Local Coverage Article Billing and Coding

Billing and Coding: Ambulance Services

A56468

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Article Information

General Information

Article ID
A56468
Article Title
Billing and Coding: Ambulance Services
Article Type
Billing and Coding
Original Effective Date
04/04/2019
Revision Effective Date
07/01/2021
Revision Ending Date
N/A
Retirement Date
N/A
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CMS National Coverage Policy

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim

Title XVIII of the Social Security Act §1861(s)(7) defines ambulance service where the use of other methods of transportation is contraindicated by the individual's condition, but only to the extent provided in regulations

Title XVIII of the Social Security Act §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member

42 CFR §410.40 addresses the coverage of ambulance services

CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 10, §10 Ambulance Service, §10.2.2 Reasonableness of the Ambulance Trip, §10.2.6 Effect of Beneficiary Death on Medicare Payment for Ground Ambulance Transports, §10.3 The Destination, §10.3.1 Institution of Beneficiary's Home, §10.3.2 Institution of Institution, §10.3.3 Separately Payable Ambulance Transport Under Part B Versus Patient Transportation that is Covered Under a Packaged Institutional Service, §10.3.4 Transports to and from Medical Services for Beneficiaries who are not Inpatients, §10.3.7 Partial Payment, §10.3.8 Ambulance Service to Physician's Office, §10.3.9 Transportation Requested by Home Health Agency, §10.3.10 Multiple Patient Ambulance Transport, §10.4 Air Ambulance Services, §10.1.1 Coverage Requirements, §10.4.4 Hospital to Hospital Transport, §10.4.5 Special Coverage Rule, §10.4.6 Special Payment Limitations, §10.4.8 Air Ambulance Transports Canceled Due to Weather or Other Circumstances Beyond the Pilot's Control, §10.4.9 Effect of Beneficiary Death on Program Payment for Air Ambulance Transports, §10.5 Joint Responses, and §20 Coverage Guidelines for Ambulance Service Claims

CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 15, §10.2 Summary of the Benefit, §10.4 Additional Introductory Guidelines, §20 Payment Rules, §20.1 Payment Under the Ambulance Fee Schedule, §20.1.1 General, §20.1.3 Services Provided, §20.1.4 Components of the Ambulance Fee Schedule, §20.3 Air Ambulance, §20.6 Payment for Non-Emergency BLS Trips to/from ESRD Facilities, §30 General Billing Guidelines, §30.1 Multi-Carrier System (MCS) Guidelines, §30.1.1 MCS Coding Requirements for Suppliers, §30.1.2 Coding Instructions for Paper and Electronic Claim Forms, §30.1.3 Coding Instructions for Form CMS-1491, §30.2 Fiscal Intermediary Shared System (FISS) Guidelines, §30.2.1 A/B MAC (A) Bill Processing Guidelines Effective April 1, 2002, as a Result of Fee Schedule Implementation, §30.2.2 SNF Billing, §30.2.3 Indian Health Services/Tribal Billing, and §30.2.4 Non-covered Charges on Institutional Ambulance Claims

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Ambulance Services L34549.

Physician Certification & Order:

The ambulance supplier is responsible for obtaining the signed written order and certification with the appropriate signatures as expeditiously as possible, and must obtain the signed order before billing for the service.

If the ambulance supplier is unable to obtain the written order and certification with appropriate signatures within 21 calendar days following the date of the service, the supplier may bill only if there is documentation of good faith effort to obtain the order and certification.

When the transport involves a ground ambulance and an air ambulance, both services may be reimbursed if both are medically necessary.

The ambulance provider or supplier must meet all coverage criteria in order for payment to be made.

Medicare requires the signature of the beneficiary, or that of his or her representative, for both the purpose of accepting assignment and submitting a claim to Medicare.

Ambulance services that are not Medicare benefits because some other form of transportation is not contraindicated, is an exclusion from Medicare benefits under the statutory definition of that benefit at §1861(s)(7). An Advance Beneficiary Notice of Noncoverage (ABN) is not needed and should not be used in the following situations: 

  1. Any denial where the patient could be transported safely by other means (these are denials under §1861(s)(7) of the Social Security Act (SSA)).
  2. Any denial that is based on not meeting an origin or destination requirement (these denials are inconsistent with 42 CFR §410.40 and generally also constitute §1861(s)(7) denials).
  3. A denial for mileage that is beyond the nearest appropriate facility (for the same reason as b. above).
  4. A denial where the physician certification statement or accepted alternative (e.g., certified mail) is not obtained (for the same reason as b. above).
  5. A convenience discharge, e.g., where the beneficiary is an inpatient at one hospital that can care for their needs, but wants to be transferred to a second hospital to be closer to family (for the same reason as b. above).

Not obtaining an ABN in these technical denial situations does not prevent the supplier or provider from collecting denied charges from the beneficiary.

CMS developed the Beneficiary Notices Initiative web page to assist suppliers and providers in informing beneficiaries that the services they are receiving are excluded from Medicare benefits. Ambulance suppliers may develop their own process to communicate to beneficiaries that they will be billed for excluded services for which the ABN is not appropriate.

Multiple patient transports - a single payment allowance for mileage will be prorated by the number of beneficiaries onboard.

Downcoding from air to ground is an §1862(a)(1)(A) denial.

Multiple arrivals - when multiple units respond to a call for services the entity that provides the transport for the beneficiary should be the only provider billing the service.

Coding Information

CPT/HCPCS Codes

Group 1

(12 Codes)
Group 1 Paragraph

Definition of Level of Service

Basic Life Support

Basic life support (BLS) is transportation by ground ambulance vehicle and the provision of medically necessary supplies and services, including BLS ambulance services as defined by the state.

The ambulance vehicle must be staffed by at least two people who meet the requirements of the state and local laws where the services are being furnished, and at least one of the staff members must be certified at a minimum as an emergency medical technician-basic (EMT-Basic) by the state or local authority where the services are being furnished and be legally authorized to operate all lifesaving and life-sustaining equipment on board the vehicle. These laws may vary from state to state or within a state. For example, only in some jurisdictions is an EMT-Basic permitted to operate limited equipment onboard the vehicle, assist more qualified personnel in performing assessments and interventions, and establish a peripheral intravenous (IV) line.

Basic Life Support (BLS) Emergency

Definition: When medically necessary, the provision of BLS services, in the context of an emergency response.

Emergency response is a BLS or ALS1 level of service that has been provided in immediate response to a 911 call or the equivalent. An immediate response is one in which the ambulance provider/supplier begins as quickly as possible to take the steps necessary to respond to the call.

Advanced Life Support, Level 1 (ALS1)

Advanced life support, level 1 (ALS1) is the transportation by ground ambulance vehicle and the provision of medically necessary supplies and services including the provision of an ALS assessment by ALS personnel or at least one ALS intervention.

An advanced life support (ALS) assessment is an assessment performed by an ALS crew as part of an emergency response that was necessary because the patient's reported condition at the time of dispatch was such that only an ALS crew was qualified to perform the assessment. An ALS assessment does not necessarily result in a determination that the patient requires an ALS level of service. In the case of an appropriately dispatched ALS Emergency service, if the ALS crew completes an ALS Assessment, the services provided by the ambulance transportation service provider or supplier shall be covered at the ALS emergency level, regardless of whether the patient required ALS intervention services during the transport, provided that ambulance transportation itself was medically reasonable and necessary, and all other coverage requirements are met.

An advanced life support (ALS) intervention is a procedure that is in accordance with state and local laws, required to be done by an emergency medical technician-intermediate (EMT-Intermediate) or EMT-Paramedic.

Advanced Life Support, Level 1 (ALS1) - Emergency

When medically necessary, the provision of ALS1 services, in the context of an emergency response. Emergency response is a BLS or ALS1 level of service that has been provided in immediate resposne to a 911 call or the equivalent. An immediate response is one in which the ambulance provider/supplier begins as quickly as possible to take the steps necessary to respond to the call.

Advanced Life Support, Level 2 (ALS2)

Advanced Life Support, level 2 (ALS2) is the transportation by ground ambulance vehicle and the provision of medically necessary supplies and services including (1) at least three separate administrations of one of more medications by intravenous (IV) push/bolus or by continuous infusion (excluding crystalloid fluids) or (2) ground ambulance transport, medically necessary supplies and services, and the provision of at least one of the ALS2 procedures listed below:

a. Manual defibrillation/cardioversion;

b. Endotracheal intubation;

c. Central venous line;

d. Cardiac pacing;

e. Chest decompression;

f. Surgical airway; or

g. Intraosseous line

Specialty Care Transport (SCT)

Specialty care transport (SCT) is the interfacility transportation of a critically injured or ill beneficiary by a ground ambulance vehicle, including the provision of medically necessary supplies and services, at a level of service beyond the scope of the EMT-Paramedic. SCT is necessary when a beneficiary's condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area, for example, emergency or critical care nursing, emergency medicine, respiratory care, cardiovascular care, or an EMT-Paramedic with additional training.

SCT is necessary when a beneficiary's condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area. The EMT-Paramedic level of care is set by each state. Medically necessary care that is furnished at a level above the EMT-Paramedic level of care may qualify as SCT. To be clear, if EMT-Paramedics- without specialty care certification or qualification - are permitted to furnish a given service in a state, then that service does not qualify for SCT. The phrase "EMT-Paramedic with additional training" recognizes that a state may permit a person who is not only certified as an EMT-Paramedic, but who also has successfully completed additional education as determined by the state in furnishing higher level medical services required by critically ill or critically injured patients, to furnish a level of services that otherwise would require a health professional in an appropriate specialty care area (for example, a nurse) to provide. "Additional training" means the specific additional training that a state requires a paramedic to complete in order to qualify to furnish specialty care to a critically ill or injured patient during a SCT.

Paramedic Intercept (PI)

Paramedic Intercept services are ALS services provided by an entity that does not provide the ambulance transport. This type of service is most often provided for an emergency ambulance transport in which a local volunteer ambulance that can provide only basic life support (BLS) level of service is dispatched to transport a patient. If the patient needs ALS services such as EKG monitoring, chest decompression, or I.V. therapy, another entity dispatches a paramedic to meet the BLS ambulance at the scene or once the ambulance is on the way to the hospital. The ALS paramedics then provide services to the patient.

This tiered approach to life saving is cost effective in many areas because most volunteer ambulances do not charge for their services and one paramedic service can cover many communities. Prior to March 1, 1999, Medicare payment could be made for these services, but could not be made directly to the intercept service provider; rather, Medicare payment could be made only when the claim was submitted by the entity that actually furnished the ambulance transport. In those areas where state laws prohibited volunteer ambulances from billing Medicare and other health insurance, the intercept service could not receive payment for treating a Medicare beneficiary and was forced to bill the beneficiary for the entire service.

Paramedic intercept services furnished on or after March 1, 1999, are payable separate from the ambulance transport when all of the requirements in the following three conditions are met:

I. The intercept service(s) is:

    • Furnished in a rural area (as defined below);
    • Furnished under a contract with one or more volunteer ambulance services; and
    • Medically necessary based on the condition of the beneficiary receiving the ambulance service.

II. The volunteer ambulance service involved must:

    • Meet Medicare's certification requirements for furnishing ambulance services;
    • Furnish services only at the BLS level at the time of the intercept; and
    • Be prohibited by state law from billing anyone for any service.

III. The entity furnishing the ALS paramedic intercept service must:

    • Meet Medicare's certification requirements for furnishing ALS services, and,
    • Bill all recipients who receive ALS paramedic intercept services from the entity, regardless of whether or not those recipients are Medicare beneficiaries.

For purposes of the paramedic intercept benefit, a rural area is an area that is designated as rural by a state law or regulation or that is located in a rural census tract of a metropolitan statistical area (as determined under the most recent version of the Goldsmith Modification). (The Goldsmith Modification is a methodology to identify small towns and rural areas within large metropolitan counties that are isolated from central areas by distance or other features). The current list of these areas is periodically published in the Federal Register.

Fixed Wing Air Ambulance (FW)

Fixed wing air ambulance is furnished when the beneficiary's 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 beneficiary's 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.

Rotary Wing Air Ambulance (RW)

Rotary wing air ambulance is furnished when the beneficiary's 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 beneficiary's 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 rotary wing air ambulance may also be necessary because the beneficiary is inaccessible by a ground or water ambulance vehicle.

Rural Air Ambulance Services

"Rural air ambulance service" means fixed wing and rotary wing air ambulance service in which the point of pick up of the individual occurs in a rural area (as defined in Section 1886(d)(2)(D)) or in a rural census tract of a metropolitan statistical area (as determined under the most recent modification of the Goldsmith Modification, originally published in the Federal Register on February 27, 1992)) (57 Fed. Reg. 6725).

Group 1 Codes
CodeDescription
A0425 GROUND MILEAGE, PER STATUTE MILE
A0426 AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, NON-EMERGENCY TRANSPORT, LEVEL 1 (ALS 1)
A0427 AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, EMERGENCY TRANSPORT, LEVEL 1 (ALS 1 - EMERGENCY)
A0428 AMBULANCE SERVICE, BASIC LIFE SUPPORT, NON-EMERGENCY TRANSPORT, (BLS)
A0429 AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY TRANSPORT (BLS-EMERGENCY)
A0430 AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES, TRANSPORT, ONE WAY (FIXED WING)
A0431 AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES, TRANSPORT, ONE WAY (ROTARY WING)
A0432 PARAMEDIC INTERCEPT (PI), RURAL AREA, TRANSPORT FURNISHED BY A VOLUNTEER AMBULANCE COMPANY WHICH IS PROHIBITED BY STATE LAW FROM BILLING THIRD PARTY PAYERS
A0433 ADVANCED LIFE SUPPORT, LEVEL 2 (ALS 2)
A0434 SPECIALTY CARE TRANSPORT (SCT)
A0435 FIXED WING AIR MILEAGE, PER STATUTE MILE
A0436 ROTARY WING AIR MILEAGE, PER STATUTE MILE

CPT/HCPCS Modifiers

N/A

ICD-10-CM Codes that Support Medical Necessity

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

N/A

ICD-10-PCS Codes

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

N/A

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
07/01/2021 R4

Under CMS National Coverage Policy updated section headings for regulations and added the following regulations: Social Security Act §1861(s)(7), Social Security Act §1862(a)(1)(A), and 42 CFR §410.40. Typographical errors were corrected throughout the article.

10/10/2019 R3

This article is being revised in order to adhere to CMS requirements per Chapter 13, Section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs and incorporate into related Billing and Coding Articles. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of the related Ambulance Services L34549 LCD and placed in this article.

05/09/2019 R2

Under Article Text added the subheading “Physician Certification & Order”. The verbiage “The ambulance supplier is responsible for obtaining the signed written order and certification with the appropriate signatures as expeditiously as possible, and must obtain the signed order before billing for the service. If the ambulance supplier is unable to obtain the written order and certification with appropriate signatures within 21 calendar days following the date of the service, the supplier may bill only if there is documentation of good faith effort to obtain the order and certification. When the transport involves a ground ambulance and an air ambulance, both services may be reimbursed if both are medically necessary. The ambulance provider or supplier must meet all coverage criteria in order for payment to be made.” was added to this section.

04/04/2019 R1

All coding located in the Coding Information section has been removed from the related Ambulance Services L34549 LCD and added to this article.

Associated Documents

Related Local Coverage Documents
LCDs
L34549 - Ambulance Services
Related National Coverage Documents
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
06/22/2021 07/01/2021 - N/A Currently in Effect You are here
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Keywords

  • Ambulance Services