evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
30 - Implementation of the Ambulance Fee Schedule  (Rev. 103; Issued:  02- 20-09; Effective Date:  01 -05-09; Implementation Date:  03 -20-09)   The Medicare program ambulance fee schedule (FS) is effective for ambulance items and services furnished on or after April 1, 2002.  Under the FS, payment for ambulance services covered under the program is based on the lower of the actual billed amount or the ambulance fee schedule amount.   The fee schedule was phased in over a 5 -year period.  The fee schedule replaced the retrospective reasonable cost reimbursement system for providers and the reasonable charge system for ambulance suppliers.  During the tran sition period, payment was based on a blend of the FS amount and the amount under its current billing methodology.  The fee schedule applies to all ambulance services, including volunteer, municipal, private, independent, and institutional providers, i.e., hospitals, skilled nursing facilities and home health agencies covered under Medicare Part B, except for services furnished by certain critical access hospitals (CAH).  Payment for ambulance items and services furnished by a CAH, or by an entity that is owned and operated by a CAH, is based on reasonable cost if the CAH or entity is the only provider or supplier of ambulance services that is located within a 35-mile drive of such CAH.  The provision is effective for ambulance services furnished on or after  December 21, 2000.   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.
(Medicare Benefit Policy Manual)
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
(Medicare Benefit Policy Manual)
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.
(Medicare Benefit Policy Manual)
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.
(Medicare Benefit Policy Manual)
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.
(Medicare Benefit Policy Manual)
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.
(Medicare Benefit Policy Manual)
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,    Be prohibited by state law from billing anyone for any service.   III. The entity furnishing the ALS paramedic intercept service must:    Meet Medicares certification requirements for furnishing ALS services, and,    Bill all recipients who receive ALS paramedic intercept serv ices from the entity, regardless of whether or not those recipients are Medicare beneficiaries.
(Medicare Benefit Policy Manual)
 Meet Medicares certification requirements for furnishing ALS services, and,    Bill all recipients who receive ALS paramedic intercept serv ices from the entity, regardless of whether or not those recipients are Medicare beneficiaries.   For purposes of the paramedic intercept benefit, a rural area is an area that is designated as rural by a state law or regulation or that is located in a rural  census tract of a metropolitan statistical area (as determined under the most recent version of the Goldsmith Modification).  (The Goldsmith Modification is a methodology to identify small towns and rural areas within large metropolitan counties that are isolated from central areas by distance or other features).  The current list of these areas is periodically published in the Federal Register.   See Pub. 100- 04, Medicare Claims Processing Manual, Chapter 15 , "Ambulance," 20.1.4 for payment of paramedic intercept services.  Services in a Rural Area   Definition:  For purposes other than the paramedic intercept benefit (as defined above), services in a rural  area are services that are furnished (1) in an area outside a Metropolitan Statistical Area (MSA); or, (2) an area identified as rural using the most recent version of the  Goldsmith Modification even though the area is within an MSA.  Emergency Response  Definition:  Emergency response is a BLS or ALS1 level of service that has been provided in immediate response to a 911 call or the equivalent.  An immediate response is one in which the ambulance provider/supplier begins as quickly as possible to take the  steps necessary to respond to the call.   The nature of an ambulances response (whether emergency or not) does not independently establish or support medical necessity for an ambulance transport.  Rather, Medicare coverage always depends on, among other t hings, whether the service(s) furnished is actually medically reasonable and necessary based on the patients condition at the time of transport.
(Medicare Benefit Policy Manual)
Application:  The phrase 911 call or the equivalent is intended to establish the standard that the nature o f the call at the time of dispatch is the determining factor.  Regardless of the medium by which the call is made (e.g., a radio call could be appropriate) the call is of an emergent nature when, based on the information available to the dispatcher at the time of the call, it is reasonable for the dispatcher to issue an emergency dispatch in light of accepted, standard dispatch protocol.  An emergency call need not come through 911 even in areas where a 911 call system exists.  However, the determination to  respond emergently with a BLS or ALS ambulance must be in accord with the local 911 or equivalent service dispatch protocol.  If the call came in directly to the ambulance provider/supplier, then the providers/suppliers dispatch protocol and the dispatc hers actions must meet, at a minimum, the standards of the dispatch protocol of the local 911 or equivalent service.  In areas that do not have a local 911 or equivalent service, the protocol and the dispatchers actions must meet, at a minimum, the standards of the dispatch protocol in another similar jurisdiction within the state, or if there is no similar jurisdiction, then the standards of any other dispatch protocol within the state.  Where the dispatch was inconsistent with this standard of protocol, including where no protocol was used, the beneficiarys condition (for example, symptoms) at the scene determines the appropriate level of payment.   EMT -Intermediate  Definition:  EMT- Intermediate is an individual who is qualified, in accordance with stat e and local laws, as an EMT -Basic and who is also certified in accordance with state and local laws to perform essential advanced techniques and to administer a limited number of medications.  EMT -Paramedic  Definition: EMT- Paramedic possesses the qualifications of the EMT- Intermediate and, in accordance with state and local laws, has enhanced skills that include being able to administer additional interventions and medications.   Interfacility Transportation   Definition:   For purposes of SCT payment, an int erfacility transportation is one in which the origin and destination are one of the following:  a hospital or skilled nursing facility that participates in the Medicare program or a hospital -based facility that meets Medicares requirements for provider -based status.
(Medicare Benefit Policy Manual)
30.1.2 - Air Ambulance Services  (Rev. 187, Issued: 05- 01-14; Effective: 08- 04-14; Implementation: 08 -04-14)  There are two categories of air ambulance services: fixed wing (airplane) and rotary wing (helicopter) aircraft. The higher operational costs of the two types of aircraft are recognized with two distinct payment amounts for air ambulance mileage.  The air ambulance mileage rate is calculated per actual loaded (patient onboard) miles flown and is expressed in statute miles (not nautical miles).   1.  Fixed Wing Air Ambulance (FW)   Fixed wing air ambulance is furnished when the beneficiarys medical condition is such that transport by ground ambulance, in whole or in part, is not appropriate.  Generally, transport by fixed wing air  ambulance may be necessary because the beneficiarys condition requires rapid transport to a treatment facility, and either great distances or other obstacles, e.g., heavy traffic, preclude such rapid delivery to the nearest appropriate facility.  Transpo rt by fixed wing air ambulance may also be necessary because the beneficiary is inaccessible by a ground or water ambulance vehicle.   2.  Rotary Wing Air Ambulance (RW)   Rotary wing air ambulance is furnished when the beneficiarys medical condition is suc h that transport by ground ambulance, in whole or in part, is not appropriate.  Generally, transport by rotary wing air ambulance may be necessary because the beneficiarys condition requires rapid transport to a treatment facility, and either great distan ces or other obstacles, e.g., heavy traffic, preclude such rapid delivery to the nearest appropriate facility.  Transport by rotary wing air ambulance may also be necessary because the beneficiary is inaccessible by a ground or water ambulance vehicle.
(Medicare Benefit Policy Manual)
Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R243BP  04/13/2018 Ambulance Transportation for a Skilled Nursing Facility (SNF) Resident in a Stay Not Covered by Part A - Medicare Benefit Policy Manual, Chapter 10 and Medicare Claims Processing Manual, Chapter 15  07/16/2018  10550 R236BP  06/17/2017 Medicare Benefit Policy Manual - Chapter 10, Ambulance Locality and Advanced Life Support (ALS) Assessment 09/18/2017  10110 R225BP  09/09/2016 Ambulance Staffing Requirements  12/12/2016  9761 R190BP  07/11/2014 Beneficiary Signature Requirements for Ambulance Services  08/12/2014  8760 R187BP  05/01/2014 Update to the Medicare Benefit Policy Manual to Restore Missing Air Ambulance Definitions  08/04/2014  8706 R133BP  10/22/2010 Air Ambulance Services  01/03/2011  7161 R130BP  07/29/2010 Definition of Ambulance Services 01/03/2011  7058 R125BP  05/14/2010 Ambulance Services -Joint Responses 06/15/2010  6949 R115BP  11/13/2009 Ambulance Services  01/04/2010  6707 R103BP  02/20/2009 Ambulance Services and Expiration of the Ambulance Fee Schedule Transition Period  03/20/2009  6318 R68BP  03/30/2007 Ambulance Fee Schedule  Ground Ambulance Services  Revision to the Specialty Care Transport (SCT) Definition  04/30/2007  5533 R14BP  05/28/2004 Ambulance Benefit Policy -Payment for Ambulance Services  07/01/2004  3225 R1BP  10/01/2003 Introduction to the Benefit Policy Manual N/A N/A Back to top of Chapter