Monday, October 11, 2010

Medically reasonable ambulance trip

Reasonableness of the Ambulance Trip

Payment is made according to the medically necessary services actually furnished. That is, payment is based on the level of service furnished (provided they were medically necessary), not simply on the vehicle used. Even if a local government requires an ALS response for all calls, payment under the Fee Schedule is made only for the level of service furnished, and then only when the service is medically necessary.


Program, reimburses for ambulance services as medically necessary and appropriate when:

* Medical/surgical or psychiatric emergencies exist; or

* No other effective and less costly mode of transportation for medical treatment can be used because of the beneficiary's medical condition.

Services that have been excluded from direct reimbursement to ambulance providers are:

* Services that are not medically necessary.

* Services that are included as a part of the base rate.

* Services for beneficiaries in a nursing facility (NF) that are reimbursed as part of the facility’s per diem or are billed separately by the facility.

* Services reimbursed as part of the Diagnosis Related Groups (DRG) rate for beneficiaries who are inpatients at a hospital, are sent to another facility for services, and returned to the originating hospital without being discharged from the originating hospital.

* Services to Medicaid Health Plan (MHP) enrollees, except for medically necessary ambulance transports related to dental, substance abuse, and community mental health services.

* Nonambulance, non-emergency medical transportation that is provided by a MHP.

* Nonambulance, non-emergency medical transportation arranged by either MDHHS or an MDHHScontracted transportation broker who reimburses the beneficiary or the transportation provider directly.

The Covered Services Section of this chapter describes the coverages and limitations for payment of ambulance services by Medicaid.

Special billing instructions follow coverage sections, where applicable. These instructions assist the ambulance provider in obtaining reimbursement and must be used in conjunction with the completion instructions found in the Billing & Reimbursement for Professionals and the Billing & Reimbursement for Institutional Providers chapters of this manual and the Healthcare Common Procedure Coding System (HCPCS) manual.


Bed-Confinement
Medical necessity is established when the patient’s condition is such that the use of any other method of transportation is contraindicated. Carriers may presume this requirement is met under certain circumstances, including when the beneficiary was bed-confined before and after the ambulance trip.

A beneficiary is bed-confined if he/she is:
• Unable to get up from bed without assistance;
• Unable to ambulate; and
• Unable to sit in a chair or wheelchair.

The term "bed confined" is not synonymous with "bed rest" or "non-ambulatory". Bed confinement, by itself, is neither sufficient nor is it necessary to determine the coverage for Medicare ambulance benefits. It is simply one element of the beneficiary's condition that may be taken into account in the carrier's determination of whether means of transport other than an ambulance were contraindicated.

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