evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
A beneficiary is bed -confined if he/she is:    Unable to get up from bed without assistance;    Unab le to ambulate; and    Unable to sit in a chair or wheelchair.   The term "bed confined" is not synonymous with "bed rest" or "nonambulatory".  Bed -confinement, by itself, is neither sufficient nor is it necessary to determine the coverage for Medicare ambulance benefits.  It is simply one element of the beneficiary's condition that may be taken into account in the A/B MAC (A)s or (B)s  determination of whether means of transport othe r than an ambulance were contraindicated.   10.2.4 - Documentation Requirements   In all cases, the appropriate documentation must be kept on file and, upon request, presented to the A/B MAC (B).  It is important to note that neither the presence nor absence of a signed physicians order for an ambulance transport necessarily proves (or disproves) whether the transport was medically necessary.  The ambulance service must meet all program coverage criteria in order for payment to be made.   10.2.5- Transport of Persons Other Than the Beneficiary  (Rev. 1, 10- 01-03)  No payment may be made for the transport of ambulance staff or other personnel when the beneficiary is not onboard the ambulance (e.g., an ambulance transport to pick up a specialty care unit from one hospital to provide services to a beneficiary at another hospital).  This policy applies to both ground and air ambulance transports.   10.2.6 - Effect of Beneficiary Death on Medicare Payment for Ground Ambulance Transports  (Rev. 103; Issued:  02- 20-09; Ef fective Date:  01 -05-09; Implementation Date:  03 -20-09)  Because the Medicare ambulance benefit is a transport benefit, if no transport of a Medicare beneficiary occurs, then there is no Medicare -covered service.  In general, if the beneficiary dies befor e being transported, then no Medicare payment may be made.  Thus, in a situation where the beneficiary dies, whether any payment under the Medicare ambulance benefit may be made depends on the time at which the beneficiary is pronounced dead by an individual authorized by the State to make such pronouncements.
(Medicare Benefit Policy Manual)
The chart below shows the Medicare payment determination for various ground ambulance scenarios in which the beneficiary dies. In each case, the assumption is that the ambulance transport would have otherwise been medically necessary.   Ground Ambulance Scenarios:  Beneficiary Death  Time of Death Pronouncement  Medicare Payment Determination  Before dispatch.  None.  After dispatch, before beneficiary is loaded onboard ambulance (before or after arrival  at the point -of-pickup). The providers/suppliers BLS base rate, no mileage or rural adjustment; use the QL modifier when submitting the claim.  After pickup, prior to or upon arrival at the receiving facility.  Medically necessary level of service furnis hed.  10.3 - The Destination  (Rev.243; Issued: 04 -13-18; Effective: 07 -16-18; Implementation: 07 -16-18)  An ambulance transport is covered to the nearest appropriate facility to obtain necessary diagnostic and/or therapeutic services (such as a CT scan or cobalt therapy) as well as the return transport.  In addition to all other coverage requirements, this tr ansport situation is covered only to the extent of the payment that would be made for bringing the service to the patient.   Medicare covers ambulance transports (that meet all other program requirements for coverage) only to the following destinations:    Hospital;   Critical Access Hospital (CAH);    Skilled Nursing Facility (SNF);    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;    Beneficiarys home;    Dialysis facility for ESRD patient who requires dialysis; or    A physicians office is not a covered destination.  However, under special circumstances an ambulance transport may temporarily stop at a physicians office wi thout affecting the coverage status of the transport.
(Medicare Benefit Policy Manual)
 A physicians office is not a covered destination.  However, under special circumstances an ambulance transport may temporarily stop at a physicians office wi thout affecting the coverage status of the transport.  As a general rule, only local transportation by ambulance is covered, and therefore, only mileage to the nearest appropriate facility equipped to treat the patient is covered.  However, if two or more facilities that meet the destination requirements can treat the patient appropriately and the locality (see 10.3.5 below) of each facility encompasses the place where the ambulance transportation of the patient began, then the full mileage to any one of t he facilities to which the beneficiary is taken is covered.  Because all duly licensed hospitals and SNFs are presumed to be appropriate sources of health care, only in exceptional situations where the ambulance transportation originates beyond the localit y of the institution to which the beneficiary was transported, may full payment for mileage be considered.  And then, only if the evidence clearly establishes that the destination institution was the nearest one with appropriate facilities under the partic ular circumstances.  (See 10.3.6  below.)  The institution to which a patient is transported need not be a participating institution but must meet at least the requirements of 1861(e)(1)  or 1861(j)(1)  of the Social Security Act (the Act.)  (See Pub. 100 -01 Medicare General Information, Eligibility, and Entitlement Manual, Chapte r 5, "Definitions," for an explanation of these requirements.)   10.3.1 - Institution to Beneficiarys Home  (Rev. 1, 10- 01-03) A3-3114.C.1, HO -236.3.A   Ambulance service from an institution to the beneficiarys home is covered when the home is within the lo cality of such institution or where the beneficiarys home is outside of the locality of such institution but the institution, in relation to the home, is the nearest one with appropriate facilities.   10.3.2 - Institution to Institution  (Rev. 14, 05- 28-04) A3-3114.C.2, HO -236.3.B
(Medicare Benefit Policy Manual)
10.3.2 - Institution to Institution  (Rev. 14, 05- 28-04) A3-3114.C.2, HO -236.3.B   Occasionally, the institution to which the patient is initially taken is found to have inadequate or unavailable facilities to provide the required care, and the patient is then transported to a second institution having appropria te facilities.  In such cases, transportation by ambulance to both institutions would be covered to the extent of the mileage to be the nearest institution with appropriate facilities.  Responsibility for payment would follow the rules in  10.3.3.  In the se cases, transportation from such second institution to the patient's home could be covered if the home is within the locality served by that institution, or the locality served by the first institution to which the patient was taken.   10.3.3 - Separately Payable Ambulance Transport Under Part B versus Patient Transportation that is Covered Under a Packaged Institutional  Service  (Rev.243; Issued: 04- 13-18; Effective: 07 -16-18; Implementation: 07- 16-18)  Transportation of a beneficiary from his or her home, an accident scene, or any other point of origin is covered under Part B as an ambulance service only to the nearest hospital, critical access hospital (CAH), or skilled nursing facility (SNF) that is ca pable of furnishing the required level and type of care for the beneficiary's illness or injury and only if medical necessity and other program coverage criteria are met.  An ambulance  transport from a SNF to the nearest supplier of medically necessary ser vices 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.
(Medicare Benefit Policy Manual)
Medicare- covered ambulance services are paid either as separately billed services, in which case the entity furnishing the ambulance service bills Part B of the program, or as a packaged service, in which case the entity furnishing the ambulance service must seek payment from the provider who is responsible for the beneficiarys care.  If either the origin or the destination of the ambulance transport is the beneficiarys home, then the ambulance transport is paid separately by Medicare Part B, and the entity that furnishes the ambulance transport may bill its A/B MAC (A) or (B) directly.  If both the origin and destination of the ambulance transport are providers, e.g., a hospital, critical access hospital (CAH), skilled nursing faci lity (SNF), then responsibility for payment for the ambulance transport is determined in accordance with the following sequential criteria.   NOTE :  These criteria must be applied in sequence as a flow chart and not independently of one another.  1. Provide r Numbers:   If the Medicare -assigned provider numbers of the two providers are different, then the ambulance service is separately billable to the program.  If the provider number of both providers is the same, then consider criterion 2, campus.  2. Camp us:  Following criterion 1, if the campuses of the two providers (sharing the same provider numbers) are the same, then the transport is not separately billable to the program.  In this case the provider is responsible for payment.  If the campuses of the two providers are different, then consider criterion 3, patient status.  Campus means the physical area immediately adjacent to the providers main buildings, other areas and structures that are not strictly contiguous to the main buildings, but are located within 250 yards of the main buildings, and any of the other areas determined on an individual case basis by the CMS regional office to be part of the providers campus.   3. Patient Status:  Inpatient vs. Outpatient
(Medicare Benefit Policy Manual)
3. Patient Status:  Inpatient vs. Outpatient  Following criteria 1 and 2, if the patient is an inpatient at both providers (i.e., inpatient status both at the origin and at the destination, providers sharing the same provider number but located on different campuses), then the transport is not separately billable.  In this case the p rovider is responsible for payment.  All other combinations (i.e., outpatient -to-inpatient, inpatient -to-outpatient, outpatient -to-outpatient) are separately billable to the program.  In the case where the point of origin is not a provider, Part A coverage  is not available because, at the time the beneficiary is being transported, the beneficiary is not an inpatient of any provider paid under Part A of the program and ambulance services are excluded from the 3- day preadmission payment window.  The transfer,  i.e., the discharge of a beneficiary from one provider with a subsequent admission to another provider, is also payable as a Part B ambulance transport, provided all program coverage criteria are met, because, at the time that the beneficiary is in transi t, the beneficiary is not a patient of either provider and not subject to either the inpatient preadmission payment window or outpatient payment packaging requirements.  This includes an outpatient transfer from a remote, off -campus emergency department (ER) to becoming an inpatient or outpatient at the main campus hospital, even if the ER is owned and operated by the hospital.
(Medicare Benefit Policy Manual)
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 beneficiary maintains inpatient status with the original provider.  Thi s 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 service 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 manner as the costs of such a transfer within a single building.   10.3.4  Transports to and from Medical Services for Beneficiaries who are not Inpatients (Rev. 14, 05- 28-04) A3-3114.C.3, HO -236.3.C, AB -00-127, B3- 2120.3C   Ambulance transports to and from a covered destination (i.e., two 1- way trips) furnished to a benef iciary who is not an inpatient of a provider for the purpose of obtaining covered medical services are covered, if all program requirements for coverage are met.
(Medicare Benefit Policy Manual)
In addition, coverage of ambulance transports to and from a destination under these circumsta nces is limited to those cases where the transportation of the patient is less costly than bringing the service to the patient.  For frequent transports of this kind subject to the A/B MAC (A)s or (B)s discretion, additional information may be required supporting the need for ambulance services relative to the option of admission to a treatment facility.   Specialized services are covered services that are not available at the facility in which the beneficiary is a patient.   10.3.5 - Locality (Rev. 236, Issued: 06 -16-17, Effective: 09- 18-17, Implementation: 09- 18-17)  The term locality with respect to ambulance service means the service area surrounding the institution to which individuals normally travel or are expected to travel to receive hospital or  skilled nursing services.  The MACs have the discretion to define locality in their service areas.   EXAMPLE:  Mr. A becomes ill at home and requires ambulance service to the hospital.  The small community in which he lives has a 35 -bed hospital.  Two larg e metropolitan hospitals are located some distance from Mr. A's community and both regularly provide hospital services to the community's residents.  The community is within the "locality" of both metropolitan hospitals and direct ambulance service to either of these (as well as to the local community hospital) is covered.   10.3.6 - Appropriate Facilities  (Rev. 1, 10- 01-03) A3-3114.C.6, HO -236.3.F   The term appropriate facilities means that the institution is generally equipped to provide the needed hospi tal or skilled nursing care for the illness or injury involved.  In the case of a hospital, it also means that a physician or a physician specialist is available to provide the necessary care required to treat the patients condition.  However, the fact that a particular physician does or does not have staff privileges in a hospital is not a consideration in determining whether the hospital has appropriate facilities.  Thus, ambulance service to a more distant hospital solely to avail a patient of the service of a specific physician or physician specialist does not make the hospital in which the physician has staff privileges the nearest hospital with appropriate facilities.
(Medicare Benefit Policy Manual)
The fact that a more distant institution is better equipped, either qualitatively or quantitatively, to care for the patient does not warrant a finding that a closer institution does not have appropriate facilities.  Such a finding is warranted, however, if the beneficiarys condition requires a higher level of trauma care or other specialized service available only at the more distant hospital.  In addition, a legal impediment barring a patients admission would permit a finding that the institution did not have appropriate facilities.  For example, the nearest tuberculosis hospital  may be in another State and that States law precludes admission of nonresidents.  An institution is also not considered an appropriate facility if there is no bed available.   The A/B MAC (A) or (B), however, will presume that there are beds available at the local institutions unless the claimant furnished evidence that none of these institutions had a bed available at the time the ambulance service was provided.   EXAMPLE:  Mr. A becomes ill at home and requires ambulance service to the hospital.  The hospitals servicing the community in which he lives are capable of providing general hospital care.  However, Mr. A requires immediate kidney dialysis, and the needed equipment is not available in any of these hospitals.  The service area of the nearest hospit al having dialysis equipment does not encompass the patients home.  Nevertheless, in this case, ambulance service beyond the locality to the hospital with the equipment is covered since it is the nearest one with appropriate facilities.   10.3.7 - Partial Payment  (Rev. 1, 10- 01-03) A3-3114.C.4, HO -236.3.D   Where ambulance service exceeds the limits defined in 10.3 through 10.3.7, above, refer to 20, item #5  for instructions on partial payment.  10.3.8 - Ambulance Service to P hysicians Office  (Rev. 1, 10- 01-03) A3-3114.C.7, HO -236.3.G, B3- 2130.3.G   These trips are covered only under the following circumstances:    The ambulance transport is enroute to a Medicare covered destination as described in 10.3 ; and
(Medicare Benefit Policy Manual)
These trips are covered only under the following circumstances:    The ambulance transport is enroute to a Medicare covered destination as described in 10.3 ; and    During the transport, the ambulance stops at a physician's office because of the patient's dire need for professional attention, and immediately thereafter, the ambulance continues to the covered destination.   In such cases, the patient will be deemed to have been transported directly to a covered destination and payment may be made for a single transport and the entire mileage of the transport, including any additional mileage traveled because of the stop at the physicians office.   10.3.9 - Transportation Requested by Home Health Agency  (Rev. 1, 10- 01-03) A3-3114.C.8, HO -236.3.H, B3- 2130.3.H   Where a home health agency has a beneficiary transported by ambulance to a hospital or skilled nursing facility to obtain needed medical services not other wise available to the individual, the trip is covered as a Part B service only if the requirements are met for ambulance transportation from wherever the patient is located (place of origin).  Such transportation is not covered as a home health service.   10.3.10 - Multiple Patient Ambulance Transport  (Rev. 103; Issued:  02- 20-09; Effective Date:  01 -05-09; Implementation Date:  03 -20-09)  Effective April 1, 2002, if two patients are transported to the same destination simultaneously, for each Medicare benef iciary, Medicare will allow 75 percent of the payment allowance for the base rate applicable to the level of care furnished to that beneficiary plus 50 percent of the total mileage payment allowance for the entire trip.   If three or more patients are trans ported to the same destination simultaneously, then the payment allowance for the Medicare beneficiary (or each of them) is equal to 60 percent of the base rate applicable to the level of care furnished to the beneficiary.  However, a single payment allowa nce for mileage will be prorated by the number of patients onboard.  This policy applies to both ground and air transports.  10.4 - Air Ambulance Services  (Rev. 103; Issued:  02- 20-09; Effective Date:  01 -05-09; Implementation Date:  03 -20-09)
(Medicare Benefit Policy Manual)
This policy applies to both ground and air transports.  10.4 - Air Ambulance Services  (Rev. 103; Issued:  02- 20-09; Effective Date:  01 -05-09; Implementation Date:  03 -20-09)  Medically appropriate air ambulance transportation is a covered service regardless of the State or region in which it is rendered.  However, A/B MACs (A) and (B) approve claims only if the beneficiarys medical condition is such that transportation by either basic or  advanced life support ground ambulance is not appropriate.   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.  Transport 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 such 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 distances or other obstacles, e.g., heavy traffic, preclude such rapid deli very 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.   10.4.1 - Coverage Requirements  (Rev. 1, 10- 01-03) A3-3114.C.11.A, B3- 2120.4A