 12-16)  There are several categories of ground ambulance services and two categories of air ambulance services under the fee s chedule.  (Note that ground refers to both land and water transportation.)  All ground and air ambulance transportation services must meet all requirements regarding medical reasonableness and necessity as outlined in the applicable statute, regulations and manual provisions.  30.1.1 - Ground Ambulance Services  (Rev. 236, Issued: 06- 16-17, Effective: 09- 18-17, Implementation: 09- 18-17)  Basic Life Support (BLS)   Definition :  BLS is transportation by ground ambulance vehicle (as defined in section 10.1, above) and the provision of medically necessary supplies and services (as defined in section 10.2, above), including BLS ambulance services as defined by the state.  The ambulance vehicle must be staffed by at least two people who meet the requirements of the state and local laws where the services are being furnished, and at least one of the staff members must be certified at a minimum as an emergency medical technician -basic (EMT -Basic) by the state or local authority where the services are being furnished and be legally authorized to operate all lifesaving and life -sustaining equipment on board the vehicle.  These laws may vary from state to state or within a state.   Basic Life Support (BLS) -  Emergency   Definition :  When medically necessary, the provision of BLS services, as specified above, in the context of an emergency response (as defined below).   Advanced Life Support, Level 1 (ALS1)   Definition:   Advanced life support, level 1 (ALS1) is the transportation by ground ambulance vehicle (as defi ned in section 10.1, above) and the provision of medically necessary supplies and services (as defined in section 10.2, above) including the provision of an ALS assessment by ALS personnel or at least one ALS intervention.  Advanced Life Support Assessment   Definition:   An ALS assessment is an assessment performed by an ALS crew as part of an emergency response (as defined below) that was necessary because the patient's reported condition at the time of dispatch was such that only an ALS crew was qualified to perform the assessment.  An ALS assessment does not necessarily result in a determination that the patient requires an ALS level of service. In the case of an appropriately dispatched ALS Emergency service, as defined below, if the ALS crew completes an  ALS Assessment, the services provided by the ambulance transportation service provider or supplier shall be covered at the ALS emergency level, regardless of whether the patient required ALS intervention services during the transport, provided that ambula nce transportation itself was medically reasonable and necessary, as defined in section 10.2, above and all other coverage requirements are met.   Advanced Life Support Intervention  Definition:   An ALS intervention is a procedure that is in accordance with  state and local laws, required to be done by an emergency medical technician- intermediate (EMT -Intermediate) or EMT -Paramedic.   Application:   An ALS intervention must be medically necessary to qualify as an intervention for payment for an ALS level of ser vice.  An ALS intervention applies only to ground transports.  Advanced Life Support, Level 1 (ALS1) -  Emergency   Definition:   When medically necessary, the provision of ALS1 services, as specified above, in the context of an emergency response, as defined below.   Advanced Life Support, Level 2 (ALS2)   Definition:   Advanced life support, level 2 (ALS2) is the transportation by ground ambulance vehicle and the provision of medically necessary supplies and services including (1) at least three separate administrations  of one or more medications by intravenous (IV) push/bolus or by continuous infusion (excluding crystalloid fluids) or (2) ground ambulance transport, medically necessary supplies and services, and the provision of at least one of the ALS2 p rocedures listed below:   a.  Manual defibrillation/cardioversion;   b.  Endotracheal intubation;   c.  Central venous line;   d.  Cardiac pacing;   e.  Chest decompression;   f.  Surgical airway; or   g. Intraosseous line.  Application: Crystalloid fluids includ e but are not necessarily limited to 5 percent Dextrose in water (often referred to as D5W), Saline and Lactated Ringers.  To qualify for the ALS2 level of payment, medications must be administered intravenously.   Medications  that are ad ministe red by ot her means, for ex ample: intramus cularly, subcutaneously, orally, subl ingually, or ne buliz ed do not  support payment at the  ALS2 level rate.  The IV medications are administered in standard doses as directed by local protocol or online medical direction.  It is not appropriate to administer a medication in divided doses in order to meet the ALS2 level of payment.  For example, if the local protocol for the treatment of supraventricular tachycardia (SVT) calls for a 6 mg dose of adenosine, the administration of  three 2 mg doses in order to qualify for the ALS 2 level is not acceptable.   The administration of an intravenous drug by infusion qualifies as one intravenous dose.  For example, if a patient is being treated for atrial fibrillation in order to slow the ventricular rate with diltiazem and the patient requires two boluses of the drug followed by an infusion of diltiazem, then the infusion would be counted as the third intravenous administration and the transport would be billed as an ALS 2 level of service .  The fractional administration of a single dose (for this purpose, meaning a standard or protocol dose) of a medication on three separate occasions does not qualify for ALS2 payment.  In other words, the administering 1/3 of a qualifying dose 3 times  does not equate to three qualifying doses to support claiming ALS2- level care.  For example, administering one -third of a dose of X medication 3 times might = Y (where Y is a standard/protocol drug amount), but the same sequence does not equal 3 times Y.  Thus, if 3 administrations of the same drug are required to claim ALS2 level care, each administration must be in accordance with local protocols; the run will not qualify at the ALS2 level on the basis of drug administration if that administration was no t according to local protocol.  The criterion of multiple administrations of the same drug requires that a suitable quantity of the drug be administered and that there be a suitable amount of time between administrations, and that both are in accordance wi th standard medical practice guidelines.  An example of a single dose of medication administered fractionally on three separate occasions that would not qualify for the ALS2 payment rate is the administration of a single 1 mg dose of IV Epinephrine in part ial increments to treat an adult pulseless Ventricular Tachycardia/Ventricular Fibrillation (VF/VT) patient.  The American Heart Association (AHA), Advanced Cardiac Life Support (ACLS) protocol calls for Epinephrine to be administered in 1 mg increments every 3 to 5 minutes.  Therefore, administering IV Epinephrine in separate increments of 0.25 mg, 0.25 mg, and 0.50 mg (for a total of 1 mg) over the course of a single 3 to 5 minute episode would not qualify for the ALS2 level of payment.  Conversely, administering three separate 1 mg doses of IV Epinephrine over the requisite protocol -based time period to a patient with unresolved VF/VT would qualify for an ALS2 level of service.  NOTE:  refer to and abide by your authorized protocols; AHAs ACLS protocols a re referenced here only by way of widely recognized example.   Another example that would not qualify  for the ALS2 payment level is administering Adenosine in three 2 mg increments (for a total of 6 mg) in treating an adult patient with Paroxysmal Supravent ricular Tachycardia (PSVT).  ACLS guidelines dictate treating PSVT with 6 mg of Adenosine by rapid intravenous push (IVP) over 1 to 2 seconds.  Should the initial 6 mg dose not eliminate the PSVT within 1 to 2 minutes, guidelines dictate that another 12 mg  of Adenosine IVP should be administered where the PSVT persists, followed by another 12 mg dose 1 to 2 minutes later; for a total of 30 mg of Adenosine.  Administering a total of 30 mg of Adenosine, involving three episodes of administration in a complete  cycle of treatment as outlined above,  would qualify for ALS2 payment.  Endotracheal (ET) intubation (which includes intubating and/or monitoring/maintaining an ET tube inserted prior to transport) is a service that qualifies for the ALS2 level of payment.  Therefore, it is not necessary to consider medications administered by ET tube to determine whether the ALS2 rate is payable.   Advanced Life Support (ALS) Personnel   Definition:  ALS personnel are individuals trained to the level of the emergency medical  technician -intermediate ( EMT- Intermediate) or paramedic.   Specialty Care Transport (SCT)   Definition:   SCT is the interfacility transportation (as defined below) of a critically injured or ill beneficiary by a ground ambulance vehicle, including the provision of medically necessary supplies and services, at a level of service beyond the scope of the EMT- Paramedic.  SCT is necessary when a beneficiarys condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area, for example, emergency or critical care nursing, emergency medicine, respiratory care, cardiovascular care, or an EMT -Paramedic with additional training.   Application:   SCT is necessary when a beneficiarys condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area.  The E MT-Paramedic level of care is set by each state.  Medically necessary care that is furnished at a level above the EMT -Paramedic level of care may qualify as SCT. To be clear, if EMT -Paramedics -  without specialty care certification or qualification -  are permitted to furnish a given service in a state, then that service does not  qualify for SCT.  The phrase EMT -Paramedic with additional training recognizes that a state may permit a person who is not only certified as an EMT -Paramedic, but who also has suc cessfully completed additional education as determined by the state in furnishing higher level medical services required by critically ill or injured patients, to furnish a level of service that otherwise would require a health professional in an appropria te specialty care area (for example, a nurse) to provide.  Additional training means the specific additional training that a state requires a paramedic to complete in order to qualify to furnish specialty care to a critically ill or injured patient durin g an SCT.   Paramedic Intercept (PI)   Definition :  Paramedic Intercept services are ALS services provided by an entity that does not provide the ambulance transport.  This type of service is most often provided for an emergency ambulance transport in which a local volunteer ambulance that can provide only BLS level of service is dispatched to transport a patient.  If the patient needs ALS services such as EKG monitoring, chest decompression, or IV therapy, another entity dispatches a paramedic to meet the BL S ambulance at the scene or once the ambulance is on the way to the hospital.  The ALS paramedics then provide services to the patient.   This tiered approach to life saving is cost effective in many areas because most volunteer ambulances do not charge for  their services and one paramedic service can cover many communities.  Prior to March 1, 1999, Medicare payment could be made for these services, but could not be made directly to the intercept service provider; rather, Medicare payment could be made only when the claim was submitted by the entity that actually furnished the ambulance transport.  In those areas where state laws prohibited volunteer ambulances from billing Medicare and other health insurance, the intercept service could not receive payment f or treating a Medicare beneficiary and was forced to bill the beneficiary for the entire service.   Paramedic intercept services furnished on or after March 1, 1999, are payable separate from the ambulance transport when all of the requirements in the following three conditions are met:   I.  The intercept service(s) is:    Furnished in a rural area (as defined below) ;   Furnished under a contract with one or more volunteer ambulance services; and,   Medically necessary based on the condition of the beneficiary r eceiving the ambulance service.   II. The volunteer ambulance service involved must:    Meet Medicares certification requirements for furnishing ambulance services;    Furnish services only at the BLS level at the time of the intercept; and,