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
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
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
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