Friday, October 21, 2016

CPT code A0425, A0427, A0428, A0433, A0426,A0429, A0430 - Ground Ambulance

Procedure code and Description

A0425 Ground mileage, per statute mile No PAR
A0426 Ambulance service, advanced life support, nonemergency transport, level 1 (ALS 1) No PAR
A0427 Ambulance service, advanced life support, emergency transport, level 1 (ALS 1 - emergency) No PAR
A0428 Ambulance service, basic life support, nonemergency transport (BLS) No PAR
A0429 Ambulance service, basic life support, emergency transport (BLS - emergency) No PAR
A0430 Ambulance service, conventional air services, transport, one way (fixed wing) No PAR
A0431 Ambulance service, conventional air services, transport, one way (rotary wing) No PAR

A0433 Advanced life support, level 2 (ALS 2) No PAR

Bill Type Codes for Ambulance Service (Ground Ambulance)

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

11x Hospital Inpatient (Including Medicare Part A)
12x Hospital Inpatient (Medicare Part B only)
13x Hospital Outpatient
22x Skilled Nursing - Inpatient (Medicare Part B only)
23x Skilled Nursing - Outpatient
83x Ambulatory Surgery Center
85x Critical Access Hospital

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

Note: The contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM), Publication 100-04, Claims Processing Manual, for further guidance.

0540 Ambulance - General Classification
0541 Ambulance - Supplies
0542 Ambulance - Medical Transport
0543 Ambulance - Heart Mobile
0544 Ambulance - Oxygen
0545 Ambulance - Air Ambulance
0546 Ambulance - Neonatal Ambulance Services
0547 Ambulance - Pharmacy
0548 Ambulance - EKG Transmission
0549 Ambulance - Other Ambulance

CPT/HCPCS Codes


Group 1 Paragraph

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.


A0425 Ground mileage

A0426 Als 1

A0427 ALS1-emergency

A0428 bls

A0429 BLS-emergency

A0433 als 2

A0434 Specialty care transport

A0999 Unlisted ambulance service


A0888 Noncovered ambulance mileage


Billing and Coding Guidelines


For claims with dates of service on or after January 1, 2001, providers must report revenue code 540 and one of the following HCPCS codes for each ambulance trip provided during the billing period:

A0426; A0427; A0428; A0429; A0430; A0431; A0432; A0433; or A0434. Providers using an ALS vehicle to furnish a BLS level of service report HCPCS code, A0426 (ALS1) or A0427 (ALS1 emergency), and are paid accordingly. In addition, all providers report one of the following mileage HCPCS codes: A0380; A0390; A0435; or A0436.  Since billing requirements do not allow for more than one HCPCS code to be reported for per revenue code line, providers must report revenue code 0540 (ambulance) on two separate and consecutive lines to accommodate both the Part B 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.

However, in the case where the beneficiary was pronounced dead after the ambulance is called but before the ambulance arrives at the scene: Payment may be made for a BLS service if a ground vehicle is dispatched or at the fixed wing or rotary wing base rate, as applicable, if an air ambulance is dispatched. Neither mileage nor a rural adjustment would be paid. The blended rate amount will otherwise apply. Providers report the A0428 (BLS) HCPCS code. Providers report modifier QL (Patient pronounced dead after ambulance called) in “HCPCS/Rates” instead of the origin and destination modifier. In addition to the QL modifier, providers report modifier QM or QN.

Service Units Reporting For line items reflecting HCPCS code A0030, A0040, A0050, A0320, A0322, A0324, A0326, A0328, or A0330 (services before January 1, 2001) or code A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434 (services on and after January 1, 2001), providers are required to report in Service Units each ambulance trip provided during the billing period. Therefore, the service units for each occurrence of these HCPCS codes are always equal to one. In addition, for line items reflecting HCPCS code A0380 or A0390, the number of loaded miles must be reported. (See examples below.) Therefore, the service units for each occurrence of these HCPCS codes are always equal to one. In addition, for line items reflecting HCPCS code A0380, A0390, A0435, or A0436, the number of loaded miles must be reported.

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 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 code A0380, A0390, A0435, or A0436, report the actual charge for mileage.

NOTE: There are instances where the provider does not incur any cost for mileage, e.g., if the beneficiary is pronounced dead after the ambulance is called but before the ambulance arrives at the scene. In these situations, providers report the base rate ambulance trip and mileage as separate revenue code lines. Providers report the base rate ambulance trip in accordance with current billing requirements. For purposes of reporting mileage, they must report the appropriate HCPCS code, modifiers, and units as a separate line item. For the related charges, providers report $1.00 in FL48 for non- covered charges. A/B MACs (A) should assign remittance adjustment Group Code OA to the $1.00 non- covered mileage line, which in turn informs the beneficiaries and providers that they each have no liability. Prior to submitting the claim to CWF, the A/B MAC (A) will remove the entire revenue code line containing the mileage amount reported in Non-covered Charges to avoid non-acceptance of the claim


FISS edits to assure proper reporting as follows:

• For claims with dates of service on or after January 1, 2001, each pair of revenue codes 0540 must 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 - A0435, A0436 or for claims with dates of service on or after April 1, 2002, A0425;

• For claims with dates of service on or after January 1, 2001, the presence of an origin and destination modifier and a QM or QN modifier for every line item containing revenue code 0540;

• The units field is completed for every line item containing revenue code 0540;

• For claims with dates of service on or after January 1, 2001, the units field is completed for every line item containing revenue code 0540;

• Service units for line items containing HCPCS codes A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434 always equal “1" For claims with dates of service on or after July 1, 2001, each 1-way ambulance trip, line- item dates of service for the ambulance service, and corresponding mileage are equal.

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 “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.


Procedure Codes for Advanced Life Support (ALS) Services

An ALS ambulance has similar equipment, crew, and certification requirements under Medicare as a basic ambulance, except the ALS ambulance has complex specialized life-sustaining equipment. It is ordinarily equipped for radio-telephone contact with a hospital or physician. A typical ALS ambulance may be a mobile coronary care unit or other vehicle appropriately equipped and staffed by personnel authorized to initiate and administer IV fluids, establish and maintain a recipient's airway, defibrillate the heart, relieve pneumothorax conditions, administer cardiopulmonary resuscitation (CPR), provide anti-shock therapy ,administer life sustaining drugs, venous blood draws, cardiac monitoring (EKG), administer pacing nebulizer and perform other advanced life support procedures or services to recipients during the transport. Documentation must support need for ALS services

Procedure Code Description

A0225 Neonatal Emergency Transport, transport of a critically ill neontate, a level of interfacility service provided beyond the scope of the Paramedic. This service should be billed only for the transport of a neonate.

A0427 Ambulance service, advanced life support, emergency transport, Level 1 (ALS1) Must provide medically necessary supplies and services, including the provision of an ALS assessment or at least one ALS intervention.

A0433 Advanced Life Support Level 2 (ALS2). The administration of at least three different medications and the provision of one or more of the following ALS procedures: Manual defibrillation/cardioversion, endotracheal intubation, central venous line, cardiac pacing, chest decompression, surgical airway, intraosseous line.

A0434 Specialty Care Transport (SCT), in a critically injured or ill patient, a level of interfacility service provided beyond the scope of the Paramedic. This service is necessary when a patient’s condition requires ongoing care that must be provided by one or more health professionals in an appropriate specialty area (for example, nursing, emergency medicine, respiratory care, cardiovascular care, or a paramedic with additional training).

For example, when a recipient is picked up at the residence (origin code R) and taken to the hospital (destination code H) for an ALS emergency transport (procedure code A0427), the claim is coded as A0427RH.

The following are all of the valid combinations for the first modifier fields:
DN EH GE HG HR JH NG RD RN
DD DR EJ GH HH IH JN NH RE SH
DG ED EN GN HI IN JR NJ RG SI
DH EE ER GR HJ JD ND NN RH I I
DJ EG GD HE HN JE NE NR RJ



ICD-9 Codes that Support Medical Necessity


Group 1 Paragraph : Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

Medical necessity and coverage of ambulance services are not based solely on the presence of a specific diagnosis. Medicare payment for ambulance transportation may be made only for those patients whose condition at the time of transport is such that ambulance transportation is necessary. For example, it is insufficient that a patient merely has a diagnosis such as pneumonia, stroke or fracture to justify ambulance transportation. In each of those instances, the condition of the patient must be such that transportation by any other means is medically contraindicated. In the case of ambulance transportation, the condition necessitating transportation is often that an accident or injury has occurred giving rise to a clinical suspicion that a specific condition exists (for instance, fractures may be strongly suspected based on clinical examination and history of a specific injury).

It is the provider’s responsibility to supply the contractor with information describing the condition of the patient that necessitated ambulance transportation. Medicare recognizes limitations of usual ambulance personnel for establishing a diagnosis and recognizes, therefore, that diagnosis coding of a patient’s condition using ICD-9-CM codes when reporting ambulance services may be less specific than for services reported by other professional providers. Providers who submit diagnosis codes should choose the code that best describes the patient’s condition at the time of transport. As a reminder to providers of ambulance services, “rule out” or “suspected” diagnoses should not be reported using specific codes. In such instances where a diagnosis is not confirmed, it is more correct to use a symptom, finding or injury code.

Reporting ambulance services using a code from the list below certifies to Medicare that the ambulance provider believes the code description reasonably reflects the condition of the patient at the time of transport and that the patient’s condition was consistent with the requirements of the Medicare ambulance transportation benefit.

The contractor recognizes that ambulance suppliers are currently not required to submit diagnosis codes on their claims if filing on a 1500 claim form or utilizing an electronic version other than the 5010 version of the 837P, though their doing so facilitates timely claim adjudication. The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. Claims without a diagnosis code from below will be adjudicated manually utilizing the information contained in the claim’s narrative field and/or medical records (the trip report and any other records supplied to Medicare by the provider upon our request). Ambulance suppliers utilizing the 5010 version of the 837P are required to submit diagnosis code(s).

Due to the large number of possible covered diagnosis codes, the Contractor is not providing a comprehensive list of covered diagnosis codes for HCPCS codes A0425, A0426, A0427, A0428, A0429, A0433 and A0434.

All ambulance transports require dual diagnosis codes as described below.

Providers should report the most appropriate ICD-9-CM code that adequately describes the patient's medical condition (for example: stroke, coma, trauma, etc.) at the time of transport as the primary diagnosis. In addition, a secondary diagnosis, from the list below, must be reported.

Additionally, the KX modifier must be reported on the claim for the service to be considered for coverage. Reporting of the KX modifier is an attestation from the provider that the services are reasonable and necessary and that there is documentation of medical necessity in the patient's record. The KX modifier should not be reported if the patient's condition does not require an ambul

Group 1 Codes

V46.11 DEPENDENCE ON RESPIRATOR, STATUS
V46.9* UNSPECIFIED MACHINE DEPENDENCE
V49.84 BED CONFINEMENT STATUS
V49.87* PHYSICAL RESTRAINTS STATUS
V71.9* OBSERVATION FOR UNSPECIFIED SUSPECTED CONDITION

Note: Use code V46.11 to denote ventilator dependency transport ONLY.

Note: Use code V46.9 to denote the need for continuous IV fluids, 'active airway management' or the need for multiple machine devices.

Note: Use code V49.87 to denote patient safety: danger to self and others - monitoring other and unspecified reactive psychosis.

Note: Use code V71.9 to denote the need for continuous clinical assessment throughout the transport.
ICD-9 Codes that DO NOT Support Medical Necessity
Note: V68.61 should be reported for those patients who were transported by ambulance but did NOT require the services of an ambulance crew.

V68.81 REFERRAL OF PATIENT WITHOUT EXAMINATION OR TREATMENT

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