(Medicare Claims Processing Manual)

Medicare Claims Processing Manual  Chapter 15 - Ambulance   Table of Contents                                                  (Rev. 12268; Issued: 09- 28-23)           (Rev. 12414; Issued: 12- 19-23)  Transmittals for Chapter 15  10 - Overview  10.1 -  Authorities  10.1.1 -  Statutes And Regulations  10.1.2 -  Other References to Ambulance Related Policies in the CMS Internet Only Manuals  10.2 -  Summary of the Benefit  10.3 -  Definitions  10.4 -  Additional Introductory Guidelines  20 - Payment Rule s 20.1 -  Payment Under the Ambulance Fee Schedule 20.1.1 -  General  20.1.2 -  Jurisdiction  20.1.3 -  Services Provided 20.1.4 -  Components of the Ambulance Fee Schedule  20.1.5  - ZIP Code Determines Fee Schedule Amounts  20.1.5.1 -  CMS Supplied National ZIP Code File and National Ambulance Fee Schedule File  20.1.6 -  Contractor Determination of Fee Schedule Amounts  20.2 -  Payment for Mileage Charges  20.3 -  Air Ambulance  20.4 -  Ambulance Inflation Factor (AIF)  20.5 -  Documentation Requirements  20.6 -  Payment for Non- Emergency BLS Trips to/from ESRD Facilities  30 - General Billing Guidelines  30.1 -  Multi- Carrier System (MCS) Guidelines  30.1.1 -  MCS  Coding Requirements for Suppliers  30.1.2 -  Coding Instructions for Paper and Electronic Claim Form s 30.1.3 -  Coding Instructions for Form CMS -1491  30.1.4 -  CWF Editing of Ambulance Claims for Inpatients  30.2 -  Fiscal Intermediary Shared System (FISS) Guidelines  30.2.1 -  A/B MAC (A) Bill Processing Guidelines Effective April 1, 2002, as a Result of Fee Schedule Implementation  30.2.2 -  SNF Billing  30.2.3 -  Indian Health Services/Tribal Billing  30.2.4 -  Non -covered Charges on Institutional Ambulance Claims  40 - Medical Conditions List and Instructions  10 - Overview  (Rev. 1696; Issued:  03- 06-09; Effective/Implementation Date:  04 -06-09)  10.1 - Authorities  (Rev. 1696; Issued:  03- 06-09; Effective/Implementation Date:  04 -06-09)  10.1.1 - Statutes and Regulations  (Rev. 1696; Issued:  03- 06-09; Effective/Implementation Date:  04 -06-09)  Section 1861(s) (7) of the Social Security Act (Act) establishes an ambulance service as a Medicare Part B service.  Payment for ambulance services is addressed at 1834(l) of the Act.  Coverage rules are addressed at 42 Code of Federal Regulations (CFR) 410.40.  Additional rules, including rules regarding vehicular and staffing requirements, are specified at 42 CFR 410.41.  Payment rules under the fee schedule established in 2002 are specified at 42 CFR Part 414, Subpart H (414.601 et seq.).  Payment rules for ambulances services furnished by a critical access hospital (CAH) or by an entity owned and operated by a CAH are specified at 42 CFR 413.70(b)(5).  Other general Medicare provisions apply to ambulance services.  See Title XVIII of the Act and 42 CFR Parts 400 to 429 to determine applicability.  10.1.2 - Other References to Ambulance Related Policies in the CMS Internet Only Manuals (IOM)  (Rev. 1696; Issued:  03- 06-09; Effective/Implementation Date:  04 -06-09)  Coverage: Manual instructions regarding coverage of ambulance services, including specifications for vehicular and staffing requirements, are specified in the Internet -Only Manual (IOM), Pub. 100- 02, Medicare Benefit Policy Manual, chapter 10.   Medical Review: Manual instructions regarding medical review for ambulance services are specified in the IOM, Pub.100- 08, Medicare Program Integrity Manual, chapter 6.   Payment and Claims Processing: This chapter restates previously issued instructions to Medicare fee-for-service claim processing contractors for processing claims under the Part B ambulance fee schedule (FS).  For historical reference, refer to http://www.cms.gov/Medicare/Medicare -Fee-for-Service -Payment/AmbulanceFeeSchedule/index.html   on the CMS website to view the previous version of this chapter.   10.2 - Summary of the Benefit  (Rev. 1696; Issued:  03- 06-09; Effective/Implementation Date:  04 -06-09)  Ambulance services are covered under Medicare Part B.  However, a Part B payment for an ambulance service furnished to a Medicare beneficiary is available only if the following, fundamental conditions are met:    Actual transportation of the beneficiary occurs.    The beneficiary is transported to an appropriate destination.   The transportation by ambulance must be medically necessary, i.e., the beneficiarys medical condition is such that other forms of transportation are medically contraindicated.    The ambulance provider/supplier meets all applicable vehicle, staffing, billing, and reporting requirements.    The transportation is not  part of a Part A service.   Other requirements specified in this chapter or in the above -cited CMS Manuals may also apply to the provider/supplier or to a particular transport or billing.   10.3 - Definitions  (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)  Most of the definitions previously found in this chapter can now be found in IOM Pub. 100- 02, Medicare Benefit Policy Manual, chapter 10 -  Ambulance Services.  Other definitions pertaining to payment and claims processing follow.   A/B MAC (A)   Definition: For the purposes of this chapter only, the term refers to those contractors that process claims for institutionally -based ambulance providers billed on the ASC X12 837 institutional claim transaction or Form CMS -1450.   A/B MAC (B)   Definition: For the purposes of this chapter only, the term refers to those contractors that process claims for ambulance suppliers billed on the ASC X12 837professional claim transaction or a CMS -1500 form.  Date of Service   Definition: The date of service (DOS) of an ambulance service is the date that the loaded ambulance vehicle departs the point of pickup. In the case of a ground transport, if the beneficiary is pronounced dead after the vehicle is dispatched but before the (now deceased) beneficiary is loaded into the vehicle, the DOS is the date of the vehicle s dispatch.  In the case of an air transport, if the beneficiary is pronounced dead after the aircraft takes off to pick up the beneficiary, the DOS is the date of the vehicles takeoff.   Point of Pickup (POP)   Definition:  Point of pickup is the location of the beneficiary at the time he or she is placed on board the ambulance.   Application:  The ZIP Code of the POP must be reported on each claim for ambulance services so that the correct Geographic Adjustment Factor (GAF) and Rural Adjustment Factor (RAF) may be applied, as appropriate.   Provider   Definition:  For the purposes of this chapter only, the term provider is used to reference a hospital -based ambulance provider which is owned and/or operated by a hospital, critical access hospital, skilled nursing facility, comprehensive outpatient rehabilitation facility, home health agency, hospice program, or, for purposes of section 1814(g)  and section 1835(e) , a fund.   Supplier   Definition:  For the purposes of this chapter, the term supplier is defined as any ambulance service that is not institutionally based.  A supplier can be an independently owned and operated ambulance service company, a volunteer fire and/or ambulance company, a local government run firehouse based ambulance, etc., that provides Part B Medicare covered ambulance services and is enrolled as an independent ambulance supplier.   10.4 - Additional Introductory Guidelines  (Rev.4021; Issued: 04- 13-18; Effective: 07 -16-18; Implementation: 07 -16-18)  Since April 1, 2002 (the beginning of the transition to the full implementation of the ambulance fee schedule), payment for a medically necessary ambulance service is based on the level of service provided, not on the vehicle used.  Ambulance services are separately reimbursable only under Part B. Once a beneficiary is admitted to a hospital, CAH, or SNF, it may be necessary to transport the beneficiary to another hospital or other site temporarily for specialized care while the benef iciary maintains inpatient status with the original provider.  This movement of the patient is considered "patient transportation" and is covered as an inpatient hospital or CAH service and as a SNF service when the SNF is furnishing it as a covered SNF se rvice and payment is made under Part A for that service.  (If the beneficiary is a resident of a SNF and must be transported by ambulance to receive dialysis or certain other high -end outpatient hospital services, the ambulance transport may be separately payable under Part B. Also, if the beneficiary is a SNF resident and not in a Part A covered stay and must be transported by ambulance to the nearest supplier of medically necessary services not available at the SNF, the ambulance transport, including the return trip, may be covered under Part B.)  Because the service is covered and payable as a beneficiary transportation service under Part A, the service cannot be classified and paid for as an ambulance service under Part B.  This includes intra -campus transfers between different departments of the same hospital, even where the departments are located in separate buildings.  Such intra -campus transfers are not separately payable under the Part B ambulance benefit.  Such costs are accounted for in the same m anner as the costs of such a transfer within a single building. See IOM Pub. 100- 02, Medicare Benefit Policy Manual, chapter 10 -  Ambulance Services, section 10.3.3 -  Separately Payable Ambulance Transport Under Part B Versus Patient Transportation that is Covered Under a Packaged Institutional Service for further deta ils.  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.  Refer to IOM Pub. 100- 04, Medicare Claims Processing Manual, chapter 3 -  Inpatient Hospital Billing for the definitions of an inpatient for the various inpatient facility types.  All Prospective Payment Systems (PPS) have a different criteria for determining when ambulance servic es are payable (i.e., during an interrupted stay, on date of admission and date of discharge).  NOTE:  The cost of oxygen and its administration in connection with and as part of the ambulance service is covered.  Under the ambulance FS, oxygen and other items and services provided as part of the transport are included in the FS base payment rate and are N OT separately payable.  The A/B MAC (A) is responsible for the processing of claims for ambulance services furnished by a hospital based ambulance or for ambulance services provided by a supplier if provided under arrangements for an inpatient. The A/B MAC (B) is responsible for processing claims from suppliers; i.e., those entities that are not owned and operated by a provider.  See section 10.2 below for further clarification of the definition of Providers and Suppliers of ambulance services.  Effective December 21, 2000, ambulance services furnished by a CAH or an entity that is owned and operated by a CAH are paid on a reasonable cost basis, but only if the CAH or entity is the only provider or supplier of ambulance services located within a 35- mile drive of such CAH or entity. Beginning February 24, 1999, ambulance transports to or from a non- hospital -based dialysis facility, origin and destination modifier J, satisfy the programs origin and destination requirements for coverage.  Ambulance supplier services furnished under arrangements with a provider, e.g., hospital or SNF are typically not billed by the supplier to its A/B MAC (B), but are billed by the provider to its A/B MAC (A).  The A/B MAC (A) is responsible for determining whether the conditions described below are met.  In cases where all or part of the ambulance services are billed to the A/B MAC (B), the A/B MAC (B) has this responsibility, and the A/B MAC (A) shall contact the A/B MAC (B) to ascertain whether it has already determined if the crew and ambulance requirements are met.  In such a situation, the A/B MAC (A) should accept the A/B MAC (B)s determination without pursuing its own investigation. Where a provider furnishes ambulance services under arrangements with a supplier of ambulance services, such services can be covered only if the suppliers vehicles and crew meet the certification requirements applicable for independent ambulance suppliers .