Friday, November 18, 2016

Medicare Payment for Ambulance Services Furnished by Certain CAHs



Medically necessary ambulance services furnished for dates of service on or after December 21, 2000 and prior to January 1, 2004, by a CAH or by an entity that is owned and operated by the CAH are paid based on 100 percent of the reasonable costs if the 35 mile rule for reasonable cost-based payment is met.

For dates of service on or after January 1, 2004, medically necessary ambulance services furnished by a CAH or by an entity that is owned and operated by the CAH are paid based on 101 percent of the reasonable costs if the 35 mile rule for reasonable cost-based payment is met.

For dates of service on or after December 21, 2000 and prior to October 1, 2011, in order for the 35 mile rule to be met, the CAH or the entity that is owned and operated by the CAH, must be the only provider or supplier of ambulance services located within a 35 mile drive of the CAH or the entity.

For dates of service on or after October 1, 2011, in order for the 35 mile rule to be met, the CAH or the entity that is owned and operated by the CAH, must be the only provider or supplier of ambulance services located within a 35 mile drive of the CAH. Additionally, if there is no provider or supplier of ambulance services located within a 35 mile drive of the CAH but there is an entity owned and operated by the CAH located more than a 35 mile drive from the CAH, that CAH-owned and operated entity can only be paid 101 percent of reasonable costs for its ambulance services if it is the closest provider or supplier of ambulance services to the CAH.

Section 205 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000 exempts certain CAHs from the current Medicare ambulance cost per trip payment limit as well as from the ambulance fee schedule. Section 205(a) of BIPA states:

The Secretary shall pay the reasonable costs incurred in furnishing ambulance services if such services are furnished (A) by a CAH (as defined in §1861(mm)(1)), or (B) by an entity that is owned and operated by a CAH, but only if the CAH or entity is the only provider or supplier of ambulance services that is located within a 35-mile drive of such CAH.

Those CAHs and CAH-owned and operated entities that meet the 35 mile rule for reasonable cost-based payment shall report condition code B2 (CAH ambulance attestation) on their bills.

When the 35 mile rule for reasonable cost-based payment is not met, the CAH ambulance service or the ambulance service furnished by the entity that is owned and operated by the CAH, is paid based on the ambulance fee schedule.

Wednesday, November 9, 2016

Billing for Nuclear Medicine Procedures C9898




Beginning January 1, 2008, the I/OCE began editing for the presence of a radiolabeled product when a separately payable nuclear medicine procedure is present on a claim.

Hospitals should include radiolabeled product HCPCS codes on the same claim as a nuclear medicine procedure beginning on January 1, 2008.

Hospitals are required to submit the HCPCS code for the radiolabeled product on the same claim as the HCPCS code for the nuclear medicine procedure. Hospitals are also instructed to submit the claim so that the services on the claim each reflect the date the particular service was provided. Therefore, if the nuclear medicine procedure is provided on a different date of service from the radiolabeled product, the claim will contain more than one date of service. More information regarding these edits is available on the OPPS Web site at http://www.cms.hhs.gov/HospitalOutpatientPPS/.

Hospitals are instructed to use HCPCS code C9898 (Radiolabeled product provided during a hospital inpatient stay) on outpatient claims for nuclear medicine procedures to indicate that a radiolabeled product that provides the radioactivity necessary for the reported diagnostic nuclear medicine procedure was provided during a hospital inpatient stay. This HCPCS code is assigned status indicator “N” because no separate payment is made for the code under the OPPS. The effective date of the code is January 1, 2008, the date the nuclear medicine procedure-to-radiolabeled product edits were initially implemented. Because the Medicare claims processing system requires that there be a charge for each HCPCS code reported on the claim, hospitals should always report a token charge of less than $1.01 for HCPCS code C9898. The date of service reported on the claim for HCPCS code C9898 should be the same as the date of service for the nuclear medicine procedure HCPCS code, which should always accompany the reporting of HCPCS code C9898. HCPCS code C9898 should never be reported on a claim without a diagnostic nuclear medicine procedure that is subject to the nuclear medicine procedure-to-radiolabeled product edits.

More information regarding these edits is available on the OPPS Web site at http://www.cms.hhs.gov/HospitalOutpatientPPS
Future updates to this section will be communicated in a Recurring Update Notification.

Friday, October 21, 2016

Ground Ambulance Procedure code A0425, A0427, A0428, A0433

Bill Type Codes for Ambulance Service (Ground Ambulance)

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 policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

11x Hospital Inpatient (Including Medicare Part A)
12x Hospital Inpatient (Medicare Part B only)
13x Hospital Outpatient
22x Skilled Nursing - Inpatient (Medicare Part B only)
23x Skilled Nursing - Outpatient
83x Ambulatory Surgery Center
85x Critical Access Hospital

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 policy 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 policy should be assumed to apply equally to all Revenue Codes.

Note: The contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM), Publication 100-04, Claims Processing Manual, for further guidance.

0540 Ambulance - General Classification
0541 Ambulance - Supplies
0542 Ambulance - Medical Transport
0543 Ambulance - Heart Mobile
0544 Ambulance - Oxygen
0545 Ambulance - Air Ambulance
0546 Ambulance - Neonatal Ambulance Services
0547 Ambulance - Pharmacy
0548 Ambulance - EKG Transmission
0549 Ambulance - Other Ambulance

CPT/HCPCS Codes


Group 1 Paragraph

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.


A0425 Ground mileage

A0426 Als 1

A0427 ALS1-emergency

A0428 bls

A0429 BLS-emergency

A0433 als 2

A0434 Specialty care transport

A0999 Unlisted ambulance service


A0888 Noncovered ambulance mileage
ICD-9 Codes that Support Medical Necessity


Group 1 Paragraph : Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

Medical necessity and coverage of ambulance services are not based solely on the presence of a specific diagnosis. Medicare payment for ambulance transportation may be made only for those patients whose condition at the time of transport is such that ambulance transportation is necessary. For example, it is insufficient that a patient merely has a diagnosis such as pneumonia, stroke or fracture to justify ambulance transportation. In each of those instances, the condition of the patient must be such that transportation by any other means is medically contraindicated. In the case of ambulance transportation, the condition necessitating transportation is often that an accident or injury has occurred giving rise to a clinical suspicion that a specific condition exists (for instance, fractures may be strongly suspected based on clinical examination and history of a specific injury).

It is the provider’s responsibility to supply the contractor with information describing the condition of the patient that necessitated ambulance transportation. Medicare recognizes limitations of usual ambulance personnel for establishing a diagnosis and recognizes, therefore, that diagnosis coding of a patient’s condition using ICD-9-CM codes when reporting ambulance services may be less specific than for services reported by other professional providers. Providers who submit diagnosis codes should choose the code that best describes the patient’s condition at the time of transport. As a reminder to providers of ambulance services, “rule out” or “suspected” diagnoses should not be reported using specific codes. In such instances where a diagnosis is not confirmed, it is more correct to use a symptom, finding or injury code.

Reporting ambulance services using a code from the list below certifies to Medicare that the ambulance provider believes the code description reasonably reflects the condition of the patient at the time of transport and that the patient’s condition was consistent with the requirements of the Medicare ambulance transportation benefit.

The contractor recognizes that ambulance suppliers are currently not required to submit diagnosis codes on their claims if filing on a 1500 claim form or utilizing an electronic version other than the 5010 version of the 837P, though their doing so facilitates timely claim adjudication. The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. Claims without a diagnosis code from below will be adjudicated manually utilizing the information contained in the claim’s narrative field and/or medical records (the trip report and any other records supplied to Medicare by the provider upon our request). Ambulance suppliers utilizing the 5010 version of the 837P are required to submit diagnosis code(s).

Due to the large number of possible covered diagnosis codes, the Contractor is not providing a comprehensive list of covered diagnosis codes for HCPCS codes A0425, A0426, A0427, A0428, A0429, A0433 and A0434.

All ambulance transports require dual diagnosis codes as described below.

Providers should report the most appropriate ICD-9-CM code that adequately describes the patient's medical condition (for example: stroke, coma, trauma, etc.) at the time of transport as the primary diagnosis. In addition, a secondary diagnosis, from the list below, must be reported.

Additionally, the KX modifier must be reported on the claim for the service to be considered for coverage. Reporting of the KX modifier is an attestation from the provider that the services are reasonable and necessary and that there is documentation of medical necessity in the patient's record. The KX modifier should not be reported if the patient's condition does not require an ambul

Group 1 Codes

V46.11 DEPENDENCE ON RESPIRATOR, STATUS
V46.9* UNSPECIFIED MACHINE DEPENDENCE
V49.84 BED CONFINEMENT STATUS
V49.87* PHYSICAL RESTRAINTS STATUS
V71.9* OBSERVATION FOR UNSPECIFIED SUSPECTED CONDITION

Note: Use code V46.11 to denote ventilator dependency transport ONLY.

Note: Use code V46.9 to denote the need for continuous IV fluids, 'active airway management' or the need for multiple machine devices.

Note: Use code V49.87 to denote patient safety: danger to self and others - monitoring other and unspecified reactive psychosis.

Note: Use code V71.9 to denote the need for continuous clinical assessment throughout the transport.
ICD-9 Codes that DO NOT Support Medical Necessity
Note: V68.61 should be reported for those patients who were transported by ambulance but did NOT require the services of an ambulance crew.

V68.81 REFERRAL OF PATIENT WITHOUT EXAMINATION OR TREATMENT

Tuesday, August 30, 2016

CMS Supplied National ZIP Code File and National Ambulance Fee Schedule File



CMS will provide each contractor with two files: a national ZIP Code file and a national Ambulance FS file.

A. The national ZIP5 Code file is a file of 5-digit USPS ZIP Codes that will map each ZIP Code to the appropriate FS locality. Every 2 months, CMS obtains an updated listing of ZIP Codes from the USPS. On the basis of the updated USPS file, CMS updates the Medicare ZIP Code file and makes it available to contractors.


The following is a record layout of the ZIP5 file effective January 1, 2009


ZIP5 CODE to LOCALITY RECORD LAYOUT


Field Name           Position         Format         COBOL Description

State                 1-2               X(02)        Alpha State Code

ZIP Code             3-7          X(05)                 Postal ZIP Code

Carrier                     8-12          X(05)           Medicare Part B Carrier Number

Pricing Locality       13-14             X(02)              Pricing Locality

Rural Indicator             15               X(01)                  Effective 1/1/07 Blank = urban,                                                                                                                                         R =rural, B=super rural

Beneficiary Lab CB Locality         16-17             X(02)                 Lab competitive bid locality;
                          Z1= CBA1
                                    Z2= CBA2
                  Z9= Not a demonstration locality

Rural Indicator 2        18                   X(01)               What was effective 12/1/06 Blank=urban, R=rural,                                                                                                                                    B =super rural

Filler                19-20              X(02)

Plus Four Flag                  21              X(01)              0 = no +4 extension
                                                                 1 = +4 extension

Filler                22-75           X(54)      

Year/Quarter              76-80           X(05)                YYYYQ



NOTE: Effective October 1, 2007, claims for ambulance services will continue to be submitted and priced using 5-digit ZIP Codes. Contractors will not need to make use of the ZIP9 file for ambulance claims.


Beginning in 2009, contractors shall maintain separate ZIP Code files for each year which will be updated on a quarterly basis. Claims shall be processed using the correct ZIP Code file based on the date of service submitted on the claim.


A ZIP Code located in a rural area will be identified with either a letter “R” or a letter “B.” Some ZIP Codes will be designated as rural due to the Rural Urban Commuting Area (RUCA) Score even though the ZIP Code may be located, in whole or in part, within an MSA or Core Based Statistical Area (CBSA).

A“B” designation indicates that the ZIP Code is in a rural county (or RUCA area) that is comprised by the lowest quartile by population of all such rural areas arrayed by population density. Effective for claims with dates of service between July 1, 2004 and December 31, 2010, contractors must apply a bonus amount to be determined by CMS to the base rate portion of the payment under the FS for ground ambulance services with a POP “B” ZIP Code. This amount is in addition to the rural bonus amount applied to ground mileage for ground transports originating in a rural POP ZIP Code.

Each calendar quarter beginning October 2007, CMS will upload updated ZIP5 and ZIP9 ZIP Code files to the Direct Connect (formerly the Network Data Mover). Contractors shall make use of the ZIP5 file for ambulance claims and the ZIP9 file as appropriate per IOM Pub. 100-04, Medicare Claims Processing Manual, chapter 1 –General Billing Requirements , section 10.1.1.1 - Payment Jurisdiction Among Local Carriers for Services Paid Under the Physician Fee Schedule and Anesthesia Services and the additional information found in Transmittal 1193, Change Request 5208, issued March 9, 2007. The updated files will be available for downloading on approximately November 15th for the January 1 release, approximately February 15th for the April 1 release, approximately May 15th for the July 1 release, and approximately August 15th for the October 1 release.



1. Upon quarterly Change Requests communicating the availability of updated ZIP Code files, go to the Direct Connect and search for the files. Confirm that the release number (last 5 digits) corresponds to the upcoming calendar quarter. If the release number (last 5 digits) does not correspond to the upcoming calendar quarter, notify CMS.

2. After confirming that the ZIP Code files on the Direct Connect corresponds to the next calendar quarter, download the files and incorporate the files into your testing regime for the upcoming model release.

The names of the files will be in the following format: MU00.AAA2390.ZIP5.LOCALITY.Vyyyyr and MU00.AAA2390.ZIP9.LOCALITY.Vyyyyr where “yyyy” equals the calendar year and “r” equals the release number with January =1, April =2, July =3, and October =4. So, for example, the names of the file updates for October 2007 are MU00.AAA2390.ZIP5.LOCALITY.V20074 and MU00.AAA2390.ZIP9.LOCALITY.V20074. The release number for this file is 20074, release 4 for the year 2007.

When the updated files are loaded to the Direct Connect, they will overlay the previous ZIP Code files.

Friday, August 26, 2016

Payment Guideline for multiple ambulance usage

Jurisdiction of the claim is based on whether only one ambulance vehicle or multiple vehicles were used.

A. One Ambulance Vehicle Used

If only one vehicle is used to transport the patient from the point of initial pickup to the final destination, jurisdiction is with the carrier serving the point of origin, i.e., home station of the vehicle. This carrier has qualification information on the ambulance supplier and in most cases all other pertinent details necessary to adjudicate a claim.

EXAMPLE: A patient is picked up at the Johns Hopkins Hospital in Baltimore, Maryland and transported to his home in West Virginia by an ambulance dispatched from the area of the patient’s home. The carrier serving the point of origin of the ambulance, Nationwide Mutual Insurance Company, Part B carrier for the State of West Virginia, has jurisdiction of any claim filed. In this case Nationwide should have all the data necessary to make proper payment, i.e., certification of the ambulance company, price information and data pertaining to the nearest appropriate company, price information and data pertaining to the nearest appropriate facility. Had an ambulance whose home station was in Baltimore been used, the carrier servicing Baltimore, Maryland would have had jurisdiction. The Baltimore carrier would then have had
to obtain data concerning the nearest appropriate facility to the patient’s home from Nationwide


B. More Than One Vehicle Used

If more than one vehicle is used in transporting the patient to their destination, jurisdiction of the claim lies with:

• The carrier serving the home base of the ambulance taking the patient on the first leg of the trip, on a trip to a distant institution more remote than the nearest appropriate facility; or

• The carrier serving the home base of the ambulance taking the patient on the final leg of the trip home, on a trip from an institution more remote than the nearest appropriate facility.

• If there is no claim for the final leg of the trip, the carrier serving the patient’s home area handles any resulting claims or disallowance actions.

EXAMPLE: A patient is transported by ambulance from a hospital in Miami Beach, Florida to Miami International Airport and from there by air ambulance to LaGuardia Airport in Queens, New York City. At the airport he is picked up by an ambulance (based in Yonkers, New York) and taken to his home in Yonkers, New York. The carrier that handles the adjudication is the carrier whose area of responsibility includes Yonkers, New York, since partial reimbursement is based upon the nearest appropriate facility to his residence when he is being returned home from a distant institution.

In rules A and B above, the principle followed is that the carrier having the information to determine the “nearest appropriate facility” is the one to adjudicate the claim. In any event, before any partial reimbursement can be made, the carriers as designated in rules A and B, must have all the information concerning the patient’s transportation, from initial pickup to final destination.

Tuesday, August 23, 2016

Definition - What is Emergency, Medical necessity

DEFINITIONS

Emergency - A serious medical condition or symptom resulting from Injury, Sickness or [1Mental Illness][2mental illness] which is both of the following:

• Arises suddenly

• In the judgment of a reasonable person, requires immediate care and treatment, generally received within 24 hours of onset, to avoid jeopardy to life or health

Medically Necessary (UHIC 2011 COC) - health care services provided for the purpose of preventing, evaluating, diagnosing or treating a Sickness, Injury, [Mental Illness,] [mental illness,] substance use disorder, condition, disease or its symptoms, that are all of the following as determined by us or our designee, within our sole discretion.

• In accordance with Generally Accepted Standards of Medical Practice

• Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for your Sickness, Injury, [Mental Illness,] [mental illness,] substance use disorder, disease or its symptoms

• Not mainly for your convenience or that of your doctor or other health care providerNot more costly than an alternative drug, service(s) or supply that is at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of your Sickness, Injury, disease or symptoms


Generally Accepted Standards of Medical Practice are standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, relying primarily on controlled clinical trials, or, if not available, observational studies from more than one institution that suggest a causal relationship between the service or treatment and health outcomes.

If no credible scientific evidence is available, then standards that are based on Physician specialty society recommendations or professional standards of care may be considered. We reserve the right to consult expert opinion in determining whether health care services are Medically Necessary. The decision to apply Physician specialty society recommendations, the choice of expert and the determination of when to use any such expert opinion, shall be within our sole discretion.


We develop and maintain clinical policies that describe the Generally Accepted Standards of Medical Practice scientific evidence, prevailing medical standards and clinical guidelines supporting our determinations regarding specific services. These clinical policies (as developed by us and revised from time to time), are available to Covered Persons on [myuhc.com] or by calling Customer Care at the telephone number on your ID card, and to Physicians and other health care professionals on UnitedHealthcareOnline.

Saturday, August 20, 2016

What are situation ambulance service will not be paid ?

Coverage Limitations and Exclusions

The following services are not eligible for coverage:

1. Ambulance services from providers that are not properly licensed to be performing the ambulance services rendered.

2. Air ambulance that does not meet the covered indications in the Air Ambulance criteria listed above.

3. Non-ambulance transportation. Non-ambulance transportation is not covered even if rendered in an Emergency situation. Examples include but are not limited to commercial or private airline or helicopter, a police car ride to a hospital, medi-van transportation, wheel-chair van, taxi ride, bus ride, etc.

4. Ambulance transportation when other mode of transportation is appropriate. Except as indicated under the Indications for Coverage section of this policy, ambulance services when transportation by other means would not endanger the enrollee’s health, are not covered.

5. Ambulance transportation to a home, residential, domiciliary or custodial facility is not covered.

6. Ambulance transportation that violates the notification criteria listed in the Indications for Coverage section above.

7. Ambulance transportation for patient convenience or other miscellaneous reasons for patient and/or family. Examples include but are not limited to:

a. Patient wants to be at a certain hospital or facility for personal/preference reasons;

b. Patient is in foreign country, or out of state, wants to come home to for a surgical procedure or treatment (this includes those recently discharged from inpatient care);

c. Patient is going to a routine service and is medically able to use another mode of transportation but can’t find it;

d. Patient is deceased (ie, transportation to the coroner’s office or mortuary)

8. Ambulance transportation deemed not appropriate. Examples include but are not limited to:


a. Hospital to home

b. Home to physician’s office

c. Home (eg. residence, nursing home, domiciliary or custodial facility) to a hospital for a scheduled service


Additional Information:

• If the patient is at a Skilled Nursing Facility/Inpatient Rehabilitation Facility and has met the annual day/visit limit on Skilled Nursing Facility/Inpatient Rehabilitation Facility Services, ambulance transports (during the non-covered days) are not eligible.

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