Monday, May 23, 2016

Importance of Origin and Milage in Ambulance billing - Where to report zip CODE box 23


Electronic billers should refer to the Implementation Guide to determine how to report the origin information (e.g., the ZIP Code of the point of pickup). Beginning with the early implementation of version 5010 of the ASC X12 837 professional claim format on January 1, 2011, electronic billers are required to submit, in addition to the loaded ambulance trip’s origin information (e.g., the ZIP Code of the point of pickup), the loaded ambulance trip’s destination information (e.g., the ZIP code of the point of drop-off). Refer to the appropriate Implementation Guide to determine how to report the destination information. Only the ZIP Code of the point of pickup will be used to adjudicate and price the ambulance claim, not the point of drop-off. However, the point of drop-off is an additional reporting requirement on version 5010 of the ASC X12 837 professional claim format.

Where the CMS-1500 Form is used the ZIP code is reported in item 23. Since the ZIP Code is used for pricing, more than one ambulance service may be reported on the same paper claim for a beneficiary if all points of pickup have the same ZIP Code. Suppliers must prepare a separate paper claim for each trip if the points of pickup are located in different ZIP Codes.

Claims without a ZIP Code in item 23 on the CMS-1500 Form item 23, or with multiple ZIP Codes in item 23, must be returned as unprocessable. A/B MACs (B) use message N53 on the remittance advice in conjunction with reason code 16.

ZIP Codes must be edited for validity.

The format for a ZIP Code is five numerics. If a nine-digit ZIP Code is submitted, the last four digits are ignored. If the data submitted in the required field does not match that format, the claim is rejected.


Generally, each ambulance trip will require two lines of coding, e.g., one line for the service and one line for the mileage. Suppliers who do not bill mileage would have one line of code for the service.

Beginning with dates of service on or after January 1, 2011, mileage billed must be reported as fractional units in the following situations:

• Where billing is by ASC X12 claims transaction (professional or institutional), and

• Where billing is by CMS-1500 paper form.

Electronic billers should see the appropriate Implementation Guide to determine where to report the fractional units. Item 24G of the Form CMS-1500 paper claim is used.

Fractional units are not required on Form CMS-1450

For trips totaling up to 100 covered miles suppliers must round the total miles up to the nearest tenth of a mile and report the resulting number with the appropriate HCPCS code for ambulance mileage. The decimal must be used in the appropriate place (e.g., 99.9).
For trips totaling 100 covered miles and greater, suppliers must report mileage rounded up to the next whole number mile without the use of a decimal (e.g., 998.5 miles should be reported as 999).

For trips totaling less than 1 mile, enter a “0” before the decimal (e.g., 0.9).

For mileage HCPCS billed on a the ASC X12 837 professional transaction or the CMS-1500 paper form only, contractors shall automatically default to “0.1” units when the total mileage units are missing.

Friday, May 20, 2016

Ambulance Services Requiring Medical Necessity

Medical necessity documentation (see Section 4100 of the General Special Requirements Provider Manual) must be attached to the claim form when billing for nonemergency transports, waiting time, multiple patients on one ambulance trip, and air ambulance transportation. When the beneficiary is Kansas Medical Assistance Program (KMAP) eligible plus qualified Medicare
beneficiary (QMB), and Medicare allows the service, medical necessity (MN) need not be attached to the claim. However, it must be available in the provider's file. The documentation must be printed and legible.

MN for nonemergency ambulance transportation must state the reason the trip is required (hospital discharge or medical service) and the medical reason the beneficiary could not be transported by car or van.

MN for air ambulance transportation must indicate the beneficiary's medical condition required immediate and rapid ambulance transportation that could not have been provided by land ambulance and one of the following:

** The point of pickup is inaccessible by land vehicle.

** Great distances or other obstacles are involved in getting the beneficiary to the nearest hospital with appropriate facilities.
** The beneficiary's condition is such that the time needed to transport by land, or the instability of transportation by land, poses a threat to the beneficiary's survival or seriously endangers the beneficiary's health.

If a determination is made that transport by ambulance was necessary, however, land ambulance service would have sufficed, payment for the air ambulance service will be the lesser of the billed charges and the maximum allowable for ground ambulance.

Wednesday, May 18, 2016

Ambulance CPT CODE FULL list


The following codes and definitions are effective for billing ambulance services on or after January 1, 2001.


HCPCS Code                                         Description of HCPCS Codes

A0425                    BLS mileage (per mile)

A0425                      ALS mileage (per mile)

A0426               Ambulance service, Advanced Life Support (ALS), non-emergency transport, Level 1

A0427              Ambulance service, ALS, emergency transport, Level 1

A0428        Ambulance service, Basic Life Support (BLS), non-emergency transport

A0429        Ambulance service, basic life support (BLS), emergency transport

A0430               Ambulance service, conventional air services, transport, one way, fixed wing (FW)

A0431             Ambulance service, conventional air services, transport, one way, rotary wing (RW)

A0432          Paramedic ALS intercept (PI), rural area transport furnished by a volunteer ambulance company,                                                       which is prohibited by state law from billing third party payers.

A0433            Ambulance service, advanced life support, level 2 (ALS2)

A0434             Ambulance service, specialty care transport (SCT)

A0435               Air mileage; FW, (per statute mile)

A0436            Air mileage; RW, (per statute mile)

NOTE: PI, ALS2, SCT, FW, and RW assume an emergency condition and do not require an emergency designator.

Sunday, May 15, 2016


When participants are transported by ambulance to an emergency room for treatment and then released without admission to the hospital, the return trip is not covered under the MO HealthNet Emergency Ambulance program. Return trips to the nursing home when the participant has been discharged from a hospital stay are also not covered under the Emergency Ambulance program, 13 CSR 70-6.010(6). Additional transports not covered in the Emergency Ambulance program include:

• transportation to a physician or dentist's office or a participant's home;

• ambulance services to a hospital for the first stage of labor; or,

• transport of a participant pronounced dead before the ambulance is called.

Transport by ambulance may be covered under the Non-Emergency Medical
Transportation (NEMT) program for eligible participants if it is the most appropriate mode of transportation based on the participant's medical needs. Hospital staff, nursing home staff, social workers, case managers, family members and other related parties
may call the NEMT broker for MO HealthNet toll free at 1-866-269-5927 to arrange nonemergency medical transportation to and from medical providers for eligible participants. NEMT services are available 24 hours per day, 7 days per week. To provide adequate time for NEMT services to be arranged, a participant or someone calling on their behalf should call at least five (5) calendar days in advance. For hospital discharges it may require up to three (3) hours to arrange the appropriate mode of transportation.

Neither the participant nor MO HealthNet is responsible for payment if physicians, hospital staff, or others arrange ambulance transports for non-emergency trips that are covered under the NEMT program without authorization from the NEMT broker.

Missouri Code of State Regulations 13 CSR 70-4.030 (2) states a "service will not be the liability of the participant if the service would have been otherwise payable by the MO HealthNet agency at the MO HealthNet allowable amount had the provider followed all of the policies, procedures and rules applicable to the service as of the date provided."

The NEMT broker provides the most appropriate mode of transportation based on the patient's medical needs. If a patient is confined to a bed but does not require anymedical equipment or medical attention en route, a stretcher van may be authorized. If the patient required medical attention or equipment en route, an ambulance will be authorized. When arranging non-emergency medical transportation, notify the NEMT broker if the patient is bed confined and whether or not medical attention or equipment is needed. For more information on the NEMT program and all modes of transportation under NEMT, please refer to section 22 of any MO HealthNet provider manual located on the MHD web site.

Friday, May 13, 2016

Payment for Non-Emergency Trips to/from ESRD Facilities - CPT code A0428

Effective for transports occurring on and after October 1, 2013, fee schedule payments for non-emergency basic life support (BLS) transports of individuals with end-stage renal disease (ESRD) to and from renal dialysis treatment be reduced by 10%. The payment reduction affects transports (base rate and mileage) to and from hospital-based and freestanding renal dialysis treatment facilities for dialysis services provided on a non-emergency basis. Non-emergency BLS ground transports are identified by Healthcare Common Procedure Code System (HCPCS) code A0428. Ambulance transports to and from renal dialysis treatment are identified by modifier codes “G” (hospital-based ESRD) and “J” (freestanding ESRD facility) in either the first position (origin code) or second position (destination code) within the two-digit ambulance modifier. (See Section 30 (A) for information regarding modifiers specific to ambulance.)

Effective for claims with dates of service on and after October 1, 2013, the 10% reduction will be calculated and applied to HCPCS code A0428 when billed with modifier code “G” or “J”. The reduction will also be applied to any mileage billed in association with a non-emergency transport of a beneficiary with ESRD to and from renal dialysis treatment. BLS mileage is identified by HCPCS code


The 10% reduction will be taken after calculation of the normal fee schedule payment amount, including any add-on or bonus payments, and will apply to transports in rural and urban areas as well as areas designated as “super rural”.

Payment for emergency transports is not affected by this reduction. Payment for non-emergency BLS transports to other destinations is also not affected. This reduction does not affect or change the Ambulance Fee Schedule.

Note: The 10% reduction applies to beneficiaries with ESRD that are receiving non-emergency BLS transport to and from renal dialysis treatment. While it is possible that a beneficiary who is not diagnosed with ESRD will require routine transport to and from renal dialysis treatment, it is highly unlikely. However, contractors have discretion to override or reverse the reduction on appeal if they deem it appropriate based on supporting documentation.

Tuesday, May 10, 2016

Ambulance billing covered CPT Codes and how much copay would be collected - Medicaid patient


KMAP beneficiaries will be assigned to one or more benefit plans. These benefit plans entitle the beneficiary to certain services. If there are questions about service coverage for a given benefit plan, refer to Section 2000 of the General Benefits Provider Manual for information on the plastic State of Kansas Medical Card and eligibility verification.

For example, only the following emergency transportation procedure codes are covered under the MediKan program. See Appendix I of the Ambulance Provider Manual for a full listing description of services.

A0225               A0380                A0390                A0427                 A0429                          A0430
A0431              A0433                 A0434               A0435                  A0436

Covered Services

** Emergency ambulance transportation provided by Basic Life Support (BLS)/Advanced Life Support (ALS) services

** Nonemergency ambulance transportation with the exception of adult care home residents (see page 8-4) for the following:

o Discharge from hospital to residence or other less expensive care

o Trips from residence to closest available medically necessary services

o Trips from one institution to another to receive a medical service not available in the first institution

** Supplies

** Waiting Time


Nonemergency ambulance transportation requires a copayment from the beneficiary of $3 per date of service. When procedure A0426 or A0428 is billed in conjunction with one of the other nonemergency procedure codes (such as S0215) for the same dates of services, copayment will be collected from the beneficiary only once.

Bill all services occurring on the same date on the same claim form. If multiple claims are submitted for the same date(s) of service, the $3 copayment requirement will be deducted for each claim submitted. Do not reduce the charges or balance due by the copayment amount. This reduction will be made automatically during claim processing.

Sunday, May 8, 2016

Ambulance Inflation Factor (AIF)

Section 1834(l)(3)(B) of the Social Security Act (the Act) provides the basis for an update to the payment limits for ambulance services that is equal to the percentage increase in the consumer price index for all urban consumers (CPI-U) for the 12-month period ending with June of the previous year. Section 3401 of the Affordable Care Act amended Section 1834(l)(3) of the Act to apply a productivity adjustment to this update equal to the 10-year moving average of changes in economy-wide private nonfarm business multi-factor productivity beginning January 1, 2011. The resulting update percentage is referred to as the Ambulance Inflation Factor (AIF). These updated percentages are issued via Recurring Update Notifications.

Part B coinsurance and deductible requirements apply to payments under the ambulance fee schedule.

Following is a chart tracking the history of the AIF:

CY       AIF
2003    1.1
2004    2.1
2005    3.3
2006    2.5
2007    4.3
2008    2.7
2009    5.0
2010    0.0
2011    -0.1
2012    2.4
2013    0.8
2014    1.0
2015    1.5
2016   -0.4

Documentation Requirements

In all cases, the appropriate documentation must be kept on file and, upon request, presented to the contractor. It is important to note that the presence (or absence) of a physician’s order for a transport by ambulance does not necessarily prove (or disprove) whether the transport was medically necessary. The ambulance service must meet all program coverage criteria in order for payment to be made.