evekhm/cms_iom_500 huggingface dataset:
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 Military base and other restricted zones, air -defense zones, and similar FAA restrictions and prohibitions;    Hazardous weather; or    Variances in departure patterns and clearance routes required by an air traffic controller.   If the air transport meets the criteria for medical necessity, Medicare pays the actual miles flown for legitimate reasons as determined by the Medicare contractor, once the Medicare beneficiary is loaded onto the air ambulance.   IOM Pub. 100- 08, Medicare Program Integrity Manual, chapter 6  Intermediary MR Guidelines for Specific Services contains instructions for Medical Review of Air Ambulance Services.   20.4 - Ambulance Inflation Factor ( AIF)  (Rev. 12414; Issued:12- 19-23; Effective: 01 -01-24; Implementation:01- 02-24)  Section 1834(l)(3)(B) of the Social Security Act (the Act) provides the basis for an update to the payment limits for ambulance services that is equal to the percentage increase in the consumer price  index  for all urban consumers (CPI -U) for the 12-month period ending with June of the previous year. Section  3401  of  the Affordable Care Act amended Section 1834(l)(3) of the Act to apply a productivity adjustment to this update equal to the 10-year moving average of changes in economy- wide private nonfarm business multi-  factor productivity beginning January 1, 2011. The resulting update percentage is referred to as the Ambulance Inflation Factor (AIF). These updated percentages are issued via Recurring Update Notifications.   Part B coinsurance and deductible requirements apply to payments under the ambulance fee schedule. Following is a chart tracking the history of the AIF:   CY AIF 2003  1.1 2004  2.1 2005  3.3 2006  2.5 2007  4.3 2008  2.7 2009  5.0 2010  0.0 2011  -0.1 2012  2.4 2013  0.8 2014  1.0 2015  1.5 2016  -0.4 2017  0.7 2018  1.1 2019  2.3 2020  0.9 2021  0.2  2022   5.1     2023       8.7   2024   2.6                                                                20.5 - Documentation Requirements  (Rev. 1696; Issued:  03- 06-09; Effective/Implementation Date:  04 -06-09)
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2022   5.1     2023       8.7   2024   2.6                                                                20.5 - Documentation Requirements  (Rev. 1696; Issued:  03- 06-09; Effective/Implementation Date:  04 -06-09)  In all cases, the appropriate documentation must be kept on file and, upon request, presented to the contractor.  It is important to note that the presence (or absence) of a physicians order for a transport by ambulance does not necessarily prove (or disprove) whether the transport was medically necessary.  The ambulance service must meet all program coverage criteria in order for payment to be made.   IOM Pub 100- 01, Medicare General Information, Eligibility, and Entitlement Manual, chapter 4 - Physician Certifications and Recertification of Services, contains specific information on supplier requirements for ambulance certification.  IOM Pub. 100- 08, Medicare Program Integrity Manual, chapter 6 - Medicare Contractor Medical Review Guidelines for Specific Services  contains information on medical review instructions of ambulance services.   20.6 - Payment for Non -Emergency Trips to/from ESRD Facilities  (Rev. 4017; Issued: 04- 06-18; Effective: 10 -01-18; Implementation: 10 -01-18)  Section 637 of the American Taxpayer Relief Act of 2012 requires that, effective for transports occurring on and after October 1, 2013, fee schedule payments for non- emergency basic life support (BLS) transports of individuals with end- stage renal disease (ESRD) to and from renal dialysis treatment be reduced by 10%.  The payment reduction affects transports  (base rate and mileage) to and from hospital -based and freestanding renal dialysis treatment facilities for dialysis services provided on a non- emergen cy basis.  Non- emergency BLS ground transports are identified by Healthcare Common Procedure Code System (HCPCS) code A0428.  Ambulance transports to and from renal dialysis treatment are identified by modifier codes G (hospital -based ESRD) and J (freestanding ESRD facility) in either the first position (origin code) or second position (destination code) within the two- digit ambulance modifier.  (See Section 30 (A) for information regarding modifiers specific to ambulance.)
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Effective for claims with dates of service on and after October 1, 2013 through September 30, 2018, the 10% reduction will be calculated and applied to HCPCS code A0428 when billed with modifier code G or J.  The reduction will also be applied to any m ileage billed in association with a non- emergency transport of a beneficiary with ESRD to and from renal dialysis treatment.  BLS mileage is identified by HCPCS code A0425.  The 10% reduction will be taken after  calculation of the normal fee schedule payment amount, including any add- on or bonus payments, and will apply to transports in rural and urban areas as well as areas designated as super rural.   Payment for emergency transports is not affected by this reduction.  Payment for non- emergency BLS transports to other destinations is also not affected. This reduction does not affect or change the Ambulance Fee Schedule.   Note:  The 10% reduction applies to beneficiaries with ESRD that are receiving non- emergency BLS transport to and from renal dialysis treatment.  While it is possible that a beneficiary who is not diagnosed with ESRD will require routine transport to and f rom renal dialysis treatment, it is highly unlikely.  However, contractors have discretion to override or reverse the reduction on appeal if they deem it appropriate based on supporting documentation.  Section 53108 of the Bipartisan Budget Act of 2018 increased the amount of the reduction described above to 23% for transports occurring on and after October 1, 2018.   30 - General Billing Guidelines  (Rev. 3076, Issued: 09- 24-14, Effective: Upon Implementation of ICD -10 ASC X12: 01- 01-12, Implementation: ICD -10: Upon Implementation of ICD -10 ASC X12: 09- 16-14)  Independent ambulance suppliers may bill on the ASC X12 837 professional claim transaction or the CMS -1500 form.  These claims are processed using the MCS system.   Institution based ambulance providers may bill on the ASC X12 837 institutional claim transaction or Form CMS 1450.  These claims are processed using the FISS system.   A. Modifiers Specific to Ambulance Service Claims
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Institution based ambulance providers may bill on the ASC X12 837 institutional claim transaction or Form CMS 1450.  These claims are processed using the FISS system.   A. Modifiers Specific to Ambulance Service Claims   For ambulance service claims, institutional- based providers and suppliers must report an origin and destination modifier for each ambulance trip provided in HCPCS/Rates.  Origin and destination modifiers used for ambulance services are created by combining two alpha characters.  Each alpha character, with the exception of X, represents an origin code or a destination code.  The pair of alpha codes creates  one modifier.  The first position alpha code equals origin; the second position alpha code equals des tination.  Origin and destination codes and their descriptions are listed below:   D = Diagnostic or therapeutic site other than P or H when these are used as origin codes;  E = Residential, domiciliary, custodial facility (other than 1819 facility); G = Hospital based ESRD facility; H = Hospital; I = Site of transfer (e.g. airport or helicopter pad) between modes of ambulance transport;  J = Freestanding ESRD facility;  N = Skilled nursing facility; P = Physicians office;  R = Residence;  S = Scene of accident or acute event;  X = Intermediate stop at physicians office on way to hospital (destination code only)   In addition, institutional -based providers must report one of the following modifiers with every HCPCS code to describe whether the service was provided under arrangement or directly:   QM -  Ambulance service provided under arrangement by a provider of services; or  QN -  Ambulance service furnished directly by a provider of services.   While combinations of these items may duplicate other HCPCS modifiers, when billed with an ambulance transportation code, the reported modifiers can only indicate origin/destination.   B. HCPCS Codes   The following codes and definitions are effective for billing ambulance services on or after January 1, 2001.   AMBULANCE HCPCS CODES AND DEFINITIONS
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B. HCPCS Codes   The following codes and definitions are effective for billing ambulance services on or after January 1, 2001.   AMBULANCE HCPCS CODES AND DEFINITIONS   HCPCS Code  Description of HCPCS Codes  A0425  BLS mileage (per mile)  A0425  ALS mileage (per mile)  A0426  Ambulance service, Advanced Life Support (ALS), non -emergency transport, Level 1  A0427  Ambulance service, ALS, emergency transport, Level 1  A0428  Ambulance service, Basic Life Support (BLS), non -emergency transport  A0429  Ambulance service, basic life support (BLS), emergency transport  A0430  Ambulance service, conventional air services, transport, one way, fixed wing (FW)  A0431  Ambulance service, conventional air services, transport, one way, rotary wing (RW)  A0432  Paramedic ALS intercept (PI), rural area transport furnished by a volunteer ambulance company, which is prohibited by state law from billing third party payers.  A0433  Ambulance service, advanced life support, level 2 (ALS2)  A0434  Ambulance service, specialty care transport (SCT)  A0435  Air mileage; FW, (per statute mile)  A0436  Air mileage; RW, (per statute mile)   NOTE:  PI, ALS2, SCT, FW, and RW assume an emergency condition and do not require an emergency designator.   Refer to IOM Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 10 - Ambulance Service, section 30.1 -  Definitions of Ambulance Services, for the definitions of levels of ambulance services under the fee schedule.   30.1 - Multi -Carrier System (MCS) Guidelines (Rev. 1696; Issued:  03- 06-09; Effective/Implementation Date:  04 -06-09) B3-5116  Payment under the fee schedule for ambulance services:    Includes a base rate payment plus a 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    Precludes a separate payment for items and services furnished under the ambulance benefit.
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 Covers both the transport of the beneficiary to the nearest appropriate facility and all items and services associated with such transport; and    Precludes 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 -  but only when such items and services are both medically necessary and covered by Medicare under the ambulance benefit.   30.1.1 - MCS Coding Requirements for Suppliers  (Rev. 1696; Issued:  03- 06-09; Effective/Implementation Date:  04 -06-09) PM AB -00-88  The ambulance fee schedule contains the following HCPCS coding logic:    Seven categories of ground ambulance services;   Two categories of air ambulance services;   Payment based on the condition of the beneficiary, not on the type of vehicle used;   Payment is determined by the point of pickup (as reported by the 5 -digit ZIP Code);   Increased payment for rural services; and   Services and supplies included in base rate.   30.1.2 - Coding Instructions for Paper and Electronic Claim Forms  (Rev. 4205, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medica re Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   Except as otherwise noted, beginning with dates of service on or after January 1, 2001, the following coding instructions must be used.  Origin
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Electronic billers should refer to the Implementation Guide to determine how to report the origin information (e.g., the ZIP Code of the point of pickup).  Beginning with the early implementation of version 5010 of the ASC X12 837 professional claim format  on January 1, 2011, electronic billers are required to submit, in addition to the loaded ambulance trips origin information (e.g., the ZIP Code of the point of pickup), the loaded ambulance trips destination information (e.g., the ZIP code of the point of drop -off).  Refer to the appropriate Implementation Guide to determine how to report the destination information.  Only the ZIP Code of the point of pickup will be used to adjudicate and price the ambulance claim, not the point of drop- off.  However, the point of drop- off is an additional reporting requirement on version 5010 of the ASC X12 837 professional claim format.  Where the CMS -1500 Form is used the ZIP code is reported in item 23.  Since the ZIP Code is used for pricing, more than one ambulance service may be reported on the same paper claim for a beneficiary if all points of pickup have the same ZIP Code.  Supplie rs must prepare a separate paper claim for each trip if the points of pickup are located in different ZIP Codes.  Claims without a ZIP Code in item 23 on the CMS -1500 Form item 23, or with multiple ZIP Codes in item 23, must be returned as unprocessable.    The contractor 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 Two.   Group Code: CO  CARC: 16  RARC: N53  MSN: N/A  ZIP Codes must be edited for validity.  The format for a ZIP Code is five numerics.  If a nine -digit ZIP Code is submitted, the last four digits are ignored.  If the data submitted in the required field does not match that format, the claim is rejected.
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Mileage  Generally, each ambulance trip will require two lines of coding, e.g., one line for the service and one line for the mileage.  Suppliers who do not bill mileage would have one line of code for the service.  Beginning with dates of service on or after January 1, 2011, mileage billed must be reported as fractional units in the following situations:    Where billing is by ASC X12 claims transaction (professional or institutional), and   Where billing is by CMS -1500 paper form.  Electronic billers should see the appropriate Implementation Guide to determine where to report the fractional units.  Item 24G of the Form CMS -1500 paper claim is used. Fractional units are not required on Form CMS -1450. For trips totaling up to 100 covered miles suppliers must round the total miles up to the nearest tenth of a mile and report the resulting number with the appropriate HCPCS code for ambulance mileage.  The decimal must be used in the appropriate place (e.g., 99.9).  For trips totaling 100 covered miles and greater, suppliers must report mileage rounded up to the next whole number mile without the use of a decimal (e.g., 998.5 miles should be reported as 999). For trips totaling less than 1 mile, enter a 0 before the decimal (e.g., 0.9).   For mileage HCPCS billed on the ASC X12 837 professional transaction or the CMS -1500 paper form only, contractors shall automatically default to 0.1 units when the total mileage units are missing.
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Multiple Patients on One Trip  Ambulance suppliers submitting a claim using the ASC X12 professional format or the CMS -1500 paper form for an ambulance transport with more than one patient onboard must use the GM modifier (Multiple Patients on One Ambulance Trip) for each service li ne item. In addition, suppliers are required to submit documentation to A/B MACs (Part B) to specify the particulars of a multiple patient transport. The documentation must include the total number of patients transported in the vehicle at the same time an d the Medicare beneficiary identifiers for each Medicare beneficiary. A/B/MACs (Part B) shall calculate payment amounts based on policy instructions found in Pub.100- 02, Medicare Benefit Policy Manual, Chapter 10  Ambulance Services, Section 10.3.10  Mul tiple Patient Ambulance Transport.  Ambulance claims submitted on or after January 1, 2011, in version 5010 of the ASC X12 837 professional claim format require the presence of a diagnosis code and the absence of diagnosis code will cause the ambulance claim to not be accepted into the claim s processing system. The presence of a diagnosis code on an ambulance claim is not required as a condition of ambulance payment policy. The adjudicative process does not take into account the presence (or absence) of a diagnosis code, but a diagnosis code is required on the ASC X12 837 professional claim format.   30.1.3 - Coding Instructions for Form CMS -1491 (Rev. 1696; Issued:  03- 06-09; Effective/Implementation Date:  04 -06-09)  Effective April 2, 2007, Form CMS -1491 will no longer be a valid format for submitting claims.  Suppliers who wish to submit a paper claim must use CMS -1500 Form.   30.1.4 - CWF Editing of Ambulance Claims for Inpatients  (Rev. 1696; Issued:  03- 06-09; Effective/Implementation Date:  04 -06-09)  Hospital bundling rules exclude payment to independent suppliers of ambulance services for beneficiaries in a hospital inpatient stay (see IOM Pub. 100- 04, Medicare Claims Processing, chapter 3 - Inpatient Hospital Billing, Section 10.4 -  Payment of Nonphysician Services for Inpatients).  CWF performs reject edits to incoming claims from suppliers of ambulance services.
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Upon receipt of a hospital inpatient claim at the CWF, CWF searches paid claim history and compares the period between the hospital inpatient admission and discharge dates to the line item service date on an ambulance claim billed by a supplier.  The CWF w ill generate an unsolicited response when the line item service date falls within the admission and discharge dates of the hospital inpatient claim.   Upon receipt of an unsolicited response, the A/B MAC (B) will adjust the ambulance claim and recoup the payment.   Ambulance services with a date of service that are the same as an admission or discharge date on an inpatient claim are separately payable and not subject to the bundling rules.  30.2 - Fiscal Intermediary Shared System (FISS) Guidelines  (Rev. 11365; Issued: 04 -28-22; Effective: 05 -31-22; Implementation: 05 -31-22)  For SNF Part A, the cost of medically necessary ambulance t ransport ation to re ceive most service s inclu ded in  the RUG rate is inclu ded in the c ost for the ser vice. Pay ment for the SNF claim  is based on the R UGs, which takes into account the cost of such transpor tation to re ceive the an cillary  servi ces.  Refer to Pub. 100- 04, Medicare Cla ims Processing Manual, chapter 6 -  SNF Inpatient Part A Billing, Section 20.3.1 - Ambulance Services,  for additional information on SNF consolidated billing and ambulance transportation.  Refer to Pub. 100- 04, Medicare Claims Processing Manual, chapter 3 -  Inpatient Hospital Billing, section 10.5 -  Hospital Inpatient Bundling, f or additional infor mation on hospital inpatient bundling of a mbulance services.   In general, the A/B MAC (A) processes clai ms for Part B  ambulance services provided by an ambulance supplier under arrange ments with hos pitals or SNFs.  These providers bill A/B MACs (A) using only Method 2.  The provider m ust furnish the following data in accordance with A/B MAC (A) instructions. The A/B MAC  (A) will make arrangem ents for the m ethod and m edia for sub mitting the data:
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 A detailed state ment of the condition necessitati ng the a mbulance service;    A state ment indic ating w hether the patie nt was a dmitted as a n inpatient.  If  yes the na me and address of the  facility must be shown;    Name and address of certifying physician;    Name and address of physician ordering ser vice if other than certifying physician;    Point of pickup (ide ntify place and co mpleted address);    Destination (identify place and com plete addres s);   Number of l oaded m iles (the nu mber of m iles tra veled when t he beneficiary was in the a mbulance);    Cost per m ile;   Mileage charge;    Mini mum or base charge; and    Charge for special item s or services.  Explain.   A. General   The reasonable cost per trip of a mbulance services furnished by a provider of services m ay not exceed the pr ior years reas onable cost per trip updated by the ambulance inflation factor.  This deter mination is ef fective with s ervices furnished during Federal Fiscal Year (FFY) 1998 (between October 1, 1997, and September 30, 1998). Providers are to bill for Part B a mbulance services using the billing m ethod of base rate inclu ding s upplies, with m ileage bil led separately as described below.   The following instructions provide billing procedures i mplementing the above provisions.  B. Applicable Bill Ty pes  The appropr iate type of  bill (13X, 22X, 23X, 83X, and 85X) m ust be re ported. For S NFs, ambulance cannot be re ported on a 21X type of bill.  C. Value Code Reporting
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C. Value Code Reporting   For clai ms with dates of service on or a fter January 1, 2001, providers must report on every Part B ambulance claim  value code A0 (zero) and the related ZIP Code of the geographic location from  which the benefici ary was placed on board the a mbulance in the Value C ode field.  T he value code is defined as ZIP Code of the location from  which the beneficiary is initially  placed on board the ambulance.  Providers report t he number in dollar portion of the form  location right justified to the le ft of the dollar /cents delimite r.  More than one a mbulance trip m ay be reported  on the sa me claim  if the ZIP Codes of all points of pickup are t he same.  How ever, since billing require ments do not allow for value codes (ZIP Codes) to be line item  specific and only one ZIP Code m ay be reported per clai m, providers must prepare a separate claim for a beneficiary for each trip if t he points of pickup are located in different ZIP Codes.   For claims with dates of service on or after April 1, 2002, providers must report value code 32 (multiple patient ambulance transport) when an ambulance transports more than one patient at a time to the same destination.  Providers must report value code 32 and the number of patie nts transported in the amount field as a whole number to the left of the delimiter.   NOTE:  Infor mation regarding the claim  form locator that corresponds to the Value Code field is found in Pub.100- 04, Medicare Claims Processing Manual,  Chapter 25 - Completing and Processing the Form CMS -1450 Data Se t.  D. Reven ue Code/HCPCS Code Reporting   Providers m ust report revenue code 054X and, for services  provided before January 1, 2001, one of the followi ng CMS HCPCS codes for each am bulance trip pr ovided duri ng the billing period: