Superseded Local Coverage Determination (LCD)

Ambulance Services (Ground Ambulance)

L35162

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Contractor Information

LCD Information

Document Information

LCD ID
L35162
LCD Title
Ambulance Services (Ground Ambulance)
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 01/01/2020
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2021 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2021 American Dental Association. All rights reserved.

Copyright © 2013 - 2021, the American Hospital Association, Chicago, Illinois. Reproduced by CMS with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312-893-6816. Making copies or utilizing the content of the UB-04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. To license the electronic data file of UB-04 Data Specifications, contact Tim Carlson at (312) 893-6816. You may also contact us at ub04@aha.org.

CMS National Coverage Policy

This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for ground ambulance services. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for ground ambulance services and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site:

IOM Citations:

  • CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 10, Ambulance Services
  • CMS IOM Publication 100-04, Medicare Claims Processing Manual,
    • Chapter 6, Section 20.3.1 Other Services Excluded from SNF PPS and Consolidated Billing
    • Chapter 15, Ambulance
  • CMS IOM Publication 100-08, Medicare Program Integrity Manual,
    • Chapter 3, Section 3.3.2.4 Signature Requirements
    • Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCD

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1861(s)(7), Ambulance Services.
  • Title XVIII of the Social Security Act, Section 1861(v)(1)(K)(ii), Bona Fide Emergency Services.
  • Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medical payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Code of Federal Register (CFR) References:

  • CFR, Title 42, Chapter IV, Subchapter B, Part 410, Subpart B, Section 410.40 - Coverage of ambulance services.
  • CFR, Title 42, Chapter IV, Subchapter B, Part 410, Subpart B, Section 410.41- Requirements for ambulance suppliers.
  • CFR, Title 42, Chapter IV, Subchapter B, Part 414, Subpart H, Section 414.605 - Definitions.
  • CFR, Title 42, Chapter IV, Subchapter B, Part 424, Subpart C, Section 424.36 - Signature requirements.
  • CFR, Title 42, Chapter IV, Subchapter B, Part 424, Subpart C, Section 424.40 - Request for payment effective for more than one claim.
  • CFR, Title 42, Chapter IV, Subchapter G, Part 482, Subpart B, Section 482.13(e) - Standard Restraint or seclusion.
  • CFR, Title 42, Chapter IV, Subchapter G, Part 482, Subpart B, Section 482.13(f) - Standard Restraint or seclusion: Staff training requirements.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

The Medicare payment benefit for ambulance services is very restricted. Ambulance suppliers must understand the benefit and refrain from seeking Medicare payment for services that do not conform to the limited benefit requirements as stated in regulation. Physicians and others who order and certify medical necessity of ambulance services must also understand and abide by the limitations of Medicare coverage of ambulance services.

Medical Necessity

Ambulance transportation is covered when the patient’s condition requires the vehicle itself or the specialized services of the trained ambulance personnel. A requirement of coverage is that the needed services of the ambulance personnel were provided and clear clinical documentation validates their medical need and their provision in the record of the service (usually the trip/run sheet).

Emergency Ambulance Services

Emergency ambulance services are a covered benefit when the services meet the medical necessity requirements as outlined in the CMS manuals and Federal Register sections listed in the CMS National Coverage Policy section above. Please refer to the listed references for full coverage details.

The patient’s condition is an emergency that renders the patient unable to be safely transported to the hospital in a moving vehicle (other than an ambulance) for the amount of time required to complete the transport. Emergency ambulance services are services provided after the sudden onset of a medical condition. For the purposes of this LCD, acute signs or symptoms of sufficient severity must manifest the emergency medical condition such that the absence of immediate medical attention could reasonably be expected to result in one or more of the following:

  • Place the patient’s health in serious jeopardy.
  • Cause serious impairment to bodily functions.
  • Cause serious dysfunction of any body organ or part.

Covered destinations for emergency ambulance services 

Please refer to CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 10, Ambulance Services, Section 3 for information on covered destinations.

Non-Emergency Ambulance Service

Non-emergency ambulance services may be those that are scheduled in advance – scheduled services being either repetitive or non-repetitive.

Refer to CFR, Title 42, Chapter IV, Subchapter B, Part 410, Subpart B, Section 410.40 for full details regarding non-emergency ambulance services.

One condition of coverage is that the beneficiary be bed-confined. Please refer to CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 10, Section 10.2.3 for additional information on bed-confinement.

Statements about the patient’s bed-confined status must be validated in the record with contemporaneous objective observations and findings as to the patient’s functional physical or mental limitations that have rendered him bed-bound.

Ambulance transportation for services excluded from SNF consolidated billing must meet the criteria as reasonable and necessary as indicated in CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 20.3.1.

Refer to CMS IOM Publications 100-04, Medicare Claims Processing Manual, Chapter 15, Section 10.4 and 100-02, Medicare Benefit Policy Manual, Chapter 10, Section 10.3.3 for information on ambulance transport for a beneficiary who is a SNF resident in a stay not covered by Part A.

Appropriate Facilities

CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 10, Section 10.3.6 outlines coverage for ambulance transports to appropriate facilities.

Special Note Regarding Patients Transported To and From Hemodialysis Centers:

Only a fraction (approximately 10 percent) of End Stage Renal Disease (ESRD) patients on chronic hemodialysis requires ambulance transportation to and from hemodialysis sessions. The presence of ESRD and the requirement for hemodialysis do not alone qualify a patient for ambulance transportation. Medicare payment requires patients transported to and from hemodialysis centers to have other conditions such as those described in the tables below and requires adequate documentation of those conditions in the ambulance supplier’s trip/run sheet and in the medical records of other providers involved with the patient’s care.

Physician Certification Statement (PCS)

For scheduled and non-scheduled non-emergency ambulance transports, providers of ambulance transportation must obtain a written statement (PCS) from the patient’s attending physician certifying that medical necessity requirements for ambulance transportation are met. Refer to CFR, Title 42, Chapter IV, Subchapter B, Part 410, Subpart B, Section 410.40 for full details regarding PCS requirements.

Tables of Medical Conditions

Medicare has established a list of medical conditions to assist with communicating patient’s conditions to the Medicare Administrative Contractors (MACs). Though not all-inclusive, the lists contain medical conditions for which ambulance transportation is commonly required and can be used to judge relative severity of conditions not listed. Please refer to the CMS IOM 100-04 Publication, Medicare Claims Processing Manual, Chapter 15, Section 40 for more information and for the link to the medical conditions.

Medicare requires the trip/run sheet to include a description of the patient’s symptoms and physical findings in sufficient detail as to demonstrate conditions such as those described in the lists.

Special Considerations Regarding Beneficiary Death

Please see CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 10, Section 10.2.6 for information on ambulance services and the death of a beneficiary.

Limitations

Medicare does not cover the following services:

  • Transportation via Mobile Intensive Care Unit (MICU) (if billed under Medicare Part A).
  • Parking fees.
  • Tolls for bridges, tunnels and highways.
  • Medicare does not provide payment for “Ambulance response and treatment, no transport.”

Non-emergency ambulance transportation is not covered for patients who are restricted to bed rest by a physician’s instructions but who do not meet the criteria as outlined in the manuals.

Per regulation, ambulance services are not based only on the diagnosis. In addition to the diagnosis meeting medical necessity the requirement that any other means of transportation is contraindicated must also be met. Therefore, in order to support medical necessity, all ambulance transports require dual diagnosis codes. Billing and Coding: Ambulance Services (Ground Ambulance), A54574 provides a list of suggested primary diagnosis codes as well as the required dual diagnosis codes. Please refer to the billing and coding article for proper billing and coding instructions.

Non-emergency ambulance transportation is not covered if transportation is provided for the patient who is transported to receive a service that could have been safely and effectively provided in the point of origin (residence, Skilled Nursing Facility [SNF], hospital, etc.). Such transportation is not covered even if the patient could only have gone for the service by ambulance.

For frequency limitations please refer to the Utilization Guidelines section of the LCD.

Notice: Services performed must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules. Please refer to the article Billing and Coding: Ambulance Services (Ground Ambulance), A54574 for appropriate CPT and diagnosis code reporting.

The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in this LCD.

Jurisdiction L Prior Authorization

Please refer to the Prior Authorization area on the Novitas website using the following URL: (please copy into your browser) http://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00083990

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

General Information

Associated Information


Refer to the Local Coverage Article: Billing and Coding: Ambulance Services (Ground Ambulance), A54574, for all coding information.


Documentation Requirements

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The medical record documentation must support the medical necessity of the services as stated in this policy. It is the responsibility of the ambulance supplier to maintain (and furnish to Medicare upon request) complete and accurate documentation of the beneficiary's condition to demonstrate the ambulance service being furnished meets the medical necessity criteria. Documentation must be legible or identifiable (submitted with a signature log). The documents required for this Medicare purpose include the following:
    • A PCS (for those services for which the physician certification is required - see Physician's Certification Statement section). The certification itself is not the sole factor used in determining whether payment for ambulance services will be allowed:
      • The PCS must be completed and signed by one of the medical professionals as outlined in CFR, Title 42, Chapter IV, Subchapter B, Part 410, Subpart B, Section 410.40.
      • A particular form or format is not required for the certification. Suppliers and physicians may develop their own certification form.
      • Ambulance company employees should not complete PCS forms on behalf of the medical professional.
      • For repetitive services, the PCS may include the expected length of time ambulance transport would be required but may not exceed 60 days.
      • Signatures on the PCS must be dated at the time they are completed.
    • Trip/Run Sheet:
    • A detailed description of the patient's condition at the time of transport.
    • The trip/run sheet must "paint a picture" of the patient's condition and must be consistent with documentation found in other supporting medical record documentation (including the physician's certification). The trip/run sheet must include:
      • A concise explanation of symptoms reported by the patient or other observers and details of the patient's physical assessments that clearly demonstrate that the patient requires ambulance transportation and cannot be safely transported by an alternate mode.
      • An objective description of the patient's physical condition in sufficient detail to demonstrate that the patient's condition or functional status at the time of transport meets Medicare limitation of coverage for ambulance services.
      • Description of the traumatic event when trauma is the basis for suspected injuries.
      • A detailed description of existing safety issues.
      • A detailed description of special precautions taken (if any) and explanation of the need for such precautions.
      • A description of specific monitoring and treatments required, ordered and performed/administered. That a treatment (such as oxygen) or monitoring (such as cardiac rhythm monitoring) was performed absent sufficient description of the patient's condition (to demonstrate that the treatment or monitoring was medically necessary) is inadequate on its own merit to justify payment for the ambulance service. For example, when oxygen is supplied as a basis for ambulance transportation, the patient's pretreatment capillary blood oxygen saturation and clinical respiratory description must be recorded. The two must be consistent with oxygen need.
    • Statements such as the following, absent supporting information in relevant bullets above, are insufficient to justify Medicare payment for ambulance services:
      • Patient complained of shortness of breath.
      • History of stroke.
      • Past history of knee replacement.
      • Hypertension.
      • Chest pain.
      • Generalized weakness/pain.
      • Is bed-confined.
    • Coverage will not be allowed if the trip/run sheet contains an insufficient description of the patient's condition at the time of transfer for Medicare to reasonably determine that other means of transportation are contraindicated. Coverage will not be allowed if the description of the patient's condition is limited to conclusory statements or opinions, such as the following:
      • "Patient is non-ambulatory."
      • "Patient moved by drawsheet."
      • "Patient could only be moved by stretcher."
      • "Patient is unable to sit, stand or walk."
  4. Signatures, including credentials, from the person(s) responsible for the care of the beneficiary must be documented: Medicare requires that services provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in accordance with Medicare’s policies. The method used must be a handwritten or electronic signature. Stamped signatures are not acceptable. Information regarding signature requirements of the person(s) responsible for care may be found in IOM Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4. For information regarding the signature requirements on the “Physician Certification Statement (PCS)”, please refer to that section above. Note that additional information regarding beneficiary signature requirements related to ambulance services, may be found in IOM Pub.100-02, Medicare Benefit Policy Manual, Chapter 10, Section 20.1.2, and CFRs referenced in this policy.
    • If the signature is found to be illegible or missing from the medical documentation, a signature log or attestation statement to determine the identity of the author may be requested.
    • A signature log includes the typed or printed name and usual signature of the author associated with initials or an illegible signature.
    • An attestation statement is required when a signature is missing from the documentation; it must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary, date of service and be specific to the service documented.
    • Person(s) responsible for the care of the beneficiary should not add late signatures to the documentation.
  5. Point of pick-up/destination (identify place and complete address).
  6. For hospital-to-hospital transports, the trip/run sheet must clearly indicate the precise treatment or procedure (or medical specialist) that is available only at the receiving hospital. Non-specific or vague statements such as "needs cardiac care" or "needs higher level of care" are insufficient.
  7. Any additional available documentation that supports medical necessity of ambulance transport (for example, emergency room report, SNF record, End Stage Renal Disease (ESRD) facility record, hospital record).
  8. Dispatch record.
  9. Documentation supporting the number of loaded miles billed. See FAQ for Ambulance posted on Novitas website. Documentation may include odometer reading, trip odometer reading, GPS system, navigation computer, mapping programs and will need to be available if requested.

Utilization Guidelines

In accordance with CMS Ruling 95-1(V), utilization of these services should be consistent with locally acceptable standards of practice.

Most patients who require ambulance transportation have a short-term need due to an acute illness or injury. Longer term repetitive or frequent ambulance transportation is medically necessary for relatively few patients. Medicare expects that more than eight covered ambulance trips per year will rarely be medically necessary for an individual beneficiary and will cover no more than 12 ambulance trips per beneficiary per year without review of the patient’s medical record.

Notice: This LCD imposes utilization guideline limitations that support automated frequency denials. Despite Medicare's allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services.

Sources of Information


Other Contractor Local Coverage Determinations

“Ambulance Services (Ground Ambulance),” TrailBlazer LCD (04001 and 04002) L26738.

“Ambulance Services (Ground Ambulance),” TrailBlazer LCD (00400) L14259, (00900) L14294.

Other Contractor Policies

Contractor Medical Directors

Bibliography

N/A

Revision History Information

Revision History DateRevision History NumberRevision History ExplanationReasons for Change
01/01/2020 R11

LCD revised and published on 03/19/2020 effective for dates of service on and after 01/01/2020. The list of providers authorized to sign the PCS in the Documentation Guidelines has been replaced with the reference to the Code of Federal Regulations (CFR) regarding PCS requirements.

  • Other (Changes to the CFR)
11/14/2019 R10

LCD revised and published on 11/14/2019. Consistent with CMS Change Request 10901, the entire coding section has been removed from the LCD and placed into the related Billing and Coding Article, A54574. All CPT codes and coding information within the text of the LCD has been placed in the Billing and Coding Article.

  • Other (CMS Change Request 10901)
03/21/2019 R9

LCD revised and published on 3/21/2019 in response to Change Request 10901 to remove CPT and ICD-10 codes and national language that is contained in manuals and/or regulations. All coding information has been added to the Billing and Coding: Ambulance Services (Ground Ambulance), A54574.

There is no change to the coverage indications/limitations content with this revision.

  • Other (Changes in response to CMS change request)
07/16/2018 R8

LCD revised and published on 08/09/2018 effective for dates of service on and after 07/16/2018 to add information regarding ambulance transport coverage under Part B for a beneficiary who is a SNF resident in a stay not covered by Part A (reference CR 10550, TN 243 and TN 4021).

Per LCD annual review, updated the IOM citations and Federal Register References in the “CMS National Coverage Policy” section. Also made updates to documentation requirement #5 regarding signatures (reference TN 751, CR 10322).

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; therefore, not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
  • Other (LCD Annual Review)
03/16/2017 R7 LCD revised and published on 03/16/2017 effective for dates of service on and after 03/16/2017 to clarify documentation requirement #5 regarding signatures: Added an IOM reference for provider signatures and clarified that the existing IOM that was referenced pertains to beneficiary signatures related to ambulance services.
  • Other (Clarification)
01/01/2016 R6 LCD revised and published on 07/14/2016 effective for dates of service on and after 01/01/2016 to clarify language regarding emergency or non-emergency ambulance ground services in the CMS National Coverage Policy section and add references regarding death of a beneficiary and references regarding signatures.
  • Provider Education/Guidance
01/01/2016 R5 LCD revised and published on 02/19/2016 effective for dates of service on and after 01/01/2016 to reflect the annual CPT/HCPCS code updates. For the following CPT/HCPCS code, either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document: A0427.
  • Revisions Due To CPT/HCPCS Code Changes
10/01/2015 R4 LCD revised and posted for notice on 08/13/2015. Because DL32606 will become effective after implementation of ICD-10, the comment revisions have been incorporated into the ICD-10 LCD. The ICD-9 document, DL32606, will be retired on 9/30/2015 to coincide with implementation of ICD-10. Please note that this LCD version (R4) is identical to LCD version R3 except that the Jurisdiction L states have been added to this version. They were inadvertently omitted from Version R3.
  • Other (Other - Revised based on comments received for DL32606.)
10/01/2015 R3 LCD revised and posted for notice on 08/13/2015. Because DL32606 will become effective after implementation of ICD-10, the comment revisions have been incorporated into the ICD-10 LCD. The ICD-9 document, DL32606, will be retired on 9/30/2015 to coincide with implementation of ICD-10.
  • Other (Revised based on comments received for DL32606.)
10/01/2015 R2 LCD revised and published 7/10/2014 to correct typographical error in the Covered destinations for "non-emergency" transports section.
  • Typographical Error
10/01/2015 R1 LCD revised and published 7/10/2014 to clarify the statement "in which the patient is admitted" under PCS requirements.
  • Provider Education/Guidance

Associated Documents

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Related National Coverage Documents
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Public Versions
Updated On Effective Dates Status
05/13/2022 01/01/2020 - N/A Currently in Effect View
03/13/2020 01/01/2020 - N/A Superseded You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

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