Monday, December 28, 2015

Ambulance Service (Ground Ambulance) Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Compliance with the provisions in this policy may be monitored and addressed through prepayment and/or post payment data analysis and subsequent medical review audits.

The Medicare payment benefit for ambulance services is very restricted. Ambulance suppliers must understand the benefit and refrain from seeking Medicare payment for services that do not conform to the limited benefit requirements as stated in regulation. Physicians and others who order and certify medical necessity of ambulance services must also understand and abide by the limitations of Medicare coverage of ambulance services. This LCD includes, for reference only, portions of CMS national payment policy as found in relevant Internet-Only Manual (IOM) sections and regulations. This LCD further provides “limited coverage” diagnosis to procedure edit requirements for ambulance suppliers who choose to submit ICD-9-CM codes on their claims. The LCD also contains utilization guidelines for the purpose of automated ambulance claim denial by the contractor in its jurisdictions.

CMS National Payment Policy 

Medicare covers ambulance services only if furnished to a beneficiary whose medical condition at the time of transport is such that transportation by other means would endanger the patient’s health. A patient whose condition permits transport in any type of vehicle other than an ambulance does not qualify for Medicare payment. Medicare payment for ambulance transportation depends on the patient’s condition at the actual time of the transport regardless of the patient’s diagnosis. To be deemed medically necessary for payment, the patient must require both the transportation and the level of service provided.

Medicare covers both emergency ambulance transportation and non-emergency ambulance transportation as follows:

Medical Necessity

Ambulance transportation is covered when the patient’s condition requires the vehicle itself and/or the specialized services of the trained ambulance personnel. A requirement of coverage is that the needed services of the ambulance personnel were provided and clear clinical documentation validates their medical need and their provision in the record of the service (usually the run sheet).

Emergency Ambulance Services

Medicare will cover emergency ambulance services when the services are medically necessary, meet the destination limits of closest appropriate facilities and are provided by an ambulance service that is licensed by the state. Emergency response means responding immediately at the Basic Life Support (BLS) or Advanced Life Support 1 (ALS1) level of service to a 911 call or the equivalent. An immediate response is one in which the ambulance supplier begins as quickly as possible to take the steps necessary to respond to the call.

Application: The determination to respond emergently with a BLS or ALS1 ambulance must be in accord with the local 911 or equivalent service dispatch protocol (ALS2 has additional requirements). If the call came in directly to the ambulance provider/supplier, then the provider's/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.

The patient’s condition is an emergency that renders the patient unable to be safely transported to the hospital in a moving vehicle (other than an ambulance) for the amount of time required to complete the transport. Emergency ambulance services are services provided after the sudden onset of a medical condition. For the purposes of this LCD, acute signs and/or symptoms of sufficient severity must manifest the emergency medical condition such that the absence of immediate medical attention could reasonably be expected to result in one or more of the following:

Place the patient’s health in serious jeopardy.
Cause serious impairment to bodily functions.
Cause serious dysfunction of any body organ or part.

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