Ambulance Services

Affected Providers

Ambulance providers and suppliers.

HCPCS & CPT Codes

Ambulance Fee Schedule & ZIP Code Files and Medicare Claims Processing Manual, Chapter 15 have the current HCPCS and CPT codes.

Background

According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, the improper payment rate for ambulance services is 13.2%, with a projected improper payment amount of $595.1 million.

We cover ambulance services via ground and air transportation, including fixed-wing and rotary-wing ambulance services when Medicare patients shouldn’t use other means of transportation. For us to consider the billed service medically necessary, the patient’s condition requires both the ambulance transportation itself and the level of service provided.

Denial Reasons

Insufficient documentation accounted for 63.5% of improper payments for ambulance services during the 2024 reporting period, while medical necessity (27.5%), incorrect coding (1%), and other errors (8%) also caused improper payments. Other errors include duplicate payment, non-covered or unallowable service, or ineligible Medicare patient errors.

Preventing Denials of Emergency Ambulance Services

We require these conditions be met for patients to be eligible for ambulance services:

• Is transported by an approved ambulance service provider or supplier.
• Suffers from an illness or injury that contraindicates transportation by other means. Patients meet this requirement if you submit documentation to your Medicare Administrative Contractor indicating the patient met at least 1 of these conditions:
  • Was transported in an emergency (for example, an accident, injury, or acute illness)
  • Needed to be restrained to prevent injury to themselves or others
  • Required oxygen or other emergency treatment during transport to the nearest suitable facility
  • Was unconscious or in shock
  • Showed signs and symptoms of acute respiratory or cardiac distress (for example, shortness of breath or chest pain)
  • Showed signs and symptoms of a possible acute stroke
  • Needed to stay immobile because of a fracture that wasn’t set or to prevent a fracture
  • Experienced a severe hemorrhage
  • Could be moved only by stretcher
  • Was bed-confined before and after the ambulance trip

Preventing Denials of Non-Emergent Ambulance Services

Non-emergency transportation by ambulance is medically necessary if either:

• The patient is bed-confined, and it’s documented that their condition contraindicates other transportation methods
• The patient’s medical condition, regardless of bed confinement, requires ambulance transportation

42 CFR 410.40(e)(3) says we cover medically necessary non-emergency ambulance services that are either unscheduled or scheduled on a nonrepetitive basis under 1 of these circumstances:

• For a facility resident who’s under a physician’s care if the ambulance provider or supplier gets a physician certification statement within 48 hours after transport.
• For a patient residing at home or in a facility not under direct care of a physician, we don’t require physician certification.

For claims that require a certification statement:

• If you can’t get a signed physician certification statement from a patient’s attending physician, they must get a non-physician certification statement.
• If you can’t get a required physician or non-physician certification statement within 21 calendar days after the date of service, document that you tried to get the requested certification; then you can send the claim.
• In all cases, the provider or supplier must keep documentation on file and present it to their contractor when asked. The physician’s or non-physician’s certification statement or signed return receipt alone doesn’t show ambulance transport was medically necessary. We require you to meet all other program criteria for us to make payment.

We may use the physician certification statement and other documentation from the patient’s medical record to support a claim that transportation by ground ambulance is medically necessary. The physician certification statement and patient’s medical records must have a detailed explanation, consistent with the patient’s current medical condition, that the patient needs ambulance transport.

Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model

When you get prior authorization for repetitive, scheduled non-emergent ambulance transport (RSNAT) services, standard Medicare coverage rules apply.

The Medicare ambulance benefit for non-emergent transportation is very limited. It’s only for patients who clinically can’t be transported by other means. Under 42 CFR 410.40(e), we cover ambulance services for patients when:

• The medical condition is such that other means of transportation are a risk to health
• Both the ambulance transportation itself and the level of service provided (for the billed service) are considered medically necessary
• The transport is for a Medicare-covered service at a covered destination, or for return from a Medicare-covered service

Repetitive ambulance service is ambulance transportation you provide with 1 of the following:

• 3 or more round trips during a 10-day period
• At least 1 round trip per week for 3 weeks

The RSNAT Prior Authorization Model reduces services that don't follow Medicare policy while maintaining or improving quality of and access to care.

Special Rules for Non-Emergency, Scheduled, Repetitive Ambulance Services

42 CFR 410.40(e)(2) says we cover medically necessary non-emergency, scheduled, repetitive ambulance services if, before providing the service, the ambulance provider or supplier gets a physician certification statement dated no earlier than 60 days before the provided service date.

In all cases, the provider or supplier must keep documentation on file and present it to their contractor when asked. The physician’s certification statement alone doesn’t show that ambulance transport was medically necessary. We require you to meet all other criteria for us to make payment.

Signature Requirements for All Ambulance Services

For you to send a claim, 42 CFR 424.36(b)(1–6) requires the patient’s signature or the signature of someone authorized to sign the claim form on the patient’s behalf. If the patient can’t sign because of a mental or physical condition, these people may sign the claim form on their behalf:

• The patient’s legal guardian.
• A relative or other person who gets Social Security or other government benefits on the patient’s behalf.
• A relative or other person who arranges the patient’s treatment or has other responsibility for their affairs.
• A representative of an agency or institution that didn’t provide the claim’s service but provided other care, services, or help to the patient.
• A representative of the provider or non-participating hospital claiming payment for services it provided if the provider or non-participating hospital can’t get a patient or representative to sign the claim.
• Your representative who’s present during an emergency or non-emergency transport if you keep certain documentation in your records for at least 4 years from the date of service. You (or your employee) can’t ask for payment except under circumstances fully documented to show the patient can’t sign and there’s no one else to sign for them.

No Surprises Act

Division BB, Title 1, of the Consolidated Appropriations Act, 2021, also called the No Surprises Act, established new requirements for providers, facilities, and air ambulance service providers to protect consumers from surprise medical bills. The No Surprises Act states there’s no balance billing for covered air ambulance services by out-of-network air ambulance providers.