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.