(Medicare Claims Processing Manual)

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%  Where the regional FS is not greater than the national FS, there is no blending and only the national FS applies.  Note that this provision affects only the FS portion of the blended transition payment rate.  This floor amount is calculated by CMS centrall y and is incorporated into the FS amount that appears in the FS file maintained by CMS and downloaded by CMS contractors.  There is no calculation to be done by the MAC  in order to implement this provision.  7. Adjustments for FS Payment Rate for Certain Rural Ground Ambulance Transports   For services furnished during the period July 1, 2004 through December 31, 2010, the base rate portion of the payment under the FS for ground ambulance transports furnished in certain rural areas is increased by a percentage amount determined by CMS.  Sect ion 3105 (c) and 10311 (c) of the Affordable Care Act amended section 1834 (1) (13) (A) of the Act to extend this rural bonus for an additional year through December 31, 2010.  This increase applies if the POP is in a rural county (or Goldsmith area) that is comprised by the lowest quartile by population of all such rural areas arrayed by population density.  CMS will determine this bonus amount and the designated POP rural ZIP Codes in which the bonus applies.  Beginning on July 1, 2004, rural areas qualif ying for the additional bonus amount will be identified with a B indicator on the national ZIP Code file.  Contractors must apply the additional rural bonus amount as a multiplier to the base rate portion of the FS payment for all ground transports origi nating in the designated POP ZIP Codes.   Subsequently, section of 106 (c) of the MMEA again amended section 1843 (l) (13) (A) of the Act to extend the rural bonus an additional year, through December 31, 2011.  8. Adjustments for FS Payment Rates for Ground Ambulance Transports   The payment rates under the FS for ground ambulance transports (both the fee schedule base rates and the mileage amounts) are increased for services furnished during the period July 1, 2004 through December 31, 2006 as well as July 1, 2008 through December  31, 2010.  For ground ambulance transport services furnished where the POP is urban, the rates are increased by 1 percent for claims with dates of service July 1, 2004 through December 31, 2006 in accordance with Section 414 of the Medicare Modernization Act (MMA) of 2003 and by 2 percent for claims with dates of service July 1, 2008 through December 31, 2010 in accordance with Section 146(a) of the Medicare Improvements for Patients and Providers Act of 2008 and Sections 3105(a) and 10311(a) of the Patient Protection and Affordable Care Act (ACA) of 2010.  For ground ambulance transport services furnished where the POP is rural, the rates are increased by 2 percent for claims with dates of service July 1, 2004 through December 31, 2006 in accordance with S ection 414 of the Medicare Modernization Act (MMA) of 2003  and by 3 percent for claims with dates of service July 1, 2008 through December 31, 2010 in accordance with Section 146(a) of the Medicare Improvements for Patients and Providers Act of 2008 and Sections 3105(a) and 10311(a) of the Patient Protection and Affordable Care Act (ACA) of 2010.  Subsequently, section 106 (a) of the Medicare and Medicaid Extenders Act of 2010 (MMEA) again amended section 1834 (1) (12) (A) of the Act to extend the payment increases for an additional year, through December 31, 2011.  These amounts are incorporated into the fee schedule amounts that appear in the Ambulance FS file maintained by CMS and downloaded by CMS contractors.  There is no calculation to be done by the MAC in order to implement this provision.  The following chart summarizes the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 payment changes for ground ambulance services that became effective on July 1, 2004 as well as the Medicare Improvement for Patients and Provide rs Act (MIPPA) of 2008 changes that became effective July 1, 2008 and were extended by the Patient Protection and Affordable Care Act of 2010 and the Medicare and Medicaid Extenders Act of 2010 (MMEA).  Summary Chart of Additional Payments for Ground Ambulance Services Provided by MMA, MIPPA and MMEA   Service  Effective Dates  Payment Increase*  All rural miles  7/1/04 - 12/31/06  2% All rural miles  7/1/08 - 12/31/11  3% Rural miles 51+  7/1/04 - 12/31/08  25% **  All urban miles  7/1/04 - 12/31/06  1% All urban miles  7/1/08 - 12/31/11  2% Service  Effective Dates  Payment Increase*  Urban miles 51+  7/1/04 - 12/31/08  25% **  All rural base rates  7/1/04 - 12/31/06  2% All rural base rates  7/1/08 - 12/31/11  3% Rural base rates (lowest quartile)  7/1/04 - 12/31/11  22.6 %**  All urban base rates  7/1/04 - 12/31/06  1% All urban base rates  7/1/08 - 12/31/11  2% All base rates (regional fee schedule blend)  7/1/04 - 12/31/09  Floor   NOTES:  *  All payments are percentage increases and all are cumulative.   **Contractor systems perform this calculation.  All other increases are incorporated into the CMS Medicare Ambulance FS file.   B. Air Ambulance Services   1. Base Rates   Each type of air ambulance service has a base rate.  There is no conversion factor (CF) applicable to air ambulance services.   2. Geographic Adjustment Factor (GAF)   The GAF, as described above for ground ambulance services, is also used for air ambulance services.  However, for air ambulance services, the applicable GPCI is applied to 50 percent of each of the base rates (fixed and rotary wing).   3. Mileage   The FS for air ambulance services provides a separate payment for mileage.   4. Adjustment for Services Furnished in Rural Areas   The payment rates for air ambulance services where the POP is in a rural area are greater than in an urban area.  For air ambulance services (fixed or rotary wing), the rural adjustment is an increase of 50 percent to the unadjusted FS amount, e.g., the applicable air service base rate multiplied by the GAF plus the mileage amount or, in other words, 1.5 times both the applicable air service base rate and the total mileage amount.   The basis for a rural adjustment for air ambulance services is determined in the same manner as for ground services.  That is, whether the POP is within a rural ZIP Code as described above for ground services.  20.1.5  - ZIP Code Determines Fee Schedule Amounts  (Rev. 3481, Issued: 03- 18-16. Effective: 06 -20-16, Implementation: 06- 20-16)  The POP determines the basis for payment under the FS, and the POP is reported by its 5- digit ZIP Code.  Thus, the ZIP Code of the POP determines both the applicable GPCI and whether a rural adjustment applies.  If the ambulance transport required a second or subsequent leg, then the ZIP Code of the POP of the second or subsequent leg determines both the applicable GPCI for such leg and whether a rural adjustment applies to such leg.  Accordingly, the ZIP Code of the POP must be reported on every claim to determine both the correct GPCI and, if applicable, any rural adjustment.  Part B contractors must report the POP ZIP Code, at the line item level, to CWF when they report all other ambulance claim information. CWF must report the POP ZIP Code to the national claims history file, along with the rest of the ambulance claims record.   A.  No ZIP Code   In areas without an apparent ZIP Code, it is the providers/suppliers responsibility to confirm that the POP does not have a ZIP Code that has been assigned by the USPS.  If the provider/supplier has made a good- faith effort to confirm that no ZIP Code for the POP exists, it may use the ZIP Code nearest to the POP.  Providers and suppliers should document their confirmation with the USPS, or other authoritative source, that the POP does not have an assigned ZIP Code and annotate the claim to indicate that a surrogate ZIP Code has been used (e.g., Surrogate ZIP Code; POP in No -ZIP).  Providers and suppliers should maintain this documentation and provide it to their contractor upon request.   Contractors must request additional documentation from providers/suppliers when a claim submitted using a surrogate ZIP Code does not contain sufficient information to determine that the ZIP Code does not exist for the POP.  They must investigate and repor t any claims submitted with an inappropriate and/or falsified surrogate ZIP Code.   If the ZIP Code entered on the claim is not in the CMS -supplied ZIP Code File, manually verify the ZIP Code to identify a potential coding error on the claim or a new ZIP Code established by the U.S. Postal Service (USPS).  ZIP Code information may be found at the USPS Web site at http://www.usps.com/ , or other commercially available sources of ZIP Code information may be consulted.   If this process validates the ZIP Code, the claim may be processed.  All such ZIP Codes are to be considered urban ZIP Codes until CMS determines that the code should be designated as rural, unless the contractor exercises its discretion to designate the Z IP Code as rural.  (See Section  20.1.5.B   New ZIP Codes)    If this process does not validate the ZIP Code, the claim must be rejected as unprocessable.   The contractor 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 Two   Group Code: CO  CARC: 16  RARC: N53  MSN: N/A  B.  New ZIP Codes   New ZIP Codes are considered urban until CMS determines that the ZIP Code is located in a rural area.  Thus, until a ZIP Code is added to the Medicare ZIP Code file with a rural designation, it will be considered an urban ZIP Code.  However, despite the de fault designation of new ZIP Codes as urban, contractors have discretion to determine that a new ZIP Code is rural until designated otherwise.  If the contractor designates a new ZIP Code as rural, and CMS later changes the designation to urban, then the c ontractor, as well as any provider or supplier paid for mileage or for air services with a rural adjustment, will be held harmless for this adjustment.   Providers and suppliers should annotate claims using a new ZIP Code with a remark to that effect.  Providers and suppliers should maintain documentation of the new ZIP Code and provide it to their contractor upon request.   If the provider or supplier believes that a new ZIP Code that the contractor has designated as urban should be designated as rural (under the standard established by the Medicare FS regulation), it may request an adjustment from the A/B MAC (A) or appeal the determination with the A/B/MAC (B), as applicable, in accordance with standard procedures.   When processing a claim with a POP ZIP Code that is not on the Medicare ZIP Code file, contractors must search the USPS Web site at http://www.usps.com/ , other governmental Web sites, and commercial Web sites, to validate the new ZIP Code.  (The Census Bureau Web site located at http://www.census.gov/  contains a list of valid ZIP Codes.)  If the ZIP Code cannot be validated using the USPS Web site or other authoritative source such as the Census Bureau Web site, reject the claim as unprocessable.   C.  Inaccurate ZIP Codes