Air Ambulance billing - Basic terms and question

Ambulance Providers

An ambulance provider is a provider that owns and operates an ambulance transportation service as an adjunct to its institutionally-based operations. These providers include:

• Hospitals

• Critical Access Hospitals (CAH)

• Skilled Nursing Facilities (SNF)

• Comprehensive Outpatient Rehabilitation Facilities

• Home Health Agencies (HHA)

• Hospice programs

Although ambulance providers can and do furnish ambulance transports that are covered under Blue Cross, an ambulance provider that transports an individual from one provider to another is generally included in the facility service the patient is admitted to at the time of the transport. For example, a member who was admitted to a hospital CAH, or SNF may require patient transportation, which is transportation to another hospital or other site while he or she receives specialized care and maintains inpatient status with the original provider. This transportation is covered under the inpatient hospital or CAH service. Patient transportation is covered as part of the facility reimbursement as a SNF service when a member is a resident of a SNF and must be transported by ambulance for an intracampus transfer between different departments of the same hospital, to receive dialysis or certain other high-end outpatient hospital services, or for transfer to another SNF.



Indications for Coverage

Emergency Ambulance (Ground, Water, or Air)

Coverage includes Emergency ambulance transportation (including wait time and treatment at the scene) by a licensed ambulance service from the location of the sudden illness or injury, to the nearest hospital where Emergency health services can be performed.



Check the member specific benefit plan document for prior authorization and notification requirements.

The following Emergency ambulance services are covered:

* Ground ambulance or air ambulance transportation requiring basic life support or advanced life support.

* Treatment at the scene (paramedic services) without ambulance transportation.

* Wait time associated with covered ambulance transportation.

* To a hospital that provides a required higher level of care that was not available at the original hospital.



Air Ambulance


As a general guideline, when it would take a ground ambulance 30-60 minutes or more to transport a member whose medical condition at the time of pick-up required immediate and rapid transport due to the nature and/or severity of the member’s illness/injury, air transportation may be appropriate.


Air ambulance transportation should meet the following criteria:

* The patient’s destination is an acute care hospital, and

* The patient’s condition is such that the ground ambulance (basic or advanced life support) would endanger the member’s life or health, or

* Inaccessibility to ground ambulance transport or extended length of time required to transport the patient via ground ambulance transportation could endanger the member, or

* Weather or traffic conditions make ground ambulance transportation impractical, impossible, or overly time consuming.
Refer to #4 (Medicare Benefit Policy Manual) in the References section below.


Q: How should we code the number of miles for ground or air ambulance trips?

A: Beginning with dates of service on and after January 1, 2011:

• For trips totaling up to 100 covered miles, suppliers must round the total miles up to the nearest tenth of a mile and report the resulting number with the appropriate healthcare common procedure coding system (HCPCS) code for ambulance mileage. The decimal must be used in the appropriate place (e.g., 99.9).

• For trips totaling 100 covered miles and greater, suppliers must report mileage rounded up to the next whole number mile without the use of a decimal (e.g., 998.5 miles should be reported as 999).

• For trips totaling less than 1 mile, enter a “0” before the decimal (e.g., 0.9).

• For mileage HCPCS billed on the ASC X12 837 professional transaction or the CMS-1500 paper form only, contractors shall automatically default to “0.1” units when the total mileage units are missing.



Additional Information:

* For covered Emergency ambulance, supplies that are needed for advanced life support or basic life support to stabilize a patient’s medical condition are covered under the ambulance benefit.

Non-Emergency Ambulance (Ground or Air) Between Facilities

Coverage includes non-Emergency ambulance transportation by a licensed ambulance service (either ground or air ambulance), between health care facilities when the ambulance transportation is any of the following:

* From a non-network hospital to a network hospital

* To a hospital that provides a required higher level of care that was not available at the original hospital

* To a more cost-effective acute care facility

* From an acute facility to a sub-acute setting


Ambulance Suppliers

An ambulance supplier is not owned or operated by an institution such as a hospital and is credentialed in Blue Cross as an independent ambulance supplier. These suppliers include:

• Volunteer fire and/or ambulance companies

• Local government ambulance companies

• Privately-owned and operated ambulance companies

• Independently-owned and operated ambulance companies



Ambulance Vehicles

Ground and air ambulance vehicles must comply with State and/or local laws governing the licensing and certification of emergency medical transportation vehicles and must be designed and equipped to respond to medical emergencies. At a minimum, ambulance vehicles must be equipped with the following:

• A stretcher

• Linens

• Emergency medical supplies

• Oxygen equipment

• Other lifesaving emergency medical equipment and reusable devices (such as inflatable leg and arm splints, backboards, and neckboards)

• Emergency warning lights, sirens, and telecommunications equipment as required by State or local laws

• A 2-way voice radio or wireless telephone. In nonemergency situations, ambulance vehicles must be capable of transporting members with acute medical conditions.




Ambulance Personnel

A BLS ambulance vehicle must be staffed by at least two individuals, one of whom must be qualified in accordance with State and/or local laws as an EMT-Basic and is legally authorized to operate all lifesaving and life-sustaining equipment on board the vehicle.

An ALS ambulance vehicle must be staffed by at least two individuals, one of whom must be qualified in accordance with State and/or local laws as an EMT-Intermediate or an EMT-Paramedic.



Statement about Ambulance Vehicles and Personnel

To indicate that you meet the above requirements, include the following information about your ambulance vehicles and personnel in a statement you provide with your credentialing application:

• The first aid, safety and other patient care items with which the vehicles are equipped;

• The extent of first-aid training acquired by the personnel assigned to the vehicles;

• An agreement to notify Blue Cross and Blue Shield of Louisiana/HMO Louisiana of any change in operation that could affect the coverage of ambulance transports; and


• Documentary evidence (such as a letter or copy of a license, permit or certificate issued by State and/or local authorities) indicating that the vehicles are equipped as required.

Q: How should the number of miles for ground or air ambulance trips be coded?

A: If your date of service is on or after January 1, 2011, then you must report the number of miles as fractional units up to 100 covered miles. When reporting fractional mileage, round the total miles up to the nearest tenth (.10) of a mile and utilize the appropriate HCPCS code for ambulance mileage (A0425, A0435, A0436), even for trips totaling less than one mile (e.g., 0.7). For trips totaling 100 covered miles and greater, the mileage can be rounded up to the next whole number.


Q: When billing Part B ambulance services, there is a requirement to answer questions in the Certificate of Medical Necessity (CMN) attachment. One of the questions asks for the number of miles. Should the number of miles specific to the CMN attachment be coded in fractional miles?

A: No, not at this time. Continue to report the number of miles on the CMN attachment using whole numbers. However, the requirement is expected to change in the near future for consistency in reporting ambulance mileage.

Q: What guidance can you provide for ambulance companies that do not have the ability to measure fractional mileage because the odometer does not show tenths of a mile?

A: Ambulance suppliers may consider measuring mileage using a separate trip odometer; however, you will still be responsible for ensuring that trip mileage is measured and reported accurately, even if you fail to reset the trip odometer at the beginning of a trip. For example, if the driver fails to reset the trip odometer at the beginning of the trip, he or she would simply document the mileage at the end of the trip and subtract the mileage for the previous trip from the total, which would leave a remaining balance that should correspond to the distance of the current trip.
Tools used to measure distance traveled (such as GPS navigation equipment) are readily available to the average consumer at a low cost. As such, ambulance companies are responsible for ensuring that they have the necessary equipment to measure fractional mileage to the tenth of a mile and ensuring that onboard vehicle gauges measuring trip mileage are in working order.

Q. Where can I find fees for ambulance services?

A. Fees for ambulance services may be found in First Coast Service Options’ fee schedule lookup. Additional information may be found here, and on the Centers for Medicare & Medicaid Services (CMS) website at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AmbulanceFeeSchedule/index.html external link.


Limitation of Liability Regarding Ambulance Services FAQs

What is a technical, or statutory, denial on an ambulance claim?

The ambulance benefit is defined in title XVIII of the Social Security Act (the Act) in §1861(s)(7): “ambulance service where the use of other methods of transportation is contraindicated by the individual's condition, but only to the extent provided in regulations.” A technical denial occurs when the ambulance transport does not meet the definition for a Medicare covered benefit. Advance Beneficiary Notice (ABN) requirements are not applicable, so an ABN is not appropriate.

What is a medical necessity denial on an ambulance claim?

This is a denial that only occurs for transports that fully meet the benefit definition under §1861(s)(7), i.e., are a Medicare covered service. If the transport is a Medicare covered service, that particular ambulance service (in part or in full) would have to be determined to be “not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member” (the criterion of §1862(a)(1)).

In general,* “medical necessity denials” apply to claims for covered services that are not covered on a specific occasion for a particular individual. We often express this as “not for Fred today.” The same services may be covered for “Fred” on other days, and “Fred” might have other services that are covered for him “today,” but the denied service is not covered for “Fred today.”

[* The exceptions to this generality are not likely to frequently apply to ambulance services.]  

Medical necessity denials trigger the protections from financial liability under the Limitation On Liability (§1879) provision which involve the use of ABNs. An ABN may be used.


Q: What guidance can you provide for ambulance companies that do not have the ability to measure fractional mileage because the odometer does not show tenths of a mile?

A: Ambulance suppliers may consider measuring mileage using a separate trip odometer; however, you will still be responsible for ensuring that trip mileage is measured and reported accurately, even if you fail to reset the trip odometer at the beginning of a trip. For example, if the driver fails to reset the trip odometer at the beginning of the trip, he or she would simply document the mileage at the end of the trip and subtract the mileage for the previous trip from the total, which would leave a remaining balance that should correspond to the distance of the current trip.

Tools used to measure distance traveled (such as GPS navigation equipment) are readily available to the average consumer at a low cost. As such, ambulance companies are responsible for ensuring that they have the necessary equipment to measure fractional mileage to the tenth of a mile and ensuring that onboard vehicle gauges measuring trip mileage are in working order.

Wait time for AMBULANCE billing

Wait Time The appropriate number of time units must be reflected in the Quantity field. One time unit represents each 30 minutes of waiting time after the first 30 minutes. No additional payment is made for the first 30 minutes of waiting time (i.e., total waiting time of 1 hour 30 minutes = 2 time units).

The Remarks section or claim attachment must include the following information:

* Total length of waiting time, including the first 30 minutes.

* Name and NPI of the physician ordering the wait.

* Reason for the wait.

Mileage When billing a mileage code, enter the number of whole miles the beneficiary was transported in the Quantity field. When billing for mileage greater than 100 miles, enter the origin and destination addresses in the Remarks section. Do not use decimals.



UNLISTED AMBULANCE SERVICE

If a service is rendered that is not included in the coverages defined under the existing procedure codes, the ambulance provider may bill the procedure under the Unlisted Ambulance Service procedure code. The claim pends for manual review to determine whether the service is reimbursable under Medicaid guidelines.

Additional considerations:

* Items included in the base rate are not separately reimbursable.

* If no transport was provided, refer to the base rate billing instructions.

* A complete description of the service must be included in the Remarks section or as an attachment to the claim.



WAITING TIME

 Waiting time is reimbursable after the first 30 minutes when a physician deems it medically necessary forthe ambulance provider to wait at a hospital while the beneficiary is being stabilized, with the intent of continuing transport to a more appropriate hospital for care or back to the point of origin.

If more than four hours of waiting time is required, providers must request individual consideration and provide documentation. Providers should refer to the Billing & Reimbursement for Professionals or the Billing & Reimbursement for Institutional Providers chapters of this manual, as appropriate, for instructions.

WATER AMBULANCE

Non-emergency ambulance services provided by marine craft must be prior authorized. Providers should refer to the General Information for Providers Chapter of this manual for information on the PA process. Emergency ambulance services provided by marine craft do not require PA.

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