Ambulance billing - Denied and Non Covered Service

Denied Services

Program payment will not be made when other transportation could be utilized without endangering the patient’s health, whether such means of transportation is actually available.

A claim may be denied on the grounds that the use of an ambulance service was unreasonable in the treatment of the illness or injury involved.

Non-Covered Services

Medicare does not cover the following services:

 Transportation in Ambi-buses, ambulettes (Mobility Assistance Vehicle (MAV)), Medi-cabs, vans, privately owned vehicles, taxicabs or wheelchair vans.

 Parking fees.

  Tolls for bridges, tunnels and highways.

What are the documents required when you submit the claims to Medicare

Documentation Requirements for Ambulance Billing

The trip record documentation of each patient encounter should include the following:

 Complete and legible information.

 Reason for the transport.

 A concise explanation of symptoms reported by the patient and/or other observers and details of the patient’s physical assessments that explain why the patient requires ambulance transportation and cannot be safely transported by an alternate mode.

 Relevant history (when available).

  Observations and findings (patient’s condition at the time of transfer).

  A description of the patient’s physical condition in sufficient detail to demonstrate that the patient’s condition or functional status at the time of transport meets Medicare limitation of coverage for ambulance services.

 A detailed description of existing safety issues.

  A detailed description of special precautions taken (if any) and explanation of the need for such precautions.

 Assessment and clinical evaluations that should include:

oVital signs.

o Neurological assessment.

o Cardiac information.

                 Documentation of procedures and supplies provided such as:

O IV therapy.

o Respiratory therapy.

o Intubation.

o Cardiopulmonary Resuscitation (CPR).

o Oxygen administered.

o Drug therapy.

o Restraints. 

 A description of specific monitoring and treatments ordered and performed/ administered; that a treatment (such as oxygen) and/or monitoring (such as cardiac rhythm monitoring) was performed absent sufficient description of the patient’s condition (to demonstrate that the treatment and/or monitoring was medically necessary) is inadequate on its own merit to justify payment for the ambulance service. 

 The patient’s progress, responses to treatment and changes as treatment is given (e.g., monitoring of vital signs after medication has been given).

· Point of pickup (identify place and complete address). 

 Number of loaded miles/cost per mile/mileage charge. For services rendered with dates of service on or after January 1, 2011, miles must be reported as fractional units. For instructions on fractional units refer to “Mileage” under the “Services and Procedure Codes” section in this manual. 

 Minimal or base charge and charge for special items or services with an explanation/itemization of the special items or services. 

 For hospital-to-hospital transports, the trip record must clearly indicate the precise treatment or procedure (or medical specialist) that is available only at the receiving hospital. Non-specific or vague statements such as “needs cardiac care” or “needs higher level of care” are insufficient. 

 Any additional available documentation that supports medical necessity of ambulance transport (e.g., emergency room report, Skilled Nursing Facility (SNF) record, End-Stage Renal Disease (ESRD) facility record, hospital record). 

 A separate run sheet for each transport (e.g., two run sheets for round trips).

 Date and legible identity of the observer. Note: Refer to Signature Guidelines for Medical Review Purposes in this section.

Note: The HCPCS codes and ICD-9-CM codes reported on the health insurance claim must be supported by the documentation on the run sheet

Signature Guidelines for Medical Review Purposes in Ambulance billing

Medicare requires that services provided/ordered be authenticated by the author. The method used must be a handwritten or electronic signature. Stamped signatures are not acceptable. These guidelines impact the ambulance trip/run sheets and the Physician Certification Statements (PCSs). 

Run sheets must have legible signatures, including credentials, from the provider(s) who renders the services documented. 

The signature of the medical professional completing the PCS must also be legible (or accompanied by a typed or printed name) and include credentials. Furthermore, signatures on the PCS must be dated at the time they are completed. 

Signature Authentication Process 

If the signature is found to be illegible or missing from the medical documentation, a signature log or attestation statement to determine the identity of the author may be requested by the reviewer before the claim is processed.

Signature Log

A signature log includes the typed or printed name and usual signature of the author associated with initials or an illegible signature. The signature log may be submitted when records are requested. The signature log may be included on the actual page where the initials or illegible signatures are used or it may be a separate document. 

Attestation Statement

An attestation statement is required when a signature is missing from the documentation; it must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary and date of service. An attestation is specific to the service documented.

Providers should not add late signatures to the medical record, but make use of the signature authentication process. When medical records are requested, you may notice changes within the request letter. To meet the requirements for signatures, additional documentation (attestation statement or signature log) may need to be submitted with your medical records.

Beneficiary Signature Requirements for ambulance billing

Medicare requires the signature of the beneficiary or that of his representative for both the purpose of accepting assignment and submitting a claim to Medicare. If the beneficiary is unable to sign because of a mental or physical condition, the following individuals may sign the claim form on behalf of the beneficiary: 

 The beneficiary’s legal guardian.

 A relative or other person who receives Social Security or other governmental benefits on behalf of the beneficiary.

 A relative or other person who arranges for the beneficiary’s treatment or exercises other responsibility for his affairs.

 A representative of an agency or institution that did not furnish the services for which payment is claimed, but furnished other care, services or assistance to the beneficiary. 

· A representative of the provider or of the non-participating hospital claiming payment for services it has furnished if the provider or non-participating hospital is unable to have the claim signed in accordance with 42 CFR 424.36(b) (1–4). 

 A representative of the ambulance provider or supplier who is present during an emergency and/or non-emergency transport, provided that the ambulance provider or supplier maintains certain documentation in its records for at least four years from the date of service.

A provider/supplier (or his employee) cannot request payment for services furnished except under circumstances fully documented to show that the beneficiary is unable to sign and that there is no other person who could sign. 

Medicare does not require that the signature to authorize claim submission be obtained at the time of transport for the purpose of accepting assignment of Medicare payment for ambulance benefits. When a provider/supplier is unable to obtain the signature of the beneficiary or that of his representative at the time of transport, the provider/supplier may obtain this signature any time prior to submitting the claim to Medicare for payment. 

If the beneficiary/representative refuses to authorize the submission of a claim, including a refusal to furnish an authorizing signature, the ambulance provider/supplier may not bill Medicare but may bill the beneficiary (or his estate) for the full charge of the ambulance items and services furnished. If, after seeing this bill, the beneficiary/ representative decides to have Medicare pay for these items and services, a beneficiary/representative signature is required and the ambulance provider/supplier must afford the beneficiary/representative this option within the claims filing period.

When Medicare covers Ambulance service - Rules and regulation

Ambulance billing - COVERAGE REQUIREMENTS 

Medicare coverage for ambulance transportation is limited by CMS national policy in accordance with federal law. Ambulance services involve the assessment and administration of emergency care by medically trained personnel and transportation of patients within an appropriate, safe and monitored environment.Ambulance transportation is a covered service under Medicare when the patient’s condition is such that the use of any other method of transportation would endanger the patient’s health.

A patient whose condition permits transport in any type of vehicle other than an ambulance would not qualify for services under Medicare.

Medicare payment for ambulance transportation depends on the patient’s condition at the actual time of the transport regardless of the patient’s diagnosis or any other reason for transport.

To be deemed medically necessary for payment, the patient must require both the transportation and the level of service provided.

For the purposes of this policy, the following definitions apply:

  Medically trained personnel refers to individuals who have fulfilled state training and educational requirements and are certified or licensed by their respective state to provide Basic Life Support (BLS) and/or Advanced Life Support (ALS) Emergency Medical Technician (EMT)-level services.

  The vehicle used as an ambulance must be specially designed or equipped to respond to medical emergencies and, in non-emergency situations, be capable of transporting beneficiaries with acute medical conditions. The vehicle must comply with state or local laws governing the licensing and certification of an emergency medical transportation vehicle. At a minimum, the ambulance must contain a stretcher, linens, emergency medical supplies, oxygen equipment and other lifesaving emergency medical equipment, and be equipped with emergency warning lights, sirens and telecommunications equipment as required by state or local law. This should include, at a minimum, one two-way voice radio or wireless telephone.

Medicare Part A and B  - Requirements for Coverage

For ambulance services to be covered by Medicare, the following requirements must be met:

 Actual transportation of the beneficiary occurs. 

Services must be medically necessary and reasonable for the condition of the patient. 

The condition of the patient would not allow transportation by other means. 

A diagnosis must be on the claim or a detailed description of the patient’s condition at the time of transfer must be submitted with the claim or provided upon request to determine medical necessity. 

Ambulance personnel should document their observations of the patient’s condition. 

Transportation to a hospital from another hospital when a patient’s needs cannot be met at the first hospital and the patient is admitted to the second hospital. 

Transportation is to an extended care facility or to the patient’s home. 

Transportation is to the closest appropriate facilities. 

Transportation is provided by an approved supplier/provider of ambulance services. 

The transportation is not part of a Part A (in patient) service.

Medical Necessity

The following conditions may establish that the patient had to be transported by ambulance:

 Patient is transported in an emergency situation; e.g., as a result of an accident or injury.

 Patient needs to be restrained.

 Patient is unconscious or in shock.

 Patient requires oxygen or other emergency treatment on the way to the destination.

 Patient must remain immobile because of a fracture or the possibility of a fracture that has not been set.

 Patient sustains an acute stroke or myocardial infarction.

 Patient is experiencing severe hemorrhaging.

 Patient has a condition that requires him to be moved only by stretcher.

 Patient has a condition that makes him bed-confined before and after the ambulance trip.

Definition of Bed-Confined

There is now a national definition of the term “bed-confined.” The patient must meet all of the following criteria

 Unable to get up from bed without assistance.

 Unable to ambulate.

 Unable to sit in a chair or wheelchair.

Note: The term “bed-confined” is not synonymous with “bed rest” or “non-ambulatory.” In addition, “bed-confined” is not meant to be the sole criterion to be used in determining if the patient must be transported by ambulance. It is one factor to be considered when making coverage determinations.