Ambulance transport billing Overview


Billing Guidelines

• Ambulance services provided by an independent ambulance provider are billed on the CMS-1500.

• Ambulance services provided by a hospital-based ambulance are billed on the UB-04 using the specific NPI assigned for ambulance. These services should not be billed under the acute hospital NPI. Hospital-based ambulance services are not allowed on inpatient claims, as ambulance transport is not included in inpatient reimbursement methods. Claims for ambulance services must be
submitted separately as an outpatient claim.


• Each claim should contain a code for a base rate. Routine supplies and equipment such as IV solutions, oxygen, tubing, masks, gloves, dressings, catheters, EKG supplies, backboards and glucose checks are included in the base rate and should not be billed separately.

• Codes should be for the level of service provided, not the type of vehicle used.


• Each claim should contain a code for mileage unless the patient was not transported. Report number of miles in the “units” field. If the patient received treatment by ambulance staff but was not transported, use A0998 (Ambulance response and treatment, no transport).

• Transport by an ambulance to a clinic or mortuary is not eligible for reimbursement.


EXAMPLES OF AMBULANCE SERVICES

• Basic Life Support (BLS) transports

• Non-emergency Transports

* Scheduled, unscheduled, repetitive and nonrepetitive ambulance trips require a physician certification statement (PCS)

* Rules for obtaining PCS are specific

• Emergency Transports

• Return trip from the ER

• Discharge from the hospital

• Transport to and from a dialysis facility 90


Level of Service

Blue Cross Blue Shield of North Dakota follows Medicare’s guidelines for determining level of service.

If an Advanced Life Support (ALS) vehicle is used but no ALS service is performed, use the appropriate Basic Life Support (BLS) codes:

• A0428 Ambulance service, basic life support, non-emergency transport (BLS)

• A0429 Ambulance service, basic life support, emergency transport (BLS - emergency)


Criteria for higher intensity services are listed below:

• A0433 (Advanced Life Support, Level 2 [ALS 2]) is the transportation by ground ambulance vehicle and the provision of medically necessary supplies and services including at least three separate administrations of one or more medications by intravenous push/bolus or by continuous infusion (excluding crystalloid fluids) OR ground ambulance transport and the provision of at least one ALS 2 procedures, such as manual defibrillation/cardioversion, endotracheal intubation, central venous line, cardiac pacing, chest decompression, surgical airway, or intraosseous line.

• A0434 (Specialty Care Transport [SCT]) is hospital-to-hospital transportation of a critically injured or ill beneficiary by a ground ambulance vehicle, including the provision of medically necessary supplies and services, at a level of service beyond the scope of the EMT-Paramedic. SCT is necessary when a beneficiary’s condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area (e.g. emergency or critical care nursing, emergency medicine, respiratory care, cardiovascular care, or a paramedic with additional training).

The Ambulance Transport Benefit

The ambulance transport benefit is a transport by an ambulance. The transport may be covered when the use of any other method of transportation is contraindicated due to the member’s condition and the additional requirements discussed below are met. Blue Cross covers and processes two types of ambulance claims:

• Ground

• Air

ALS – advanced life support

BLS – basic life support

In addition to the participating provider responsibilities outlined in this manual, ambulance providers should:

• File only the codes listed in their contracts, if applicable. This will prevent returned claims and/or delays in claim processing.

• File claims for members even if you do not have the patient’s signature. Patient signatures are not required for filing claims.

Please Note: Non-contracted, non-emergency ambulance services are paid to the member. Ambulance Modifiers Ambulance services must be reported with a combination of two modifiers listed below—the first character representing the origin and the second character representing the destination:

D Diagnostic or therapeutic site other than P or H when these are used as origin codes

E Residential, domiciliary or custodial facility

G Hospital-based dialysis facility

H Hospital

I Site of transfer between modes of ambulance transport

J Non-hospital based dialysis facility

N Skilled nursing facility (SNF)

P Physician’s office

R Residence

S Scene of accident or acute event

X Intermediate stop at physician office on the way to the hospital (destination code only) The ambulance provider must retain all appropriate documentation on file for an ambulance transport furnished to a member. This documentation must be presented to Blue Cross upon request and may be used to assess, among other things, whether the transport meets medical necessity, eligibility, coverage, Online Ambulance Speed Guide www.bcbsla.com/providers >Education on Demand benefit category and any other criteria necessary for payment. The ambulance transport is not covered if some means of transportation other than ambulance could be used without endangering the member’s health, regardless of whether the other means of transportation is actually available.


Ground Ambulance Transports

A member may be transported on land or on water for a reasonable and medically necessary ground ambulance transport. The following coverage requirements apply to ground transports:

• A Blue Cross member is transported

• The destination is local

• The facility is appropriate

• Due to the members condition, the use of any other method of transportation is contraindicated

• The purpose of the transport is to obtain a Blue Crosscovered  service or to return from obtaining such service

Ground ambulance transports include the following:

• Basic Life Support (BLS) – Includes the provision ofmedically necessary supplies and services and BLS ambulance transportation as defined by the State where you provide the transport. An emergency response is one that, at the time you are called, you respond immediately. A BLS emergency is an immediate emergency response in which you begin as quickly as possible to take the steps necessary to respond to the call.

 • Level 1 (ALS1) – Includes the provision of medically necessary supplies and services and the provision of an ALS assessment or at least one ALS intervention. An ALS assessment is performed by an ALS crew as part of an emergency response that is necessary because the member’s reported condition at the time of dispatch indicates that only an ALS crew is qualified to perform the assessment. An ALS assessment does not necessarily result in a determination that the member requires an ALS level of transport. An ALS intervention is a procedure that must be performed by an emergency medical technician-intermediate (EMT-Intermediate) or an EMT-Paramedic in accordance with State and local laws. An ALS1 emergency is an immediate emergency response in which you begin as quickly as possible to take the steps necessary to respond to the call.

An Ambulance is a specially designed or equipped vehicle used only for transporting the critically ill or injured to a health care facility. The ambulance service must meet state and local requirements for providing transportation for the sick or injured and must be operated by qualified personnel who are trained in the application of basic life support.


THE MOST COMMON AMBULANCE ERRORS:

• No PCS obtained and/or submitted with documentation (when requested)

• Billing for noncovered mileage as covered mileage

– Medicare pays only for ‘loaded’ ambulance miles

• Though a valid ICD-9 code(s) was submitted, the ICD-9 code alone was insufficient information

– Documentation did not support reported condition(s)


TIPS FOR ERROR FREE AMBULANCE CLAIMS

• Patient may have required ambulance transport to the hospital but you must consider whether they still meet coverage criteria for the return trip.

• Verify that patient’s origin and destination meet Medicare coverage.

• Could the patient have safely gone another way* Family car, taxi, wheelchair van*

• Did the patient’s condition meet the criteria for coverage*

• Is mileage, origin and destination noted*

• Is the trip sheet signed*

• Must include attendant/EMT’s credentials

• Is the trip sheet and other documentation legible*

• Do you have a PCS and is the certification still valid*

•Do you need records from hospital, nursing home or other third party to support service billed*

• Self audit

• Re-educate coders, billers and attendants if necessary

• Re-audit


BASE RATE

The ambulance provider may bill one base rate procedure code:

* Basic Life Support (BLS) Non-emergency;

* BLS Emergency;

* Advanced Life Support 1 (ALS 1) Non-emergency;

* ALS 1 Emergency;

* Advanced Life Support 2 (ALS 2);

* Neonatal Emergency Transport;

* Helicopter Air Ambulance; or

* Fixed Wing Air Ambulance Transport.

The base rate for ambulance transports must reflect the level of service rendered, not the type of vehicle in which the beneficiary was transported. Even if a local government requires an Advanced Life Support (ALS) response to all calls, the base rate billed must reflect the level of service rendered, not the type of vehicle in which the beneficiary was transported. Medicaid will only pay for the level of service required and provided.

Reimbursement for the base rate covers all services rendered except mileage that may be billed separately.

When treatment is rendered and no other care or transport is necessary, ambulance providers may bill the base rate procedure code for the level of service performed but not for mileage. (Refer to the Special Situations Section of this chapter for instructions regarding intercept situations.)




CONTINUOUS OR ROUND TRIP TRANSPORT

This type of transport is considered to be one run. The base rate code for the highest level of service performed during transport should be billed on one claim line. Loaded mileage is also billed on one claim line with the total number of whole (loaded) miles indicated as the quantity.

Refer to the Waiting Time subsection of this chapter in cases where waiting time exceeds 30 minutes.


3.4 NURSING FACILITIES

Routine, non-emergency medical transportation provided for NF residents in a van or other nonemergency vehicle is included in the facility's per diem rate. This includes transportation for medical appointments, dialysis, therapies, or other treatments not available in the facility.

When the resident’s attending physician orders non-emergency transportation by ambulance (due to the need for a stretcher or other emergency equipment), the ambulance provider may bill MDHHS directly.

The ambulance provider must maintain the physician's written order as documentation of medical necessity.

If the resident’s attending physician does not order non-emergency ambulance transport, arrangements for payment must be between the facility and the ambulance provider, and cannot be charged to the resident, the resident's family, or used to offset the patient-pay amount. This cost may not be claimed as a routine cost on Michigan’s Medicaid cost report. The cost of non-emergency ambulance transports not ordered by the resident’s physician must be identified and removed on Worksheet 1-B by the NF. For direct reimbursement by MDHHS to an enrolled ambulance provider for services provided to a Medicaid beneficiary who is a resident of a NF, refer to the Ambulance Quick Reference Guide Section of this chapter.



3.5 MULTIPLE ARRIVALS

When multiple units respond to a call for services, only the entity that actually provides services for the beneficiary may bill and be paid. The entity that rendered service/care should bill for all services furnished.

3.6 MULTIPLE BENEFICIARIES PER TRANSPORT

When more than one eligible beneficiary is transported at the same time, the only acceptable duplication of charges is half of the base rate. Separate claims must be submitted for each beneficiary. The first claim is completed in the usual mannerand the base rate billed must reflect the highest level of service performed.

Claims for additional beneficiaries must indicate the U&C base rate charge. The appropriate modifier must be reported. Providers should refer to the Billing & Reimbursement for Professionals or the Billing & Reimbursement for Institutional Providers chapters of this manual, as appropriate, for a list of modifiers.

Payment is made at 50 percent of Medicaid's reimbursement rate or 50 percent of the provider's charge (whichever is less).

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