(Medicare Claims Processing Manual)

Therefore, the service units for each  occur rence of these HCPCS codes are always equal to one.  In addition, for line ite ms reflecting HCPCS code A0380, A0390, A0435, or A0436, the num ber of loaded m iles must be reported.   H. Total Charges Reporting  For line ite ms reflecting HCPCS codes A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434;   Providers are required to repor t in T otal Char ges the actual charge for the a mbulance servi ce including all su pplies u sed for the a mbulance trip but excluding the charge for m ileage. For line items reflecting H CPCS code A0380, A0390, A0435, or A0436, report the actual c harge for mileage.   NOTE:   There are instances where the provider does not incur  any cost for m ileage, e.g., if the beneficiary is pron ounced dead after the ambulance is called b ut before the am bulance arrives at the scene.   In these situations, providers report the base rate a mbulance trip and m ileage as separate revenue code  lines.   Providers  report the base rate am bulance trip in accor dance with current bi lling require ments.  For purposes of reporting m ileage, they must report the appropr iate HCPCS c ode, m odifi ers, and units as a separate line item .  For the related  charges, providers report $1.00 in FL48 for non - covered charges.  A/B MACs (A) should assign remittance adjustment Group Code OA to the $1.00 non-  covered m ileage line, which in turn infor ms the beneficiaries  and providers that they each have no liability.  Prior to su bmitting the c laim to CWF, the A/B MAC (A) will re move the entire reve nue code line containing the m ileage amount repo rted in Non- covered Charges to avoid non- acceptance of the clai m.  NOTE:   Infor mation regarding the claim  form locator that corresponds to the Charges fields is found in Pub. 100- 04, Medicare Claims Processing Manual,  Chapter 25 - Completing and Processing the Form CMS -1450 Data Se t.  EXAM PLES:  The f ollowing provi des exam ples of  how bills f or Part B ambulance services should be com pleted based on t he reporting require ments above.  These exam ples reflect ambulance ser vices fur nished directly by providers.  Ambulance services provided under arrangem ent between  the provider and an a mbulance co mpany are reported in the sam e manner except provid ers report  a QM modifier instead of a QN modifier.   EXAM PLE 1: Claim containing only one a mbulance trip:   Providers report as follows:   Revenue Code  HCPCS/ Modifiers  Date of Service  Units  Total Charges  0540  A0428RHQN  082701  1 (trip)  100.00  0540  A0380RHQN  082701  4 (mileage)  8.00  EXAMPLE 2:  Claim contai ning multi ple am bulance tri ps:  Providers report as follows:   Revenue Code  HCPCS  Modifiers  Date of Service  Units  Total Charges  #1 #2 0540  A0429  RH QN 082801  1 (trip)  100.00  0540  A0380  RH QN 082801  2 (mileage)  4.00 0540  A0330  RH QN 082901  1 (trip)  400.00  0540  A0390  RH QN 082901  3 (mileage)  6.00  EXAM PLE 3: Claim contai ning m ore than o ne ambulance trip provided on the sa me day:   Providers report as follows:   Revenue Code  HCPCS  Modifiers  Date of Service  Units  Total Charges  0540  A0429  RH QN 090201  1 (trip)  100.00  0540  A0380  RH QN 090201  2 (mileage)  4.00 0540  A0429  HR QN 090201  1 (trip)  100.00  0540  A0380  HR QN 090201  2 (mileage)  4.00  I. Edits   FISS edits to assure proper reporting as follows:    For clai ms with dates of  service on or  after Jan uary 1, 2001, each pair of revenue codes 0540 must have one of the following a mbulance HCPCS codes -  A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434; and one of the following mileage HCPCS codes -  A0435, A 0436 or for clai ms with dates of service on or after April 1, 2002, A0425;    For clai ms with dates of service on or  after January 1, 2001, t he presence of an origin and destination m odifier and a  QM or QN modifier for every line item containing revenue code 0540;    The units field is co mpleted for every line item  containing revenue code 0540;    For clai ms with dates of service on or  after January 1, 2001, the units field is completed for every line item  containing revenue code 0540;    Service units for line ite ms containing HCPCS codes A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434 always equal 1"   For clai ms with dates of service on or a fter July 1, 2001, each 1- way ambulance trip, line - item dates of  service for the a mbulance ser vice, a nd corresp onding m ileage are eq ual.    30.2.1 - A/B MAC (A) Bill Processing Guidelines Effective April 1, 2002, as a Result of Fee Schedule Implementation  (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)  For SNF Part A, the cost of medically necessary ambulance transportation to receive most services included in the RUG rate is included in the cost for the service. Payment for the SNF claim is based on the RUGs, which takes into account the cost of such tr ansportation to receive the ancillary services.   Refer to IOM Pub. 100- 04, Medicare Claims Processing Manual, chapter 6 -  SNF Inpatient Part A Billing, Section 20.3.1 -  Ambulance Services for additional information on SNF consolidated billing and ambulance transportation.  Refer to IOM Pub. 100- 04, Medicare Claims Processing Manual, chapter 3 -  Inpatient Hospital Billing, section 10.5 -  Hospital Inpatient Bundling, for additional information on hospital inpatient bundling of ambulance services.   In general, the A/B MAC (A) processes claims for Part B ambulance services provided by an ambulance supplier under arrangements with hospitals or SNFs.  These providers bill A/B MACs (A) using only Method 2.  The provider must furnish the following data in accordance with A/B MAC (A) instructions.  The A/B MAC (A) will make arrangements for the method and media for submitting the data:    A detailed statement of the condition necessitating the ambulance service;    A statement indicating whether the patient was admitted as an inpatient.  If yes the name and address of the facility must be shown;    Name and address of certifying physician;    Name and address of physician ordering service if other than certifying physician;    Point of pickup (identify place and completed address);    Destination (identify place and complete address);    Number of loaded miles (the number of miles traveled when the beneficiary was in the ambulance);    Cost per mile;   Mileage charge;    Minimum or base charge; and   Charge for special items or services.  Explain.   A. Revenue Code Reporting on Form CMS -1450  Providers report ambulance services under revenue code 540 in FL 42 Revenue Code.   B. HCPCS Codes Reporting on Form CMS -1450  Providers report the HCPCS codes established for the ambulance fee schedule.  No other HCPCS codes are acceptable for the reporting of ambulance services and mileage.  The HCPCS code must be used to reflect the type of service the beneficiary received, not  the type of vehicle used.   Providers must report one of the following HCPCS codes in FL 44 HCPCS/Rates for each base rate ambulance trip provided during the billing period:   A0426;  A0427;  A0428;  A0429;  A0430;  A0431;  A0432;  A0433; or  A0434.  These are the same codes required effective for services January 1, 2001.   In addition, providers must report one  of HCPCS mileage codes:   A0425;  A0435; or  A0436.  Since billing requirements do not allow for more than one HCPCS code to be reported per revenue code line, providers must report revenue code 540 (ambulance) on two separate and consecutive line items to accommodate both the ambulance service and the mileage HCPCS codes for each ambulance trip provided during the billing period.  Each loaded (e.g., a patient is onboard) 1- way ambulance trip must be reported with a unique pair of r evenue code lines on the claim.  Unloaded trips and mileage are NOT  reported.  For Form CMS -1450 claims submission prior to August 1, 2011, providers code one mile for trips less than a mile.  Miles must be entered as whole numbers.  If a trip has a fraction of a mile, round up to the nearest whole number.   Beginning with dates of service on or after January 1, 2011, for Form CMS -1450 hard copy claims submissions August 1, 2011 and after, mileage must be reported as fractional units.  When reporting fractional mileage, providers must round the total miles up to the nearest tenth of a mile and the decimal must be used in the appropriate place (e.g., 99.9).   For trips totaling less than 1 mile, enter a 0 before the decimal (e.g., 0.9).   For electronic claims submissions prior to January 1, 2011, providers code one mile for trips less than a mile.  Miles must be entered as whole numbers.  If a trip has a fraction of a mile, round up to the nearest whole number.   Beginning with dates of service on or after January 1, 2011, for electronic claim submissions only, mileage must be reported as fractional units for trips totaling up to 100 covered miles.  When reporting fractional mileage, providers must round the total miles up to the nearest tenth of a mile and the decimal must be used in the appropriate place (e.g., 99.9).   For trips totaling 100 covered miles and greater, providers must report mileage rounded up to the nearest whole number mile (e.g., 999) and not use a decimal when reporting whole number miles over 100 miles.   For trips totaling less than 1 mile, enter a 0 before the decimal (e.g., 0.9).   C. Modifier Reporting   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.