evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Ambulance transports to or from a diagnostic or therapeutic site other than a hospital or renal dialysis facility (e.g., an independent diagnostic testing facility (IDTF), cancer treatment center, radiation therapy center, wound care center, etc.).  The fi rst or second character (origin or destination) of any HCPCS code ambulance modifier is D (Diagnostic or therapeutic site other than P or H), and the other modifier (origin or destination) is N (SNF). Exception: An ambulance transport from a SNF to the  nearest supplier of medically necessary services not available at the SNF where the beneficiary is a resident and not in a covered Part A stay, including the return trip, is covered under Part B provided that the ambulance transportation was medically reasonable and necessary and all other coverage requirements are met.   30.2.3 - Indian Health Service (IHS)/Tribal Billing  (Rev. 2102, Issued: 11- 19-10, Effective: 04 -01-11, Implementation: 04- 04-11)  Ambulance services furnished by IHS/Tribal hospitals including Critical Access Hospitals (CAHs) will be paid according to the appropriate payment methodology.  For dates of service on or after December 21, 2000 and prior to January 1, 2004, medically necessary ambulance services furnished by an IHS/Tribal CAH or by an entity that is owned and operated by an IHS/Tribal CAH are paid based on 100 percent of the reas onable cost if the 35 mile rule for cost- based payment is met.  In order for the 35 mile rule to be met, the IHS/Tribal CAH or the entity that is owned and operated by the IHS/Tribal CAH, must be the only provider or supplier of ambulance services that is located within a 35 mile drive of the IHS/Tribal CAH or the entity.  Those CAHs that meet the 35 mile rule for cost -based payment shall report condition code B2 (CAH ambulance attestation) on their bills.   For dates of service on or after January 1, 2004, ambulance services furnished by an IHS/Tribal CAH or by an entity that is owned and operated by an IHS/Tribal CAH are paid based on 101 percent of the reasonable cost if the 35 mile rule for cost -based paym ent is met.
(Medicare Claims Processing Manual)
When the 35 mile rule for cost -based payment is not met, the IHS/Tribal CAH ambulance service or the ambulance service furnished by the entity that is owned and operated by the IHS/Tribal CAH is paid based on the ambulance fee schedule.   Other IHS/Tribal hospital based ambulance services are reimbursed based on the ambulance fee schedule.   30.2.4 - Non-covered Charges on Institutional Ambulance Claims  (Rev. 1921, Issued: 02- 19-10, Effective: 04 -01-10, Implementation: 04- 05-10)  Medicare law contains a restriction that miles beyond the closest available facility cannot be billed to Medicare.  Non -covered miles beyond the closest facility are billed with HCPCS procedure code A0888 (non- covered ambulance mileage per mile, e.g., for  miles traveled beyond the closest appropriate facility).  These non- covered line items can be billed on claims also containing covered charges.  Ambulance claims may use the - GY modifier on line items for such non- covered mileage, and liability for the s ervice will be assigned correctly to the beneficiary.   The method of billing all miles for the same trip, with covered and non- covered portions, on the same claim is preferable in this scenario.  However, billing the non- covered mileage using condition code 21 claims is also permitted, if desired, as long as a ll line items on the claims are non-covered and the beneficiary is liable.  Additionally, unless requested by the beneficiary or required by specific Medicare policy, services excluded by statute do not have to be billed to Medicare.   When the scenario is point of pick up outside the United States, including U.S. territories but excepting some points in Canada and Mexico in some cases, mileage is also statutorily excluded from Medicare coverage.  Such billings are more likely to be subm itted on entirely non- covered claims using condition code 21.  This scenario requires the use of a different message on the Medicare Summary Notice (MSN) sent to beneficiaries.
(Medicare Claims Processing Manual)
Another scenario in which billing non- covered mileage to Medicare may occur is when the beneficiary dies after the ambulance has been called but before the ambulance arrives.  The -QL modifier should be used on the base rate line in this scenario, in place  of origin and destination modifiers, and the line is submitted with covered charges.  The -QL modifier should also be used on the accompanying mileage line, if submitted, with non- covered charges.  Submitting this non-covered mileage line is optional for providers.   Non-covered charges may also apply is if there is a subsidy of mileage charges that are never charged to Medicare.  Because there are no charges for Medicare to share in, the only billing option is to submit non- covered charges, if the provider bills Medic are at all (it is not required in such cases).  These non -covered charges are unallowable, and should not be considered in settlement of cost reports.  However, there is a difference in billing if such charges are subsidized, but otherwise would normally be charged to Medicare as the primary payer.  In this latter case, CMS examination of existing rules relating to grants policy since October 1983, supported by Federal regulations (42CFR 405.423), generally requires providers to reduce their costs by the am ount of grants and gifts restricted to pay for such costs.  Thereafter, section 405.423 was deleted from the regulations.  Thus, providers were no longer required to reduce their costs for restricted grants and gifts, and charges tied to such grants/gifts/subsidies should be submitted as covered charges.  This is in keeping with Congresss intent to encourage hospital philanthropy, allowing the provider receiving the subsidy to use it, and also requiring Medicare to share in the unreduced cost.  Treatment of subsidized charges as non- covered Medicare charges serves to reduce Medicare payment on the Medicare cost report contrary to the 1983 change in policy.   Medicare requires the use of the - TQ modifier so that CMS can track the instances of the subsidy scenario for non- covered charges.  The - TQ should be used whether the subsidizing entity is governmental or voluntary.  The - TQ modifier is not required in the  case of covered charges submitted when a subsidy has been made, but charges are still normally made to Medicare as the primary payer.
(Medicare Claims Processing Manual)
If providers believe they have been significantly or materially penalized in the past by the failure of their cost reports to consider covered charges occurring in the subsidy case, since Medicare had previous billing instructions that stated all charges i n the case of a subsidy, not just charges when the entity providing the subsidy never charges another entity/primary payer, should be submitted as non- covered charges, they may contact their A/B MAC (A) about reopening the reports in question for which the  time period in 42 CFR 405.1885 has not expired. A/B MACs (A) have the discretion to determine if the amount in question warrants reopening.  The CMS does not expect many such cases to occur.   Billing requirements for all these situations, including the use of modifiers, are presented in the chart below:    Mileage  Scenario  HCPCS  Modifiers*  Liab -ility Billing  Remit. Require-ments  MSN Message  STATUTE: Miles beyond closest facility,  OR **Pick up point outside of U.S. A0888 on line item for the non-covered mileage  -QM or  -QN, origin/destination modifier , and - GY unless condition code 21 claim used  Bene -ficiary  Bill mileage line item with A0888 -GY and other modifiers as needed to establish liability, line item will be denied; OR  bill service on condition code 21 claim, no
(Medicare Claims Processing Manual)
-GY required, claim will be denied  Group code PR, reason code 96  16.10 Medicare does not pay for this item or service; OR, Medicare no paga por este artculo o servicio  Beneficiary dies after ambulance is called  Most appropriate ambulance HCPCS mileage code (i.e., ground, air) -QL unless condition code - 21 claim  Pro-vider  Bill mileage line item with - QL as non-covered, line item will be denied  Group Code CO, reason code 96  16.58 The provider billed this charge as non-covered.  You do not have to pay this amount. OR, El proveedor facur este cargo como no cubierto.  Usted no tiene que pagar ests cantidad.  Mileage  Scenario  HCPCS  Modifiers*  Liab -ility Billing  Remit. Require-ments  MSN Message  Subsidy or government owned Ambulance, Medicare NEVER billed*** A0888 on line item for the non-covered mileage  -QM or  -QN, origin/  destination modifier, and   -TQ must be used for policy purposes  Pro-vider  Bill mileage line item with A0888, and modifiers as non-covered, line item will be denied  Group Code CO, reason code 96  16.58 The provider billed this charge as non-covered.  You do not have to pay this amount. OR, El proveedor facur este cargo como no cubierto. Usted no tiene que pagar ests cantidad.   * Current ambulance billing requirements state that either the - QM or - QN modifier must be used on services.  The - QM is used when the ambulance service is provided under arrangement by a provider of services, and the - QN when the ambulance service is pr ovided directly by a provider of services.  Line items using either the -QM or - QN modifiers are not subject to the FISS edit associated with FISS reason code 31322 so that these lines items will process to completion. Origin/destination modifiers, also r equired by current instruction, combine two alpha characters: one for origin, one for destination, and are not non -covered by definition.
(Medicare Claims Processing Manual)
** This is the one scenario where the base rate is not paid in addition to mileage, and there are certain exceptions in Canada and Mexico where mileage is covered as described in existing ambulance instructions.   ***If Medicare would normally have been billed, submit mileage charges as covered charges despite subsidies.  Medicare systems may return claims to the provider if they do not comply with the requirements in the table.   40 - Medical Conditions List and Instructions  (Rev. 3240, Issued: 04- 24-15, Effective: 07 -27-15, Implementation: 07- 27-15)  See http://www.cms.gov/Center/Provider -Type/Ambulances -Services -Center.html  for a medical conditions list and instructions to assist ambulance providers and suppliers to communicate the patient's condition to Medicare contractors, as reported by the dispatch center and as observed by the ambulance crew.  Use of the medical conditions list does not guarantee payment of the claim or payme nt for a certain level of service.   In addition to reporting one of the medical conditions on the claim, one of the transportation indicators may be included on the claim to indicate why it was necessary for the patient to be transported in a particular way or circumstance.  The provider or supplier will place the transportation indicator in the narrative field on the claim.  Information on the appropriate use of transportation indicators is also available at http://www.cms.gov/Center/Provider -Type/Ambulances -Services -Center.html
(Medicare Claims Processing Manual)
Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R12414CP  12/19/2023  Ambulance Inflation Factor (AIF) for Calendar Year (CY) 2024 and Productivity Adjustment  01/02/2024  13400  R12268CP  09/28/2023  Ambulance Inflation Factor (AIF) for Calendar Year (CY) 2024 and Productivity Adjustment - Rescinded and replaced by Transmittal 12414 01/02/2024  13400  R11642CP  10/13/2022  Ambulance Inflation Factor (AIF) for Calendar Year (CY) 2023 and Productivity Adjustment  01/03/2023  12948  R11365CP  04/28/2022  Update of Internet Only Manual (IOM), Pub. 100-04, Chapter 15 -  Ambulance  05/31/2022  12707  R11044CP  10/13/2021  Ambulance Inflation Factor (AIF) for Calendar Year (CY) 2022 and Productivity Adjustment  01/03/2022  12488  R10396CP  10/16/2020  Ambulance Inflation Factor (AIF) for Calendar Year (CY) 2021 and Productivity Adjustment  01/04/2021  12031  R4407CP  10/04/2019  Ambulance Inflation Factor for Calendar Year (CY) 2020 and Productivity Adjustment  01/06/2020  11497  R4205CP  01/18/2019  Update to Pub. 100- 04 Chapter 15 to Provide Language -Only Changes for the New Medicare Card Project  02/19/2019  11078  R4172CP  11/30/2018  Ambulance Inflation Factor for Calendar Year 2019 and Productivity Adjustment  01/07/2019  11031  R4021CP  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  R4017CP  04/06/2018  Increased Ambulance Payment Reduction for Non-Emergency Basic Life Support (BLS) Transports to and from Renal Dialysis Facilities  10/01/2018  10549  Rev #  Issue Date  Subject  Impl Date  CR#  R3893CP  10/27/2017  Ambulance Inflation Factor for CY 2018 and Productivity Adjustment  01/02/2018  10323  R3855CP  09/01/2017  Internet Only Manual (IOM) Update to Pub. 100-04, Chapter
(Medicare Claims Processing Manual)
10/27/2017  Ambulance Inflation Factor for CY 2018 and Productivity Adjustment  01/02/2018  10323  R3855CP  09/01/2017  Internet Only Manual (IOM) Update to Pub. 100-04, Chapter 15 -  Ambulance, to Restore Multiple Patients on One Trip Instructions  10/02/2017  10245  R3800CP  06/23/2017  Internet Only Manual Update to Pub. 100- 04, Chapter 15  07/25/2017  10143  R3625CP  10/14/2016  Ambulance Inflation Factor for CY 2017 and Productivity Adjustment  01/03/2017  9811 R3620CP  10/07/2016  Update to Pub 100- 04, Medicare Claims Processing Manual, Chapter 15: Ambulance  11/08/2016  9791 R3481CP  03/18/2016  Updates to Pub. 100- 04, Chapters 3, 6, 7 and 15 to Correct Remittance Advice Messages  06/20/2016  9562 R3380CP  10/23/2015  Ambulance Inflation Factor for CY 2016 and Productivity Adjustment  01/04/2016  9412 R3240CP  04/24/2015  Medicare Claims Processing Manual -  Chapter 15, Section 40, Ambulance -  Medical Conditions List 07/27/2015  9142 R3090CP  10/07/2014  Ambulance Inflation Factor for CY 2015 and Productivity Adjustment  01/05/2015  8895 R3076CP  09/24/2014  Update to Pub. 100- 04, Chapter 15 to Provide Language -Only Changes for Updating ICD -10, ASC X12, and Medicare Administrative Contractors (MAC) Implementation  09/16/2014  8604 R3057CP  08/29/2014  Ambulance Inflation Factor for CY 2015 and Productivity Adjustment   Rescinded and replaced by Transmittal 3090 01/05/2015  8895 R3027CP  08/14/2014  Update to Pub. 100- 04, Chapter 15 to Provide Language -Only Changes for Updating ICD -10, ASC X12, and Medicare Administrative 09/16/2014  8604 Rev #  Issue Date  Subject  Impl Date  CR#  Contractors (MAC) Implementation   Rescinded and replaced by Transmittal 3076 R2908CP  03/14/2014  Update to Pub. 100- 04, Chapter 15 to Provide Language -Only Changes for Updating ICD -10 and ASC X12  Rescinded and replaced by Transmittal 3027  10/01/2014  8604
(Medicare Claims Processing Manual)
Update to Pub. 100- 04, Chapter 15 to Provide Language -Only Changes for Updating ICD -10 and ASC X12  Rescinded and replaced by Transmittal 3027  10/01/2014  8604 R2788CP  09/20/2013  Ambulance Inflation Factor for CY 2014 and Productivity Adjustment  01/06/2014  8452 R2703CP  05/10/2013  Ambulance Payment Reduction for Non-Emergency Basic Life Support (BLS) Transports to and from Renal Dialysis Facilities  10/07/2013  8269 R2620CP  12/21/2012  Ambulance Inflation Factor CY 2013 and Productivity Adjustment  01/07/2013  8156 R2383CP  01/12/2012  FISS Claims Processing Updates for Ambulance Services  04/02/2012  7557 R2336CP  10/28/2011  FISS Claims Processing Updates for Ambulance Services  Rescinded and replaced by Transmittal 2383  04/02/2012  7557 R2318CP  10/13/2011  Update to the Internet Only Manual Pub. 100- 04, Chapter 15 -  Ambulance, to Include the Medicare and Medicaid Extenders Act of 2010 (MMEA) Provisions  01/03/2012  7558 R2313CP  09/30/2011  Update to the Internet Only Manual Pub. 100- 04, Chapter 15 -  Ambulance, to Include the Medicare and Medicaid Extenders Act of 2010 (MMEA) Provisions  Rescinded and replaced by Transmittal 2318 01/03/2012  7558 R2310CP  09/23/2011  Ambulance Inflation Factor for CY 2012  01/03/2012  7546 R2162CP  02/22/2011  Updates to the Internet Only Manual Pub. 100-04, Chapter 1 -  General Billing Requirements, Chapter 15 - Ambulance, and Chapter 26 - 03/21/2011  7018 Rev #  Issue Date  Subject  Impl Date  CR#  Completing and Processing Form CMS -1500 Data Set  R2124CP  12/23/2010  Updates to the Internet Only Manual Pub. 100-04, Chapter 1 -  General Billing Requirements, Chapter 15 -  Ambulance, and Chapter 26 -  Completing and Processing Form CMS -1500 Data Set -  Rescinded and replaced by Transmittal 2162  01/25/2011  7018 R2104CP  11/19/2010  Ambulance Inflation Factor for CY 2011 and Productivity Adjustment  01/03/2011  7042 R2103CP  11/19/2010  Fractional
(Medicare Claims Processing Manual)
by Transmittal 2162  01/25/2011  7018 R2104CP  11/19/2010  Ambulance Inflation Factor for CY 2011 and Productivity Adjustment  01/03/2011  7042 R2103CP  11/19/2010  Fractional Mileage Units Submitted on Ambulance Claims  01/03/2011  7065 R2102CP  11/19/2010  Systems Changes Necessary to Implement Technical Correction Related to Critical Access Hospital Services, Section 3128 of the Affordable Care Act, Pub. 118- 148 04/04/2011  7219 R2074CP  10/25/2010  Ambulance Inflation Factor (AIF) for CY 2011 and Productivity Adjustment  Rescinded and replaced by Transmittal 2104 01/03/2011  7042 R2069CP  10/15/2010  Ambulance Inflation Factor (AIF) for CY 2011 and Productivity Adjustment  Rescinded and replaced by Transmittal 2074 01/03/2011  7042 R2065CP  10/15/2010  Fractional Mileage Units Submitted on Ambulance Claims  Rescinded and replaced by Transmittal 2103  01/03/2011  7065 R2029CP  08/13/2010  Fractional Mileage Units Submitted on Ambulance Claims  Rescinded and replaced by Transmittal 2065  01/03/2011  7065 R1942CP  04/02/2010  Update to the Medical Conditions List and Instructions  05/03/2010  6896 Rev #  Issue Date  Subject  Impl Date  CR#  R1921CP  02/19/2010  Billing for Services Related to Voluntary Uses of Advanced Beneficiary Notices of Noncoverage (ABNs)  04/05/2010  6563 R1894CP  01/15/2010  Billing for Services Related to Voluntary Uses of Advanced Beneficiary Notices of Noncoverage (ABNs)  Rescinded and replaced by Transmittal 1921  04/05/2010  6563 R1861CP  11/27/2009  Ambulance Inflation Factor for CY 2010  01/04/2010  6631 R1840CP  10/29/2009  Billing for Services Related to Voluntary Uses of Advanced Beneficiary Notices of Noncoverage (ABNs)  Rescinded and replaced by Transmittal 1894  04/05/2010  6563 R1821CP  09/25/2009  Billing for and Ambulance Transport with More Than One Patient Onboard 10/26/2009  6621 R1696CP
(Medicare Claims Processing Manual)
 Rescinded and replaced by Transmittal 1894  04/05/2010  6563 R1821CP  09/25/2009  Billing for and Ambulance Transport with More Than One Patient Onboard 10/26/2009  6621 R1696CP  03/06/2009  Updates to the Medicare Claims Processing Manual, Publication 100- 04, Chapter 15  04/06/2009  6347 R1682CP  02/13/2009  Clarification of Date of Service (DOS) of Ambulance Services  03/13/2009  6372 R1607CP  10/03/2008  Ambulance Inflation Factor for CY 2009  01/05/2009  6113 R1591CP  09/09/2008  ZIP Code Files by Date of Service -  Replaced by Transmittal 1591  07/07/2008  5881 R1472CP  03/06/2008  Update of Institutional Claims References  04/07/2008  5893 R1463CP  02/22/2008  ZIP Code Files by Date of Service -  Replaced by Transmittal 1591  07/07/2008  5881 R1421CP  01/25/2008  Update of Institutional Claims References -  Rescinded and Replaced by Transmittal 1472 04/07/2008  5893 R1375CP  11/09/2007  Ambulance Inflation Factor for CY 2008  01/07/2008  5801 Rev #  Issue Date  Subject  Impl Date  CR#  R1333CP  08/17/2007  Ambulance: New Remark Code for Denying Separately Billed Services  10/01/2007  5659 R1318CP  08/17/2007  Ambulance: New Remark Code for Denying Separately Billed Services -  Replaced by Transmittal 1333  10/01/2007  5659 R1249CP  05/25/2007  Update to Publication 100- 04, Chapters 1 and 15 for ZIP5 and ZIP9 Medicare Zip Code Files.  10/01/2007  5578 R1185CP  02/23/2007  Ambulance Fee Schedule -Medical Conditions List 04/02/2007  5442 R1144CP  12/29/2006  Elimination of CMS -1491 and CMS -1490U Forms  04/02/2007  5390 R1102CP  11/03/2006  Ambulance Inflation Factor (AIF) for CY 2007  01/02/2007  5358 R1100CP  11/03/2006  Jurisdiction for Ambulance Supplier Claims  01/01/2008  5203 R852CP  02/10/2006  Corrected Ambulance Fee Schedule file for CY 2006
(Medicare Claims Processing Manual)
for CY 2007  01/02/2007  5358 R1100CP  11/03/2006  Jurisdiction for Ambulance Supplier Claims  01/01/2008  5203 R852CP  02/10/2006  Corrected Ambulance Fee Schedule file for CY 2006 02/24/2006  4362 R789CP  12/23/2005  Ambulance Medical Conditions List  03/27/2006  4221 R762CP  11/25/2005  Ambulance Inflation Factor (AIF) for CY 2006  01/03/2006  4061 R668CP  09/02/2005  Enforcement of Hospital Inpatient Bundling: Carrier Denial of Ambulance Claims during an Inpatient Stay  01/03/2006  3933 R622CP  07/29/2005  Enforcement of Hospital Inpatient Bundling: Carrier Denial of Ambulance Claims during an Inpatient Stay  01/03/2006  3933 R459CP  02/04/2005  Change To CWF SNF Edits For  Consolidated Billing for Ambulance Transport to or From Therapeutic Sites -- replaces R342CP  04/04/2005  3676 R437CP  01/21/2005  This instruction revises Section 30, Chapter 6 to include ICD -9-CM coding guidance for Skilled 02/22/2005  3664 Rev #  Issue Date  Subject  Impl Date  CR#  Nursing Facilities (SNFs) and removes Home Health Agency (HHA) Types of Bill from various sections of Chapter 15 to conform with existing policy. R425CP  01/10/2005  Payment of Ambulance Services to Indian Health Service (IHS) or Tribal Hospitals Including (CAHs)  04/03/2005  3521 R411CP  12/23/2004  Ambulance Inflation Factor (AIF) for CY 2005  01/03/2005  3599 R395CP  12/15/2004  Ambulance Fee Schedule -  Medical Conditions List 01/03/2005  3619 R367CP  11/12/2004  Replaced by Revision 425CP  04/04/2005  3521 R342CP  10/29/2004  Change to the Common Working File (CWF) Skilled Nursing Facility (SNF) Consolidated Billing (CB) Edits for Ambulance Transports to or from a Diagnostic or Therapeutic Site  04/04/2005  3427 R220CP  06/25/2004  Implementation of Section 414 of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003  07/06/2004  3099 R212CP  06/18/2004  Replaced
(Medicare Claims Processing Manual)
3427 R220CP  06/25/2004  Implementation of Section 414 of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003  07/06/2004  3099 R212CP  06/18/2004  Replaced by Revision 220CP  07/06/2004  3099 R185CP  05/28/2004  Change to the Common Working File (CWF) Skilled Nursing Facility (SNF) Consolidated Billing (CB) Edits for Drugs and Electrocardiogram (EKG) Testing Provided During an Ambulance Transport  10/04/2004  3212 R163CP  04/30/2004  Change to the Common Working File (CWF) Skilled Nursing Facility (SNF) Consolidated Billing (CB) Edits for Ambulance Transports to or from a Diagnostic or Therapeutic Site Other than a Physician's Office or Hospital  10/04/2004  3196 Rev #  Issue Date  Subject  Impl Date  CR#  R088CP  02/06/2004  Implementation of Changes to Payment for Ambulance Services Required by Section 414 of MMA  07/05/2004  3099 R059CP  01/02/2004  Corrects the "Ambulance HCPCS Codes Crosswalk and Definitions," makes technical corrections to the manual, and adds a new carrier requirement for HCPCS code A0800  01/05/2004  3035 R056CP  12/24/2003  Ambulance Inflation Factor (AIF) for CY 2004 including the 2004 AIF for determining the payment limit for ambulance services required by $1834(1) of the Social Security Act (the Act), the blending percentages applicable to CY 2004, and the address of the ambulance fee schedule file for CY 2004  01/05/2004  3000 R001CP  10/01/2003  Initial Publication of Manual  NA NA Back to top of Chapter