Friday, August 5, 2016

Air Ambulance billing basic - CPT cod A0430, A0431

 Air Ambulance

Ambulance Services, section 10.4 – Air Ambulance Services, and section 30.1.2 – Definitions of Air Ambulance Services for additional information on the coverage and definitions of air ambulance services. Under certain circumstances, transportation by airplane or helicopter may qualify as covered ambulance services. If the conditions of coverage are met, payment may be made for the air ambulance services.


Air ambulance services are paid at different rates according to two air ambulance categories:

• AIR ambulance service, conventional air services, transport, one way, fixed wing (FW) (HCPCS code A0430)

• AIR ambulance service, conventional air services, transport, one way, rotary wing (RW) (HCPCS code A0431)

Covered air ambulance mileage services are paid when the appropriate HCPCS code is reported on the claim:

• HCPCS code A0435 identifies FIXED WING AIR MILEAGE

• HCPCS code A0436 identifies ROTARY WING AIR MILEAGE

Effective for claims with dates of service on or after January 1, 2011, air mileage must be reported in fractional numbers of loaded statute miles flown. Contractors must ensure that the appropriate air transport code is used with the appropriate mileage code.

Air ambulance services may be paid only for ambulance services to a hospital. Other destinations e.g., skilled nursing facility, a physician’s office, or a patient’s home may not be paid air ambulance. The destination is identified by the use of an appropriate modifier as defined in Section 30(A) of this chapter.

Claims for air transports may account for all mileage from the point of pickup, including where applicable: ramp to taxiway, taxiway to runway, takeoff run, air miles, roll out upon landing, and taxiing after landing. Additional air mileage may be allowed by the contractor in situations where additional mileage is incurred, due to circumstances beyond the pilot’s control. These circumstances include, but are not limited to, the following:

• Military base and other restricted zones, air-defense zones, and similar FAA restrictions and prohibitions;

• Hazardous weather; or

• Variances in departure patterns and clearance routes required by an air traffic controller.

If the air transport meets the criteria for medical necessity, Medicare pays the actual miles flown for legitimate reasons as determined by the Medicare contractor, once the Medicare beneficiary is loaded onto the air ambulance.

IOM Pub. 100-08, Medicare Program Integrity Manual, chapter 6 – Intermediary MR Guidelines for Specific Services contains instructions for Medical Review of Air Ambulance Services


Contractor Determination of Fee Schedule Amounts


The FS amount is determined by the FS locality, based on the POP of the ZIP Code. Use the ZIP Code of the POP to electronically crosswalk to the appropriate FS amount. All ZIP Codes on the ZIP Code file are urban unless identified as rural by the letter “R” or the letter “B.” Contractors determine the FS amount as follows:

• If an urban ZIP Code is reported with a ground or air HCPCS code, the contractors determine the amount for the service by using the FS amount for the urban base rate. To determine the amount for mileage, multiply the number of reported miles by the urban mileage rate.

• If a rural ZIP Code is reported with a ground HCPCS code, the contractor determines the amount for the service by using the FS amount for the rural base rate. To determine the amount for mileage, contractors must use the following formula:

o For services furnished on or after July 1, 2004, for rural miles 1-17, the rate equals 1.5 times the rural ground mileage rate per mile. Therefore, multiply 1.5 times the rural mileage rate amount on the FS to derive the appropriate FS rate per mile;

o For services furnished during the period July 1, 2004 through December 31, 2008, for all ground miles greater than 50 (i.e., miles 51+), the FS rate equals 1.25 times the applicable mileage rate (urban or rural). Therefore, multiply 1.25 times the urban or rural, as appropriate, mileage rate amount on the FS to derive the appropriate FS rate per mile.

? If a rural ZIP Code is reported with an air HCPCS code, the contractor determines the FS amount for the service by using the FS amount for rural air base rate. To determine the amount allowable for the mileage, multiply the number of loaded miles by the rural air mileage rate.

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