Tuesday, October 12, 2010

CPT code A0427, A0428, A0426, A0130,A0425 - non emergency transport

Procedure code and description

A0425 Ground mileage, per statute mile

A0426 Ambulance service, advanced life support, nonemergency transport, level 1 (ALS 1)

A0427 Ambulance service, advanced life support, emergency transport, level 1 (ALS 1 - emergency)

A0428 Ambulance service, basic life support, nonemergency transport, (BLS)

Advanced Life Support, Level 1 (ALS1) Non-emergency - ALS1 is transportation by ground ambulance vehicle, and the provision of, medically necessary supplies and services including an ALS assessment by ALS personnel or at least one ALS intervention.

Advance Life Support Assessment – An ALS assessment is an assessment performed by an ALS crew as part of an emergency response that was necessary because the patient’s reported condition at the time of dispatch was such that only an ALS crew was qualified to perform the assessment. An ALS assessment does not necessarily result in a determination that the patient requires ALS level of service.

The determination to respond emergently with an ALS ambulance must be in accord with the local 911 or equivalent service dispatch protocol. If the call came in directly to the ambulance supplier, then the supplier’s dispatch protocol must meet, at a minimum, the standards of the dispatch protocol of the local 911 or equivalent service. In areas that do not have a local 911 or equivalent service, then the protocol must meet, at a minimum, the standards of a dispatch protocol in another similar jurisdiction within the State or, if there is no similar jurisdiction within the State, then the standards of any other dispatch protocol within the State. Where the dispatch was inconsistent with this standard of protocol, including where no protocol was used, the beneficiary’s condition (for example, symptoms) at the scene determines the appropriate level of payment.

Advance Life Support Personnel – Advance Life Support personnel is an individual trained to the level of the emergency medical technician-intermediate (EMT-Intermediate) or paramedic.

• The EMT-Intermediate is defined as an individual who is qualified, in accordance with State and local laws, as an EMT-Basic and who is also certified in accordance with State and local laws to perform essential advanced techniques and to administer a limited number of medications

• The EMT-Paramedic is defined as possessing the qualifications of the EMT-Intermediate and in accordance with State and local laws, possesses enhanced skills including the ability to administer additional interventions and medications.

Advance Life Support Intervention – Advanced life support (ALS) intervention is a procedure that is, in accordance with State and local laws, required to be performed by an emergency medical technician-intermediate (EMT-Intermediate) or EMT-Paramedic. An ALS intervention must be medically necessary to qualify for payment as an ALS level of service. An ALS intervention applies only to ground transports.

Ambulance and Chair Car, Non Emergency Transportation A0130 (w/c car) A0426, A0428 (ambulance)


1.   One of the following conditions is present:

a.   The  member  to be transported is bed confined. Bed confinement is defined as:

a)   Unable to get up from bed without assistance,
b)   Unable to ambulate, and
c)   Unable to sit in a chair or wheelchair


b.   Transportation by chair car is required because transportation in a private vehicle  would be detrimental to the member’s health.

2.   Transportation will be to one of the following destinations:

2 a.   To the nearest hospital, critical access hospital, or skilled nursing facility (SNF)   capable o f furnishing type/level of care

b.   From hospital, critical access hospital or

 SNF to home

c.   From SNF to nearest facility for medically necessary services not available at SNF,  including return trip

d.   For end stage renal disease, from home to nearest dialysis facility including return trip

The  member  must be bed confined before and after the transport. The medical condition is such that  the member  can be moved only by stretcher and any other method of transport would result in injury or  would be detrimental to the  member ’s health

Non -emergency transportation to a physician’s office  for routine care does not meet the destination  requirement. The transport must be to the nearest and most appropriate facility which is generally  equipped to provide the needed hospital or SNF care for the illness or injury involved

Providers must report one of the following HCPCS codes in FL 44 “HCPCS/Rates” for each base rate ambulance trip provided during the billing period:

A0433; or

Since billing requirements do not allow for more than one HCPCS code to be reported per revenue code line, providers must report revenue code 540 (ambulance) on two separate and consecutive line items to accommodate both the ambulance service and the mileage HCPCS codes for each ambulance trip provided during the billing period. Each loaded (e.g., a patient is onboard) 1-way ambulance trip must be reported with a unique pair of revenue code lines on the claim. Unloaded trips and mileage are NOT reported.

 Service Units Reporting

For line items reflecting HCPCS codes A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434, providers are required to report in FL 46 “Service Units” for each ambulance trip provided. Therefore, the service units for each occurrence of these HCPCS codes are always equal to one. In addition, for line items reflecting HCPCS code A0425, A0435, or A0436, providers must also report the number of loaded miles

 Total Charges Reporting

For line items reflecting HCPCS codes A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434, providers are required to report in FL 47, “Total Charges,” the actual charge for the ambulance service including all supplies used for the ambulance trip but excluding the charge for mileage. For line items reflecting HCPCS codes A0425, A0435, or A0436, providers are to report the actual charge for mileage.

 Edits (A/MAC Claims with Dates of Service On or After 4/1/02)

For claims with dates of service on or after April 1, 2002, A/MACs perform the following edits to assure proper reporting:

Edit to assure each pair of revenue codes 540 have one of the following ambulance HCPCS codes - A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434; and one of the following mileage HCPCS codes - A0425, A0435, or A0436.

Edit to assure the presence of an origin, destination modifier, and a QM or QN modifier for every line item containing revenue code 540;

Edit to assure that the unit’s field is completed for every line item containing revenue code 540;

Edit to assure that service units for line items containing HCPCS codes A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434 always equal “1"; and Edit to assure on every claim that revenue code 540, a value code of A0 (zero), and a corresponding ZIP Code are reported. If the ZIP Code is not a valid ZIP Code in accordance with the USPS assigned ZIP Codes, intermediaries verify the ZIP Code to determine if the ZIP Code is a coding error on the claim or a new ZIP Code from the USPS not on the CMS supplied ZIP Code File.

Beginning with dates of service on or after April 1, 2012, edit to assure that only nonemergency trips (i.e., HCPCS A0426, A0428 [when A0428 is billed without modifier QL]) require an NPI in the Attending Physician field. Emergency trips do not require an NPI in the Attending Physician field (i.e., A0427, A0429, A0430, A0431, A0432, A0433, A0434 and A0428 [when A0428 is billed with modifier QL])

Medically Necessary (UHIC 2011 COC)

Non-emergency ambulance transportation is medically necessary when the patient's condition requires treatment at another facility and when another mode of transportation would endanger the patient’s medical condition. If another mode of transportation could be used safely and effectively, then ambulance transportation is not medically necessary.

Benefit Level for Non-Emergency Ambulance

The applicable benefit for eligible non-Emergency ambulance transportation depends on the patient pick-up location (origin) as follows:

* If the patient is inpatient and is transported from a hospital to another hospital or inpatient facility, coverage levels for these ambulance services may vary. Please refer to the member specific benefit plan document to determine benefits. The following are UHIC examples for inpatient ambulance transfer:

o UHIC 2001 COC: The Hospital Inpatient Stay section of the COC

o UHIC 2007 and 2011 COC: The Ambulance Services section of the COC

* If the patient is in a sub-acute setting and is transported to an outpatient facility and back (outpatient hospital, outpatient facility, or physician’s office), these ambulance services are covered under the benefits that apply to that sub-acute setting. For example, if the patient is at a Skilled Nursing Facility, the ambulance transport to an outpatient facility (dialysis facility or radiation whether or not it is attached to a hospital) and back is covered under the Skilled Nursing Facility/Inpatient Rehabilitation Facility Services section of the COC.


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

The prior authorization request I submitted was affirmed. Then I submitted a claim for the same beneficiary for a non-repetitive service, so the Unique Tracking Number (UTN) was not included. Why did the claim reject asking for a UTN on a non-repetitive service?

The prior authorization program applies to all non-emergent (A0426, A0428) ambulance transports, regardless of the origin or destination (MLN SE1514 external link , PDF 138 KB). If the Medicare beneficiary has already met the criteria to establish that their ALS or BLS non-emergent transports are repetitive and a claim for a non-repetitive transport is submitted, this transport would count towards their number of affirmed transports. Submit the UTN on the claim. This will not permit the number of affirmed transports on that UTN to be exceeded.


A claim may be made to MDHHS for a medically necessary non-emergency transport only when:

* the transport is ordered by the beneficiary’s attending physician;

* the ambulance provider obtains a written order (e.g., physician certification statement) from the beneficiary’s attending physician certifying the medical necessity of the transport; and,

* the transport is provided in a licensed BLS or ALS vehicle.

Ambulance providers must retain appropriate documentation of the medical necessity of the transport in their files. A copy of the physician’s order for non-emergency ambulance transport in the patient’s medical record is acceptable documentation.
The written order must contain, at a minimum, the following information:

* beneficiary’s name and Medicaid identification (ID) number;

* attending physician’s NPI number and attending physician or provider signature;

* type of transport necessary;

* explanation of the medical necessity for ambulance transport (i.e., why other means of transport could not be used);

* origin and destination;

* diagnosis;

* frequency of needed transports (required for ongoing, planned treatment); and

* type of ongoing treatment (required for ongoing, planned treatment).

A separate physician’s order is required for each individual transport, unless a beneficiary has a chronic medical condition that requires planned treatment. For chronic conditions, a physician may order nonemergency transportation for a maximum time period of up to 60 days in a single order. The physician’s order for ongoing treatment must state the frequency of the transport and the type of ongoing treatment necessary.

If the ambulance provider is unable to obtain a signed physician certification statement from the beneficiary’s attending physician, a signed certification statement must be obtained from the physician’s assistant, nurse practitioner, clinical nurse specialist, registered nurse, or discharge planner who isknowledgeable about the beneficiary’s condition and who is employed by the attending physician or facility to which the beneficiary was admitted.

Non-emergency transport in a Medi-van or other wheelchair-equipped vehicle is not a covered service for ambulance providers. However, Medicaid beneficiaries or transportation providers may receive reimbursement for this type of transport directly from the local MDHHS office, an MDHHS contracted transportation broker or, if the beneficiary is enrolled, an MHP.

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