Monday, July 25, 2016

CPT code A0431 and A0430

CPT A0431

A0431 its a HCPCS code. Ambulance service, conventional air services, transport, one way (rotary wing) (RW).

The Healthcare Common Prodecure Coding System (HCPCS) is a collection of codes that represent procedures, supplies, produts and services which may be provided to Medicare beneficiaries and to indivisuals enrolled in private health insurance programs. 

Rotary wing air ambulance is furnished when the beneficiary's medical condition is such that transport by ground ambulance, in whole or in part, is not appropriate. Generally, transport by rotary wing air ambulance may be necessary because the beneficiary's condition requires rapid transport to a treatment facility, and either great distances or other obstacles, e.g., heavy traffic, preclude such rapid delivery to the nearest appropriate facility. Transport by rotary wing air ambulance may also be necessary because the beneficiary is inaccessible by a land or water ambulance vehicle.


Emergency Fix Wing Air Ambulance (A0430) and Emergency Rotary Air Ambulance (A0431) 

Emergency Air Ambulance rate calculation: 

1. “Both Fixed Wing and Rotary Air Ambulance claims will paid using the following State Plan rates:

 a. Mile “1” = $586.00 Additional Miles = $13.00 

 Example: Trip was for 83 loaded miles. First (1) mile = $ 586.00 82 miles x $13.00 = $1,066.00 Total charge $1,652.00



2. For your convenience an Emergency Air Ambulance State Plan rate table is listed on page 4. The rate table is calculated up to 200 miles. DO NOT use rate table for trips over 200 miles. You would be adding in the base rate twice. Trips over 200 miles can be calculated by adding the rate of $3,173.00 for 200 miles plus $13.00 per mile over 200. 

Note: All claims must have attachments that include ambulance Pre-hospital Patient Care Report (PPCR) that establish medical necessity for emergency ground service. Beginning and ending mileage must be included on PPCR. 

Saturday, July 23, 2016

Indian Health Service (IHS)/Tribal Billing


Ambulance services furnished by IHS/Tribal hospitals including Critical Access Hospitals (CAHs) will be paid according to the appropriate payment methodology.

For dates of service on or after December 21, 2000 and prior to January 1, 2004, medically necessary ambulance services furnished by an IHS/Tribal CAH or by an entity that is owned and operated by an IHS/Tribal CAH are paid based on 100 percent of the reasonable cost if the 35 mile rule for cost-based payment is met. In order for the 35 mile rule to be met, the IHS/Tribal CAH or the entity that is owned and operated by the IHS/Tribal CAH, must be the only provider or supplier of ambulance services that is located within a 35 mile drive of the IHS/Tribal CAH or the entity. Those CAHs that meet the 35 mile rule for cost-based payment shall report condition code B2 (CAH ambulance attestation) on their bills.

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

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

Other IHS/Tribal hospital based ambulance services are reimbursed based on the ambulance fee schedule.


Wednesday, July 20, 2016

Limitation of payment on Ambulance services

Limitations

** The medical condition of the beneficiary must necessitate ambulance transportation.

Emergency situations in which services are performed after the providers response to the onset of a medical condition manifested by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in one of the following:

o Place the beneficiary's health in serious jeopardy

o Seriously impair bodily functions; or

o Result in serious dysfunction of any bodily organ or part


** Trips that could have been scheduled are not considered emergencies.

Nonemergency transportation when the beneficiary's condition is such that a car or van cannot be used, e.g.:

o Beneficiary unconscious

o Beneficiary cannot sit up

o Oxygen or other life support required

o Extreme obesity or position of cast(s)

o Restraints required



Ambulance transportation for a deceased person is covered only if the person was pronounced dead while enroute to or upon arrival at destination. If the person was pronounced dead after the ambulance was called, but before pickup, the service to the point of pickup is covered. When an ambulance responds to a 911 call that is determined upon patient assessment to be nonemergent and the patient is transported, the ambulance provider must bill one of the nonemergency ambulance transportation procedure codes.
Emergency 911 calls that do not result in transporting the patient are not covered and may be billed to the patient.

Friday, July 15, 2016

Basics of Air Ambulance billing

Air Ambulance Services

1. Base Rates

Each type of air ambulance service has a base rate. There is no conversion factor (CF) applicable to air ambulance services.


2. Geographic Adjustment Factor (GAF)

The GAF, as described above for ground ambulance services, is also used for air ambulance services. However, for air ambulance services, the applicable GPCI is applied to 50 percent of each of the base rates (fixed and rotary wing).


3. Mileage

The FS for air ambulance services provides a separate payment for mileage.


4. Adjustment for Services Furnished in Rural Areas

The payment rates for air ambulance services where the POP is in a rural area are greater than in an urban area. For air ambulance services (fixed or rotary wing), the rural adjustment is an increase of 50 percent to the unadjusted FS amount, e.g., the applicable air service base rate multiplied by the GAF plus the mileage amount or, in other words, 1.5 times both the applicable air service base rate and the total mileage amount.

The basis for a rural adjustment for air ambulance services is determined in the same manner as for ground services. That is, whether the POP is within a rural ZIP Code as described above for ground services.

Sunday, July 10, 2016

Components of the Ambulance Fee Schedule - Part 2

   
5. Adjustment for Certain Ground Mileage for Rural Points of Pickup (POP)

The payment rate is greater for certain mileage where the POP is in a rural area to account for the higher costs per ambulance trip that are typical of rural operations where fewer trips are made in any given period.

Ambulance billing definiton

If the POP is a rural ZIP Code, the following calculations should be used to determine the rural adjustment portion of the payment allowance. For loaded miles 1-17, the rural adjustment for ground mileage is 1.5 times the rural mileage allowance.

For services furnished during the period July 1, 2004 through December 31, 2008, a 25 percent increase is applied to the appropriate ambulance FS mileage rate to each mile of a transport (both urban and rural POP) that exceeds 50 miles (i.e., mile 51 and greater).


The following chart summarizes the above information:

Service                        Dates of Service          Bonus                    Calculation


Loaded miles 1-17, Rural POP           Beginning 4/1/02            50%         FS Rural mileage * 1.5

Loaded miles 18-50, Rural POP          4/1/02 – 12/31/03         25%          FS Rural mileage * 1.25

All loaded miles                       7/1/04 – 12/31/08          25%        FS Urban or Rural

(Urban or Rural POP) 51+                                   mileage * 1.25



The POP, as identified by ZIP Code, establishes whether a rural adjustment applies to a particular service. Each leg of a multi-leg transport is separately evaluated for a rural adjustment application. Thus, for the second (or any subsequent) leg of a transport, the ZIP Code of the POP establishes whether a rural adjustment applies to such second (or subsequent) transport.

For the purpose of all categories of ground ambulance services except paramedic intercept, a rural area is defined as a U.S. Postal Service (USPS) ZIP Code that is located, in whole or in part, outside of either a Metropolitan Statistical Area (MSA) or in New England, a New England County Metropolitan Area (NECMA), or is an area wholly within an MSA or NECMA that has been identified as rural under the “Goldsmith modification.” (The Goldsmith modification establishes an operational definition of rural areas within large counties that contain one or more metropolitan areas. The Goldsmith areas are so isolated by distance or physical features that they are more rural than urban in character and lack easy geographic access to health services.)

For Paramedic Intercept, an area is a rural area if:

• It is designated as a rural area by any law or regulation of a State;

• It is located outside of an MSA or NECMA; or

• It is located in a rural census tract of an MSA as determined under the most recent Goldsmith modification.

http://www.ambulancebillingtips.com/2010/10/ambulance-billing-abbreviation-term.html Ambulance Services, section 30.1.1 – Ground Ambulance Services for coverage requirements for the Paramedic Intercept benefit. Presently, only the State of New York meets these requirements.

Although a transport with a POP located in a rural area is subject to a rural adjustment for mileage, Medicare still pays the lesser of the billed charge or the applicable FS amount for mileage. Thus, when rural mileage is involved, the contractor compares the calculated FS rural mileage payment rate to the provider’s/supplier’s actual charge for mileage and pays the lesser amount.

The CMS furnishes the ambulance FS files to claims processing contractors electronically. A version of the Ambulance Fee Schedule is also posted to the CMS website (http://www.cms.hhs.gov/AmbulanceFeeSchedule/02_afspuf.asp) for public consumption. To clarify whether a particular ZIP Code is rural or urban, please refer to the most recent version of the Medicare supplied ZIP Code file.



6. Regional Ambulance FS Payment Rate Floor for Ground Ambulance Transports

For services furnished during the period July 1, 2004 through December 31, 2009, the base rate portion of the payment under the ambulance FS for ground ambulance transports is subject to a minimum amount. This minimum amount depends upon the area of the country in which the service is furnished. The country is divided into 9 census divisions and each of the census divisions has a regional FS that is constructed using the same methodology as the national FS. Where the regional FS is greater than the national FS, the base rates for ground ambulance transports are determined by a blend of the national rate and the regional rate in accordance with the following schedule:


Year        National FS Percentage     Regional FS Percentage

7/1/04 - 12/31/04           20%               80%

CY 2005                  40%                     60%

CY 2006                      60%                 40%

CY 2007 – CY 2009             80%                  20%

CY 2010 and thereafter            100%               0%



Where the regional FS is not greater than the national FS, there is no blending and only the national FS applies. Note that this provision affects only the FS portion of the blended transition payment rate. This floor amount is calculated by CMS centrally and is incorporated into the FS amount that appears in the FS file maintained by CMS and downloaded by CMS contractors. There is no calculation to be done by the Medicare B/MAC or A/MAC in order to implement this provision.


7. Adjustments for FS Payment Rate for Certain Rural Ground Ambulance Transports

For services furnished during the period July 1, 2004 through December 31, 2010, the base rate portion of the payment under the FS for ground ambulance transports furnished in certain rural areas is increased by a percentage amount determined by CMS . Section 3105 (c) and 10311 (c) of the Affordable Care Act amended section 1834 (1) (13) (A) of the Act to extend this rural bonus for an additional year through December 31, 2010. This increase applies if the POP is in a rural county (or Goldsmith area) that is comprised by the lowest quartile by population of all such rural areas arrayed by population density. CMS will determine this bonus amount and the designated POP rural ZIP Codes in which the bonus applies. Beginning on July 1, 2004, rural areas qualifying for the additional bonus amount will be identified with a “B” indicator on the national ZIP Code file. Contractors must apply the additional rural bonus amount as a multiplier to the base rate portion of the FS payment for all ground transports originating in the designated POP ZIP Codes.

Subsequently, section of 106 (c) of the MMEA again amended section 1843 (l) (13) (A) of the Act to extend the rural bonus an additional year, through December 31, 2011.


8. Adjustments for FS Payment Rates for Ground Ambulance Transports

The payment rates under the FS for ground ambulance transports (both the fee schedule base rates and the mileage amounts) are increased for services furnished during the period July 1, 2004 through December 31, 2006 as well as July 1, 2008 through December 31, 2010. For ground ambulance transport services furnished where the POP is urban, the rates are increased by 1 percent for claims with dates of service July 1, 2004 through December 31, 2006 in accordance with Section 414 of the Medicare Modernization Act (MMA) of 2004 and by 2 percent for claims with dates of service July 1, 2008 through December 31, 2010 in accordance with Section 146(a) of the Medicare Improvements for Patients and Providers Act of 2008 and Sections 3105(a) and 10311(a) of the Patient Protection and Affordable Care Act (ACA) of 2010. For ground ambulance transport services furnished where the POP is rural, the rates are increased by 2 percent for claims with dates of service July 1, 2004 through December 31, 2006 in accordance with Section 414 of the Medicare Modernization Act (MMA) of 2004 and by 3 percent for claims with dates of service July 1, 2008 through December 31, 2010 in accordance with Section 146(a) of the Medicare Improvements for Patients and Providers Act of 2008 and Sections 3105(a) and 10311(a) of the Patient Protection and Affordable Care Act (ACA) of 2010. Subsequently, section 106 (a) of the Medicare and Medicaid Extenders Act of 2010 (MMEA) again amended section 1834 (1) (12) (A) of the Act to extend the payment increases for an additional year, through December 31, 2011. These amounts are incorporated into the fee schedule amounts that appear in the Ambulance FS file maintained by CMS and downloaded by CMS contractors. There is no calculation to be done by the Medicare carrier or intermediary in order to implement this provision.

The following chart summarizes the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 payment changes for ground ambulance services that became effective on July 1, 2004 as well as the Medicare Improvement for Patients and Providers Act (MIPPA) of 2008 changes that became effective July 1, 2008 and were extended by the Patient Protection and Affordable Care Act of 2010 and the Medicare and Medicaid Extenders Act of 2010 (MMEA).


Summary Chart of Additional Payments for Ground Ambulance Services Provided by MMA, MIPPA and MMEA

Service                                              Effective Dates                                                Payment Increase*

All rural miles                                     7/1/04 - 12/31/06                                                     2%

All rural miles                                     7/1/08 – 12/31/11                                                     3%

Rural miles 51+                                  7/1/04 - 12/31/08                                                     25% **

All urban miles                                   7/1/04 - 12/31/06                                                     1%

All urban miles                                   7/1/08 – 12/31/11                                                     2%

Urban miles 51+                                7/1/04 - 12/31/08                                                      25% **

All rural base rates                            7/1/04 - 12/31/06                                                       2%

All rural base rates                             7/1/08 – 12/31/11                                                      3%

Rural base rates (lowest quartile)         7/1/04 - 12/31/11                                                     22.6 %**

All urban base rates                            7/1/04 - 12/31/06                                                       1%

All urban base rates                            7/1/08 – 12/31/11                                                       2%

All base rates (regional fee schedule blend)   7/1/04 - 12/31/09                                              Floor



NOTES: * All payments are percentage increases and all are cumulative.

**Contractor systems perform this calculation. All other increases are incorporated into the CMS Medicare Ambulance FS file.


Friday, July 8, 2016

When provider can submit to PART B - SNF Ambulance claims

SNF Billing

The following ambulance transportation and related ambulance services for residents in Part A stays are not included in the PPS rate. They may be billed as Part B services by the supplier only in the following situations:

The ambulance trip is to the SNF for admission (the second character (destination) of any ambulance HCPCS code modifier is N (SNF) other than modifier QN, and the date of service is the same as the SNF 21X admission date.)

• The ambulance trip is from the SNF to home (the first character (origin) of any HCPCS code ambulance modifier is N (SNF)), and date of ambulance service is the same date as the SNF through date, and the SNF patient status (FL 22) is other than 30.)

• The ambulance trip is to a hospital based or non-hospital based ESRD facility (either one of any HCPCS code ambulance modifier codes is G (Hospital based dialysis facility) or J (Non-hospital based dialysis facility).

• The ambulance trip is from the SNF to another SNF (the first and second character (origin and destination) of any ambulance HCPCS code modifier is “N” (SNF)) and the beneficiary is not in a Part A stay.

Ambulance payment associated with the following outpatient hospital service exclusions is paid under the ambulance fee schedule:

• Cardiac catheterization;

• Computerized axial tomography (CT) scans;

Magnetic resonance imaging (MRIs);

• Ambulatory surgery involving the use of an operating room, including the insertion, removal, or replacement of a percutaneous esophageal gastrostomy (PEG) tube in the hospital’s gastrointestinal (GI) or endoscopy suite;

• Emergency services;

• Angiography;

• Lymphatic and Venous Procedures; and

• Radiation therapy.


The following ambulance transportation and related ambulance services for residents in a Part A stay are included in the SNF PPS rate and may not be billed as Part B services by the supplier. In these scenarios, the services provided are subject to SNF CB and the first SNF is responsible for billing the services to the A/MAC:

• A beneficiary’s transfer from one SNF to another before midnight of the same day. The first and second characters (origin and destination) of any HCPCS code ambulance modifier are “N” (SNF).

• A transport between two SNFs is not separately payable when a beneficiary is in a Part A covered SNF stay, and will result in a denial of a claim for such a transport. When billing for ambulance transports, suppliers should indicate whether the transport was part of a SNF Part A covered stay, using the appropriate origin/destination modifier (e.g., “NH” for a transport from a SNF to a hospital).

• Suppliers should bill with an “NN” origin/destination modifier when a SNF to SNF transport occurs. A transport between two SNFs is not separately payable when a beneficiary is in a Part A covered SNF stay, and will result in a denial of a claim for such a transport.

o Ambulance transports to or from a diagnostic or therapeutic site other than a hospital or renal dialysis facility (e.g., an independent diagnostic testing facility (IDTF), cancer treatment center, radiation therapy center, wound care center, etc.). The first or second character (origin or destination) of any HCPCS code ambulance modifier is “D” (Diagnostic or therapeutic site other than P or H), and the other modifier (origin or destination) is “N” (SNF).

Tuesday, July 5, 2016

Components of the Ambulance Fee Schedule - Part 1

The mileage rates provided in this section are the base rates that are adjusted by the yearly ambulance inflation factor (AIF). The payment amount under the fee schedule is determined as follows:

• For ground ambulance services, the fee schedule amount includes:

1. A money amount that serves as a nationally uniform base rate, called a “conversion factor” (CF), for all ground ambulance services;

2. A relative value unit (RVU) assigned to each type of ground ambulance service;

3. A geographic adjustment factor (GAF) for each ambulance fee schedule locality area (geographic practice cost index (GPCI));

4. A nationally uniform loaded mileage rate;

5. An additional amount for certain mileage for a rural point-of-pickup; and

6. For specified temporary periods, certain additional payment amounts as described in section


• For air ambulance services, the fee schedule amount includes:

1. A nationally uniform base rate for fixed wing and a nationally uniform base rate for rotary wing;

2. A geographic adjustment factor (GAF) for each ambulance fee schedule locality area (GPCI);

3. A nationally uniform loaded mileage rate for each type of air service; and


4. A rural adjustment to the base rate and mileage for services furnished for a rural point-of-pickup.


A. Ground Ambulance Services

1. Conversion Factor

The conversion factor (CF) is a money amount used to develop a base rate for each category of ground ambulance service. The CF is updated annually by the ambulance inflation factor and for other reasons as necessary.

2. Relative Value Units

Relative value units (RVUs) set a numeric value for ambulance services relative to the value of a base level ambulance service. Since there are marked differences in resources necessary to furnish the various levels of ground ambulance services, different levels of payment are appropriate for the various levels of service. The different payment amounts are based on level of service. An RVU expresses the constant multiplier for a particular type of service (including, where appropriate, an emergency response). An RVU of 1.00 is assigned to the BLS of ground service, e.g., BLS has an RVU of 1; higher RVU values are assigned to the other types of ground ambulance services, which require more service than BLS.

The RVUs are as follows:

Service Level                                            RVU

BLS                                                        1.00

BLS - Emergency                                    1.60

ALS1                                                      1.20

ALS1- Emergency                                   1.90

ALS2                                                      2.75

SCT                                                       3.25

PI                                                          1.75



3. Geographic Adjustment Factor (GAF)

The GAF is one of two factors intended to address regional differences in the cost of furnishing ambulance services. The GAF for the ambulance FS uses the non-facility practice expense (PE) of the geographic practice cost index (GPCI) of the Medicare physician fee schedule to adjust payment to account for regional differences. Thus, the geographic areas applicable to the ambulance FS are the same as those used for the physician fee schedule.

The location where the beneficiary was put into the ambulance (POP) establishes which GPCI applies. For multiple vehicle transports, each leg of the transport is separately evaluated for the applicable GPCI. Thus, for the second (or any subsequent) leg of a transport, the POP establishes the applicable GPCI for that portion of the ambulance transport.

For ground ambulance services, the applicable GPCI is multiplied by 70 percent of the base rate. Again, the base rate for each category of ground ambulance services is the CF multiplied by the applicable RVU. The GPCI is not applied to the ground mileage rate.


4. Mileage

In the context of all payment instructions, the term “mileage” refers to loaded mileage. The ambulance FS provides a separate payment amount for mileage. The mileage rate per statute mile applies for all types of ground ambulance services, except Paramedic Intercept, and is provided to all Medicare contractors electronically by CMS as part of the ambulance FS. Providers and suppliers must report all medically necessary mileage, including the mileage subject to a rural adjustment, in a single line item.