evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
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 .
(Medicare Claims Processing Manual)
Effective January 1, 2006, items and services which include but are not limited to oxygen, drugs, extra attendants, supplies, EKG, and night differential are no longer paid separately for ambulance services.  This occurred when CMS fully implemented the Ambulance Fee Schedule, and therefore, payment is based solely on the ambulance fee schedule.  Effective for claims on or after October 1, 2007, if ambulance claims submitted with a code(s) that is/are not separately billable the payment for the code(s) is included in the base rate.   Contractors 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 Four.   Group Code: CO  CARC: 97  RARC: N390  MSN: 1.6  This is true whether the primary transportation service is allowed or denied.  When the service is denied, the services are not separately billable to the beneficiaries as they are already part of the base rate.  Payment for ambulance services may be made only on an assignment related basis. Prospective payment systems, including the Ambulance Fee Schedule, are exempt from Inherent Reasonableness provisions.  20 - Payment Rules (Rev. 1696; Issued:  03- 06-09; Effective/Implementation Date:  04 -06-09) B3-4115, 5116, PM AB -02-131  Medicare covered ambulance services are paid based on the Medicare ambulance fee schedule.   The following subsections describe how contractors calculate the payment amount. Section 20.1 and its subsections describe how the payment amount is calculated for the fee schedule. The other subsections in 20 provide information on certain components of the payment amount (e.g., mileage) or specialized payment amounts (e.g., air ambulance).   20.1 - Payment Under the Ambulance Fee Schedule  (Rev. 1696; Issued:  03- 06-09; Effective/Implementation Date:  04 -06-09)  20.1.1 - General  (Rev. 1696; Issued:  03- 06-09; Effective/Implementation Date:  04 -06-09)  Payment under the fee schedule for ambulance services:    Includes a base rate payment plus a separate payment for mileage;    Covers both the transport of the beneficiary to the nearest appropriate facility and all items and services associated with such transport; and
(Medicare Claims Processing Manual)
Payment under the fee schedule for ambulance services:    Includes a base rate payment plus a separate payment for mileage;    Covers both the transport of the beneficiary to the nearest appropriate facility and all items and services associated with such transport; and    Does not include a separate payment for items and services furnished under the ambulance benefit.   Payment for items and services is included in the fee schedule payment.  Such items and services include but are not limited to oxygen, drugs, extra attendants, and EKG testing (e.g., ancillary services) - but only when such items and services are both medically necessary and covered by Medicare under the ambulance benefit.   For additional information on the fee schedule, contractors may refer to the Ambulance Services Center on the CMS Web site at http://www.cms.gov/Medicare/Medicare -Fee-for-Service- Payment/AmbulanceFeeSchedule/index.html   20.1.2 - Jurisdiction  (Rev. 1696; Issued:  03- 06-09; Effective/Implementation Date:  04 -06-09)  Claims jurisdiction for suppliers is considered to be where the ambulance vehicle is garaged or hangared.  Claims jurisdiction for institutional based providers is based on the primary location of the institution.   20.1.3 - Services Provided  (Rev. 1696; Issued:  03- 06-09; Effective/Implementation Date:  04 -06-09) AB-03-106  Payment is based on the level of service provided, not on the vehicle used. Occasionally, local jurisdictions require the dispatch of an ambulance that is above the level of service that ends up being provided to the Medicare beneficiary.  In this, as in m ost instances, Medicare pays only for the level of service provided, and then only when the service provided is medically necessary.   20.1.4 - Components of the Ambulance Fee Schedule  (Rev. 3800, Issued: 06- 23-17, Effective: 07 -25-17, Implementation: 07- 25-17)  The mileage rates provided in this section are the base rates that are adjusted by the yearly ambulance inflation factor (AIF).  The payment amount under the fee schedule is determined as follows:    For ground ambulance services , the fee schedule amount includes:   1. A money amount that serves as a nationally uniform base rate, called a conversion factor (CF), for all ground ambulance services;
(Medicare Claims Processing Manual)
 For ground ambulance services , the fee schedule amount includes:   1. A money amount that serves as a nationally uniform base rate, called a conversion factor (CF), for all ground ambulance services;   2. A relative value unit (RVU) assigned to each type of ground ambulance service;   3. A geographic adjustment factor (GAF) for each ambulance fee schedule locality area (geographic practice cost index (GPCI));   4. A nationally uniform loaded mileage rate;   5. An additional amount for certain mileage for a rural point -of-pickup; and   6. For specified temporary periods, certain additional payment amounts as described in section 20.1.4A, below.    For air ambulance services , the fee schedule amount includes:   1. A nationally uniform base rate for fixed wing and a nationally uniform base rate for rotary wing;   2. A geographic adjustment factor (GAF) for each ambulance fee schedule locality area (GPCI);   3. A nationally uniform loaded mileage rate for each type of air service; and  4. A rural adjustment to the base rate and mileage for services furnished for a rural point -of-pickup.   A. Ground Ambulance Services   1. Conversion Factor   The conversion factor (CF) is a money amount used to develop a base rate for each category of ground ambulance service. The CF is updated annually by the ambulance inflation factor and for other reasons as necessary.   2. Relative Value Units   Relative value units (RVUs) set a numeric value for ambulance services relative to the value of a base level ambulance service. Since there are marked differences in resources necessary to furnish the various levels of ground ambulance services, different levels of payment are appropriate for the various levels of service.  The different payment amounts are based on level of service.  An RVU expresses the constant multiplier for a particular type of service (including, where appropriate, an emergency response).  An RVU of 1.00 is assigned to the BLS of ground service, e.g., BLS has an RVU of 1; higher RVU values are assigned to the other types of ground ambulance services, which require more service than BLS.  The RVUs are as follows:   Service Level  RVU  BLS 1.00 BLS - Emergency  1.60 ALS1  1.20 ALS1 - Emergency  1.90 ALS2  2.75 SCT 3.25 PI 1.75  3. Geographic Adjustment Factor (GAF)
(Medicare Claims Processing Manual)
3. Geographic Adjustment Factor (GAF)   The GAF is one of two factors intended to address regional differences in the cost of furnishing ambulance services.  The GAF for the ambulance FS uses the non- facility practice expense (PE) of the geographic practice cost index (GPCI) of the Medicare physician fee schedule to adjust payment to account for regional differences.  Thus, the geographic areas applicable to the ambulance FS are the same as those u sed for the physician fee schedule.   The location where the beneficiary was put into the ambulance (POP) establishes which GPCI applies.  For multiple vehicle transports, each leg of the transport is separately evaluated for the applicable GPCI.  Thus, for the second (or any subsequent) leg of a transport, the POP establishes the applicable GPCI for that portion of the ambulance transport.   For ground ambulance services, the applicable GPCI is multiplied by 70 percent of the base rate. Again, the base rate for each category of ground ambulance services is the CF multiplied by the applicable RVU.  The GPCI is not applied to the ground mileage rate.   4. Mileage   In the context of all payment instructions, the term mileage refers to loaded mileage.  The ambulance FS provides a separate payment amount for mileage.  The mileage rate per statute mile applies for all types of ground ambulance services, except Paramedic Intercept, and is provided to all Medicare contractors electronically by CMS as part of the ambulance FS. Providers and suppliers must report all medically necessary mileage, including the mileage subject to a rural adjustment, in a single line item.   5. Adjustment for Certain Ground Mileage for Rural Points of Pickup (POP)   The payment rate is greater for certain mileage where the POP is in a rural area to account for the higher costs per ambulance trip that are typical of rural operations where fewer trips are made in any given period.   If the POP is a rural ZIP Code, the following calculations should be used to determine the rural adjustment portion of the payment allowance.  For loaded miles 1- 17, the rural adjustment for ground mileage is 1.5 times the rural mileage allowance.   For services furnished during the period July 1, 2004 through December 31, 2008, a 25 percent increase is applied to the appropriate ambulance FS mileage rate to each mile of a transport (both urban and rural POP) that exceeds 50 miles (i.e., mile 51 and greater).
(Medicare Claims Processing Manual)
The following chart summarizes the above information:   Service  Dates of Service  Bonus  Calculation  Loaded miles 1 -17, Rural POP  Beginning 4/1/02  50% FS Rural mileage * 1.5 Loaded miles 18 -50, Rural POP  4/1/02 - 12/31/03  25% FS Rural mileage * 1.25 All loaded miles (Urban or Rural POP) 51+  7/1/04 - 12/31/08  25% FS Urban or Rural mileage * 1.25   The POP, as identified by ZIP Code, establishes whether a rural adjustment applies to a particular service.  Each leg of a multi -leg transport is separately evaluated for a rural adjustment application.  Thus, for the second (or any subsequent) leg of a tr ansport, the ZIP Code of the POP establishes whether a rural adjustment applies to such second (or subsequent) transport.  For the purpose of all categories of ground ambulance services except paramedic intercept, a rural area is defined as a U.S. Postal Service (USPS) ZIP Code that is located, in whole or in part, outside of either a Metropolitan Statistical Area (MSA) or in New England, a New England County Metropolitan Area (NECMA), or is an area wholly within an MSA or NECMA that has been identified as rural under the Goldsmith modification.  (The Goldsmith modification establishes an operational definition of rural areas within large counties that contain one or more metropolitan areas. Th e Goldsmith areas are so isolated by distance or physical features that they are more rural than urban in character and lack easy geographic access to health services.)   For Paramedic Intercept, an area is a rural area if:    It is designated as a rural area by any law or regulation of a State;   It is located outside of an MSA or NECMA; or   It is located in a rural census tract of an MSA as determined under the most recent Goldsmith modification.   See IOM Pub. 100- 02, Medicare Benefit Policy Manual, chapter 10 -  Ambulance Services, section 30.1.1 -  Ground Ambulance Services for coverage requirements for the Paramedic Intercept benefit.  Presently, only the State of New York meets these requirements.
(Medicare Claims Processing Manual)
Although a transport with a POP located in a rural area is subject to a rural adjustment for mileage, Medicare still pays the lesser of the billed charge or the applicable FS amount for mileage.  Thus, when rural mileage is involved, the contractor compare s the calculated FS rural mileage payment rate to the providers/suppliers actual charge for mileage and pays the lesser amount.  The CMS furnishes the ambulance FS files to claims processing contractors electronically.  A version of the Ambulance Fee Schedule is also posted to the CMS website (http://www.cms.gov/Medicare/Medicare -Fee-for-Service-Payment/AmbulanceFeeSchedule/afspuf.html  ) for public consumption.  To clarify whether a particular ZIP Code is rural or urban, please refer to the most recent version of the Medicare supplied ZIP Code file.   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
(Medicare Claims Processing Manual)
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