Description
Medicare pays for emergency ambulance services when a beneficiary's medical condition at the time of transport is such that other means of transportation or levels of service are contraindicated (i.e. would endanger the beneficiary, cause serious impairment to bodily functions or serious dysfunction of any body organ or part). The beneficiary's condition must require the ambulance transportation itself and the level of service provided in order for the billed service to be considered medically necessary. The level of service is determined based on the patient's condition, and not the vehicle used. Medical documentation for ambulance services will be reviewed to determine the Medicare defined conditions have been met for payment.
Affected Code(s)
A0427, A0429, A0425
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer.
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits.
3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s)(7)- Definitions of Services, Institutions, Etc.
4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861 (v)(1)(K)(ii) – Reasonable Cost.
5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(l) (10)-(16)- Establishment of Fee Schedule for Ambulance Services.
6. 42 CFR §405.929- Post-Payment Review
7. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
8. 42 CFR §405.986- Good Cause for Reopening
9. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
10. 42 CFR §424.5- Basic Conditions, (a)(6) Sufficient Information
11. 42 CFR 410.40- Coverage of ambulance services, (a) Definitions, (c) Levels of service, and (e)(1) and (3) Medical necessity requirements.
12. 42 CFR 410.41- Requirements for ambulance providers and suppliers, (c) Billing and reporting requirements.
13. 42 CFR §411.15- Particular Services Excluded from Coverage, (k)(1) Any Services that are not Reasonable and Necessary.
14. 42 CFR 424.36- Signature Requirements
15. 42 CFR 414.605 Definitions
16. 42 CFR 414.610 Basis of Payment
17. 42 CFR 424.37 Evidence of Authority to Sign In on behalf of the Beneficiary.
18. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
19. Medicare Benefit Policy Manual, Chapter 10- Ambulance Services, §10- Ambulance Service, §20- Coverage Guidelines for Ambulance Service Claims, §30.1.1- Ground Ambulance Services
20. Medicare Claims Processing Manual, Chapter 15- Ambulance, §10.4 – Additional Introductory Guidelines, §20.5 – Documentation Requirements, and §30- General Billing Guidelines, (A)- Modifiers Specific to Ambulance Service Claims and (B)- HCPCS Codes
21. Novitas LCD L35162, Ambulance Services (Ground Ambulance), Effective Date 10/01/2015, Revised 01/01/2020
22. Novitas LCA A54574, Billing and Coding: Ambulance Services (Ground Ambulance), Effective 10/01/2015, Revised 10/01/2022
23. First Coast Service Options (FCSO), LCA A52588, Billing for Ground Ambulance Services when the Beneficiary is Pronounced Deceased. Effective Date 10/01/2015, Retired 10/25/2022.
24. FCSO, LCD L37697, Emergency and Non-Emergency Ground Ambulance Services, Effective Date 6/28/2018, Revised 11/28/2019
26. FCSO LCA A57674, Billing and Coding: Emergency and Non-
Emergency Ground Ambulance Services, Effective 10/03/18,
27. Palmetto, LCD L34549, Ambulance Services, Effective 10/01/15, Revised 07/29/21
28. Palmetto, LCA A56468, Billing and Coding Ambulance Services, Effective 04/04/19, Revised 07/01/21
29. HCPCS Level II Codebook