(Medicare Claims Processing Manual)

Refer to Pub. 100- 04, Medicare Cla ims 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 Pub. 100- 04, Medicare Claims Processing Manual, chapter 3 -  Inpatient Hospital Billing, section 10.5 -  Hospital Inpatient Bundling, f or additional infor mation on hospital inpatient bundling of a mbulance services.   In general, the A/B MAC (A) processes clai ms for Part B  ambulance services provided by an ambulance supplier under arrange ments with hos pitals or SNFs.  These providers bill A/B MACs (A) using only Method 2.  The provider m ust furnish the following data in accordance with A/B MAC (A) instructions. The A/B MAC  (A) will make arrangem ents for the m ethod and m edia for sub mitting the data:   A detailed state ment of the condition necessitati ng the a mbulance service;    A state ment indic ating w hether the patie nt was a dmitted as a n inpatient.  If  yes the na me and address of the  facility must be shown;    Name and address of certifying physician;    Name and address of physician ordering ser vice if other than certifying physician;    Point of pickup (ide ntify place and co mpleted address);    Destination (identify place and com plete addres s);   Number of l oaded m iles (the nu mber of m iles tra veled when t he beneficiary was in the a mbulance);    Cost per m ile;   Mileage charge;    Mini mum or base charge; and    Charge for special item s or services.  Explain.   A. General   The reasonable cost per trip of a mbulance services furnished by a provider of services m ay not exceed the pr ior years reas onable cost per trip updated by the ambulance inflation factor.  This deter mination is ef fective with s ervices furnished during Federal Fiscal Year (FFY) 1998 (between October 1, 1997, and September 30, 1998). Providers are to bill for Part B a mbulance services using the billing m ethod of base rate inclu ding s upplies, with m ileage bil led separately as described below.   The following instructions provide billing procedures i mplementing the above provisions.  B. Applicable Bill Ty pes  The appropr iate type of  bill (13X, 22X, 23X, 83X, and 85X) m ust be re ported. For S NFs, ambulance cannot be re ported on a 21X type of bill.  C. Value Code Reporting   For clai ms with dates of service on or a fter January 1, 2001, providers must report on every Part B ambulance claim  value code A0 (zero) and the related ZIP Code of the geographic location from  which the benefici ary was placed on board the a mbulance in the Value C ode field.  T he value code is defined as ZIP Code of the location from  which the beneficiary is initially  placed on board the ambulance.  Providers report t he number in dollar portion of the form  location right justified to the le ft of the dollar /cents delimite r.  More than one a mbulance trip m ay be reported  on the sa me claim  if the ZIP Codes of all points of pickup are t he same.  How ever, since billing require ments do not allow for value codes (ZIP Codes) to be line item  specific and only one ZIP Code m ay be reported per clai m, providers must prepare a separate claim for a beneficiary for each trip if t he points of pickup are located in different ZIP Codes.   For claims with dates of service on or after April 1, 2002, providers must report value code 32 (multiple patient ambulance transport) when an ambulance transports more than one patient at a time to the same destination.  Providers must report value code 32 and the number of patie nts transported in the amount field as a whole number to the left of the delimiter.   NOTE:  Infor mation regarding the claim  form locator that corresponds to the Value Code field is found in Pub.100- 04, Medicare Claims Processing Manual,  Chapter 25 - Completing and Processing the Form CMS -1450 Data Se t.  D. Reven ue Code/HCPCS Code Reporting   Providers m ust report revenue code 054X and, for services  provided before January 1, 2001, one of the followi ng CMS HCPCS codes for each am bulance trip pr ovided duri ng the billing period:   A0030 (discontinued 12/31/2000); A0040 (discontinued 12/31/2000);  A0050 (discontinued 12/31/2000); A0320 (discontinued 12/31/2000); A0322 (discontinued 12/31/2000); A0324 (discontinued 12/31/2000); A0326 (discontinued 12/31/2000); A0328, (discontinued 12/31/2000); or A0330 (discontinued 12/31/2000).   In addition, providers report one of A0380 or A0390 for m ileage HCPCS codes.  No other HCPCS codes are acceptable for rep orting a mbulance ser vices and m ileage.  Providers report one of the following revenue codes:  0540;  0542;  0543;  0545;  0546; or  0548.  Do not report revenue codes 0541, 0544, or 0547.   For claims with  dates of service on or after January 1, 2001, providers must report revenue code 540 and one of the following HCPCS codes for each a mbulance trip provided during the billing period:   A0426; A0427; A0428; A0429; A0430; A0431; A0432; A0433; or A0434.   Providers using an ALS vehicle to furnish a BLS level of service report H CPCS code, A0426 (ALS1) or A0427 (ALS1 e mergen cy), and are paid accordingly.  In addition, all providers  report one of the following m ileage HCPCS codes:  A0380; A0390; A0435; or A0436.   Since billing  requi rements do not all ow for more than one HCPCS code to be repor ted for per revenue code line, providers m ust report revenue code 0540 (a mbulance) on two separate and consecutive lines to accom modate both the Part B a mbulance service and the m ileage HCPCS codes for each ambulance trip provided during t he billing period.  Each loaded (e.g., a patient is onboard) 1- way ambulance trip m ust be reported with a unique pair of revenue code lines on the  claim.  Unloaded trips and m ileage are NOT reported.  However, in the case where the beneficiar y was pronounced dead after the a mbulance is called/dispatched but before the a mbulance arri ves at t he scene:  Pay ment may be m ade for a BLS service if a ground vehicle is dispatched or at the fixed wing or rotary wing base rate, as applicable, if an air am bulance is di spatched.  Neither m ileage nor a rural adjust ment would be paid.  The ble nded rate amount w ill otherwise ap ply. Providers or suppliers report the A0428 (BLS) non -emergency or A0429 (BLS) emergency transport HCPCS c ode if an emergency response and m odifier QL (Patient pronounced dead after a mbulance called) in HCPCS/Rates instead of the ori gin and destination modifier for ground vehicles.  In addition to the QL  modifier, institutional- based providers repo rt modifier QM or QN.  If the time of death pronouncement is after takeoff to point of pickup but before the beneficiary is loaded on- board the air ambulance, air ambulance providers or suppliers bill the A0430 or A0431 depending on the type of aircraft and modifier QL.   If the ambulance is called/dispatched but the beneficiary dies on the scene prior to the arrival of the ambulance: Payment may be made for BLS service if a ground vehicle is dispatched or at the fixed wing or rotary wing base rate, as applicable, if an air  ambulance is di spatched.  Neither m ileage nor a rural adjust ment would be paid. Providers or suppliers report the A0428 (BLS) non -emergency or A0429 (BLS) emergency transport HCPCS c ode if an emergency response and modifier QL for ground vehicles.  Air am bulance providers or suppliers bill the A0430 or A0431 depending on the type of aircraft and modifier QL, if the time of death pronouncement is after takeoff to point of pickup but before the beneficiary is loaded on- board the air ambulance.   If the beneficiary dies after the ambulance is dispatched but before the beneficiary is loaded onboard the ambulance (before or after arrival at the point -of-pickup): Medicare payment determination is providers or suppliers BLS base rate, no mileage or rural adjustment; providers or suppliers report the A0428 (BLS) non- emergency or A0429 (BLS) emergency transport HCPCS code if an emergency response and modifier QL. However, if the beneficiary dies after pickup, prior to or upon arrival at the receiving fa cility: Medically necessary level of service furnished will be the payment determination.    NOTE:  Infor mation regarding the claim  form locator that corresponds to the HCPCS code is found in Pub. 100- 04, Medicare Claims Processing Manual,  Chapter 25 - Completing and Processing the Form CMS -1450 Data Se t.  E. Modifier Reporting   See the above Section 30 (A)  (Modifiers Specific to A mbulance Service Claims)  for instructions regarding the usage of m odifier s.  F. Line -Item Dates of Service Rep orting   Providers are required to report  line-item dates of service per revenue code line.  This m eans that they m ust report two separate revenue code lines for every ambulance trip provided d uring the billing period along with the date of each trip.  T his includes situations in which m ore than one a mbulance  service is provided to the sa me beneficiary on the sam e day.  Line -item dates of servi ce are reported in t he Servi ce Date f ield.  NOTE:   Infor mation regarding the claim  form locator that corresponds to the Service Date is found i n Pub. 100- 04, Medicare Claims Processing Manual,  Chapter 25 -  Completing and Processing the Form CMS -1450 Data Se t.  G. Servi ce Units Reporting   For line ite ms reflecting HCPCS code A0030, A0040, A0050, A0320, A0322, A0324, A0326, A0328, or A0330 (services before January 1, 2001) or code A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434 (services on and after January 1, 2001), providers are required to report  in Service Units each am bulance trip provided during the billing per iod.  Therefore, the service u nits for each occurrence of these HCPCS codes are always equal to one.  In addition, for line ite ms reflecting HCPCS code A0380 or A0390, the nu mber of loaded m iles must be reported.  (See exa mples below.)   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.