Local Coverage Determination (LCD): Transportation Services: Ambulance (L34302)

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1 Local Coverage Determination (LCD): Transportation Services: Ambulance (L34302) Contractor Information Contractor Name Cahaba Government Benefit Administrators, LLC LCD Information Document Information LCD ID L34302 Original ICD-9 LCD ID L30022 LCD Title Transportation Services: Ambulance AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date Revision Ending Date Retirement Date Notice Period Start Date Notice Period End Date

2 medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association. UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ( AHA ), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. CMS National Coverage Policy Title XVIII, Social Security Act, section 1833 (e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. Title XVIII, Social Security Act, section 1861 (v)(1)(k)(ii)defines emergency service. Title XVIII, Social Security Act, section 1861(s)(7) outlines 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. Title XVIII, Social Security Act, sections 1861 (s) and (t) outline coverage for drugs and biologicals and services and supplies.

3 Title XVIII, Social Security Act, section 1862(a)(1)(A) allows coverage and payment for only those services that are considered to be medically reasonable and necessary. 42 Code of Federal Regulations (42 CFR) Parts: o o o Medicare Benefit Policy Manual (Pub ), Chapter 10 Medicare Claims Processing Manual (Pub ), Chapter 15 Medicare Program Integrity Manual (Pub ): o Chapter 6, Section 6.4 o Chapter 13 Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity Indications Emergency - Ambulance Services (Ground) 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. Medical Necessity 1. Medical necessity is established if the patient's condition is an emergency and the patient is unable to go to the hospital by other means. 2. An emergency means services provided after the sudden onset of a medical condition, manifesting itself by acute signs or symptoms of sufficient severity

4 such that the absence of immediate medical attention could reasonably be expected to result in the following: placing the patient's health in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. 3. The definition of 911 call is described in the Utilization Guidelines section. Destination Covered destinations for emergency ambulance services include: 4. Acute care hospitals 5. Physician's office only if, during an emergency transportation to a hospital when, because of dire need for professional attention, the ambulance stops at a physician's office en route and immediately thereafter continues to the hospital. In such cases, the patient will be deemed not to have been transported to the physician's office and payment may be made for the entire trip. 6. Transfer site (airport/helicopter). As a general rule, only local transportation by an ambulance is covered. A. In order for ambulance services to be a covered benefit the transport must be to the nearest institution with appropriate facilities for the treatment of the illness or injury involved. The term "appropriate facilities" means that the institution is generally equipped to provide the needed hospital care for the illness or injury involved. It is the institution, its equipment, its personnel and its capability to provide the services necessary to support the required medical care that determine whether it has appropriate facilities. B. The fact that a more distant institution is better equipped, either qualitatively or quantitatively, to care for the patient does not warrant a finding that a closer institution does not have "appropriate facilities." However, a legal impediment barring a patient's admission would permit a

5 finding that the institution did not have "appropriate facilities". For example, the nearest appropriate specialty hospital may be in another state and that state's law precludes admission of nonresidents. C. In the case of ambulance services to a facility other than the closest appropriate facility, only those miles to the closest facility are eligible for coverage. Certification A Physician Certification Statement is not required for emergency transports. Non Emergency Ambulance Service (Ground) For non-emergency ambulance transportation, transportation by ambulance is appropriate if the beneficiary is bed-confined and it is documented that the beneficiary's medical condition is such that other methods of transportation are contraindicated, or if his or her medical condition, regardless of bed-confinement, is such that transportation by ambulance is medically required. Medicare coverage for non-emergency ambulance services is available: 1. Only when transportation by any other means is contraindicated by the medical condition of the patient; 2. Only to specific destinations; and 3. Only when certified as medically necessary by a physician directly responsible for the patient's care, with limited exceptions. (See Certification section below for special rules for scheduled, repetitive ambulance services and ambulance services that are either unscheduled or scheduled on a non-repetitive basis). NOTE: All three of the above criteria must be met. Medical Necessity Ambulance transport in non-emergency situations must meet medical necessity guidelines.

6 4. Medical necessity is established for non-emergency ambulance services when the patient's condition is such that the use of any other method of transportation (such as: taxi, private car, wheelchair van, or other type of vehicle) is contraindicated. If the condition contraindicating other means of transportation is "bed confined", the patient must meet the following condition of "bed confined." The inability to: A. Get up from bed without assistance;and B. Ambulate; AND C. Sit in a chair (including a wheelchair). NOTE: All three components must be met in order for the patient to be considered "bed-confined." It does not include a patient who is restricted to bed rest on a physician's instructions due to a short-term illness. Examples of situations in which patients are bed confined and cannot be moved by wheelchair, but must be moved by stretcher include: D. Contractures creating non-ambulatory status and patient cannot sit. E. Severe generalized weakness. F. Severe vertigo causing inability to remain upright. G. Immobility of lower extremities (patient in spica cast, fixed hip joints, or lower extremity paralysis) and unable to be moved by wheelchair. 5. If some means of transportation other than an ambulance (such as: private car, wheel chair van, etc.) could be utilized without endangering the individual's health, whether or not such other transportation is actually available, no payment may be made for ambulance service.

7 6. If transportation is for the purpose of receiving an excluded service (such as a routine dental examination) then the transportation is also excluded even if the patient could only have gone by ambulance. 7. If transportation is for the purpose of receiving a service that could have been safely and effectively provided in the point of origin (residence, Skilled Nursing Facility (SNF), hospital, etc.) then the transport is not covered even if the patient could only have gone by ambulance. 8. Ambulance transportation for services excluded from SNF consolidated billing must meet the criteria as reasonable and necessary (i.e. other means contraindicated). Destination Covered destinations for "non-emergency" transports include: 9. Acute care hospitals (Appropriate facility) 10. Inpatient Rehabilitation Facilities (IRFs) 11. Long-Term Acute Care (LTAC) Hospitals 12. SNF 13. Dialysis Facilities- ambulance services furnished to a maintenance dialysis patient should show that the patient's condition requires ambulance services 14. From a SNF to the nearest supplier of medically necessary services not available at the SNF where the beneficiary is a resident, including the return trip 15. The patient's residence (only if this is a return from an "appropriate facility")

8 A. In order for ambulance services to be a covered benefit the transport must be to the nearest institution with appropriate facilities for the treatment of the illness or injury involved. The term "appropriate facilities" means that the institution is generally equipped to provide the needed hospital or skilled nursing care for the illness or injury involved. It is the institution, its equipment, its personnel and its capability to provide the services necessary to support the required medical care that determine whether it has appropriate facilities. B. The fact that a more distant institution is better equipped, either qualitatively or quantitatively, to care for the patient does not warrant a finding that a closer institution does not have "appropriate facilities." However, a legal impediment barring a patient's admission would permit a finding that the institution did not have "appropriate facilities." For example, the nearest appropriate specialty hospital may be in another State and that State's law precludes admission of nonresidents C. In the case of ambulance services that are to a facility other than the closest appropriate facility, only those miles to the closest facility are eligible for coverage. Certification NOTE: If the transport is for the purpose of receiving a non-covered service, then the transport is also non-covered, even if the destination is an "appropriate facility." 16. Providers/suppliers of ambulance transportation must obtain a written certification from the physician for all scheduled transports certifying the medical necessity of the ambulance services. Requirements for non-emergency ambulance transportation include: A. Scheduled, repetitive ambulance services: The physician's order must be dated no earlier than 60 days in advance of the transport for repetitive patients whose transportation is scheduled in advance.

9 B. Unscheduled or scheduled on a non-repetitive basis: i. For residents in facilities who are under the direct care of a physician, written certification of medical necessity can be obtained within 48 hours after the transport. ii. If the ambulance provider/supplier is unable to obtain a signed physician certification statement from the beneficiary s attending physician, a signed certification statement must be obtained from either the physician assistant (PA), nurse practitioner (NP), clinical nurse specialist (CNS), a registered nurse (RN), or discharge planner, who has personal knowledge of the beneficiary s condition at the time the ambulance transport is ordered or the service is furnished. This individual must be employed by the beneficiary s attending physician or by the hospital or facility where the beneficiary is being treated and from which the beneficiary is transported. Medicare regulations for PAs, NPs, and CNSs apply and all applicable State licensure laws apply. iii. The ambulance provider/supplier is responsible for obtaining the signed certification with the appropriate signatures as expeditiously as possible, and must obtain the signed order before billing for the service. iv. If the ambulance provider/supplier is unable to obtain the written certification with appropriate signatures within 21 days after delivery of service the provider/supplier may bill only if there is documentation of good faith effort to obtain the order and certification. Acceptable documentation includes a signed return receipt from the U.S. Postal Service or other similar service that evidences that the ambulance provider/supplier attempted to obtain the required signature.

10 17. For a beneficiary residing at home or in a facility who is not under the direct care of a physician, a physician certification is not required. NOTE: It is important to note that the presence of the signed physician certification statement does not necessarily demonstrate that the transport was medically necessary. The ambulance provider/supplier must meet all coverage criteria in order for payment to be made. Emergency Air Ambulance Transportation 1. Medically appropriate air ambulance transportation either by means of a helicopter or fixed wing aircraft is a covered service regardless of the state or region in which it is rendered only if the beneficiary's medical condition required immediate and rapid ambulance transportation that could not have been provided by land ambulance, or either: A. The point of pick-up is inaccessible by land vehicle (this condition could be met in Hawaii, Alaska, and in other remote or sparsely populated areas of the continental United States), or B. Great distances or other obstacles (for example, heavy traffic) are involved in getting the patient to the nearest hospital with appropriate facilities as described in this policy. 2. Medicare payment determination for various air ambulance scenarios in which the flight is aborted due to bad weather, or other circumstances beyond the pilot s control is as follows: A. If the flight is aborted anytime before the beneficiary is loaded on board (i.e. prior to or after take-off to point-of-pickup), then there is no provision for Medicare payment. B. If the flight is aborted after the beneficiary is loaded onboard from transport, the Medicare payment is for the appropriate air base rate, mileage, and rural adjustment. Medical Necessity

11 Medical appropriateness is only established when the beneficiary's condition is such that the time needed to transport a beneficiary by land, or the instability of transportation by land, poses a threat to the beneficiary's survival or seriously endangers the beneficiary's health. These conditions may include, but are not limited to: 3. Intracranial bleeding - requiring neurosurgical intervention; 4. Cardiogenic shock; 5. Burns requiring treatment in a Burn Center; 6. Conditions such as carbon monoxide poisoning requiring treatment in a Hyperbaric Oxygen Unit; 7. Multiple severe injuries; 8. Life-threatening trauma. Destination Air ambulance transport is covered for transfer of a patient between hospitals when: 9. The point from which the beneficiary is transported to the nearest hospital with appropriate facilities is inaccessible by land vehicle, or great distances, or other obstacles (e.g. heavy traffic), AND 10. The beneficiary s medical condition is not appropriate for transport by either BLS or ALS ground ambulance. Certification

12 Certification requirements for air ambulance are based on the level of service provided (i.e. emergency and non-emergency). For the specific requirements, please see the corresponding ground transport physician certification requirements (i.e. emergency and non-emergency). Limitations Ambulance Services are not covered in the following circumstances: 1. Failure to obtain appropriate physician order and/or certification (as defined and required in this LCD) prior to billing for services. 2. When other means of transportation are not contraindicated. Coverage will not be allowed if the only documentation of medical necessity is "non-ambulatory". 3. Transfer from a hospital or SNF, which has appropriate facilities, to a second hospital or SNF. 4. The patient is not transported. (See exception re: patient death). 5. The patient is ambulatory and there is no emergency. 6. Transportation is to a non-covered destination. 7. Transportation is for purposes of obtaining a non-covered service. 8. Air Ambulance services are not covered for transport to a facility that is not an acute care hospital, such as a nursing facility, physician's office or a beneficiary's home.

13 9. If a determination is made that transport by ambulance was necessary, but land ambulance service would have sufficed, payment for the air ambulance service is based on the amount payable for land transport, if less costly. 10. If the transport was medically appropriate but the beneficiary could have been treated at a nearer hospital than the one to which he or she was transported, the transport payment is limited to the rate for the distance from the point of pickup to that nearer hospital. 11. Transport was to a funeral home. 12. The ambulance was used solely because other means of transportation were unavailable. 13. The individual merely needed assistance in getting from his room or home to a vehicle. Coding Information Bill Type Codes: 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. 999x Not Applicable 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

14 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. CPT/HCPCS Codes Group 1 Paragraph: Definition of Level of Service Please refer to the Medicare Benefit Policy Manual (Pub ), Chapter 10, Sections 10.4 and 30.1, which can be viewed at the following link: Medicare Benefit Policy Manual (Pub ), Chapter 10. Group 1 Codes: A0425 Ground mileage A0426 Als 1 A0427 ALS1-emergency A0428 bls A0429 BLS-emergency A0430 Fixed wing air transport A0431 Rotary wing air transport A0432 PI volunteer ambulance co A0433 als 2 A0434 Specialty care transport A0435 Fixed wing air mileage A0436 Rotary wing air mileage A0888 Noncovered ambulance mileage A0998 Ambulance response/treatment ICD-10 Codes that Support Medical Necessity Group 1 Paragraph: ICD-10 codes must be coded to the highest level of specificity. Consult the Official ICD-10-CM Guidelines for Coding and Reporting in the current ICD-10-CM book for correct coding guidelines. This LCD does not take precedence over the Correct Coding Initiative (CCI). Medical Necessity is not based exclusively on diagnosis (ICD-10-CM codes)

15 Group 1 Codes: Group 1Codes ICD-10 Code Description XX000 Not Applicable Showing 1 to 1 of 1 entries in Group 1 ICD-10 Codes that DO NOT Support Medical Necessity Group 1 Paragraph: Any ICD-10-CM code that is not listed in the "ICD-10 Codes that Support Medical Necessity" section of this LCD. Group 1 Codes: Group 1Codes ICD-10 Code Description XX000 Not Applicable Showing 1 to 1 of 1 entries in Group 1 Additional ICD-10 Information General Information Associated Information Documentation Requirements 1. The ambulance provider/supplier is responsible for maintaining complete and accurate documentation of the beneficiary's condition to demonstrate that the ambulance service being furnished meets the medical necessity criteria. If documentation is requested for review, please submit the following:

16 A. Physician written order for transport (if applicable) B. A signed and dated Physician Certification for Non-emergency Transport C. Beneficiary Financial Signature Requirements: i. Medicare requires the signature of the beneficiary, or that of his or her representative, for both the purpose of accepting assignment and submitting a claim to Medicare. ii. Medicare does not require that the signature to authorize claim submission be obtained at the time of transport for the purpose of accepting assignment of Medicare payment for ambulance benefits. When a provider/supplier is unable to obtain the signature of the beneficiary, or that of his or her representative, at the time of transport, it may obtain this signature any time prior to submitting the claim to Medicare for payment. iii. Refer to the Medicare Benefit Policy Manual (Pub ), Chapter 10, Section for complete details of the Beneficiary Signature Requirements. D. Trip record to include: i. Detailed statement of the condition necessitating the ambulance ii. Statement if patient was admitted as an inpatient iii. Point of pick-up (identify place and complete address) iv. Number of loaded miles/cost per mile/mileage charge v. Minimal or base charge and charge for special items or services with an explanation E. Rationale for condition (bed confined if applicable) F. Any further documentation that supports the medical necessity of ambulance transport (i.e. emergency room report)

17 G. Hospital discharge/transfer summary, if applicable. 2. Documentation must support CMS 'signature requirements' as described in the Medicare Program Integrity Manual (Pub ), Chapter 3. Utilization Guidelines 1. The phrase 911 call or equivalent is intended to establish the standard that the nature of the call at the time of dispatch is the determining factor. Regardless of the medium by which the call is made (e.g., a radio call could be appropriate) the call is of an emergent nature when, based on the information available to the dispatcher at the time of the call, it is reasonable for the dispatcher to issue an emergency dispatch in light of accepted, standard dispatch protocol. An emergency call need not come through 911 even in areas where a 911 call system exists. However, the determination to respond emergently must be in accord with the local 911 or equivalent service dispatch protocol. If the call came in directly to the ambulance provider/supplier, then the provider s/supplier s dispatch protocol and the dispatcher s actions 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 both the protocol and the dispatcher s actions must meet, at a minimum, the standards of the dispatch protocol in another similar jurisdiction within the State, or if there is no similar jurisdiction, then the standards of any other dispatch protocol within the State. Where the dispatch was inconsistent with the 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. 2. Multiple Patient Ambulance Transport - If two patients are transported to the same destination simultaneously, for each Medicare beneficiary, Medicare will allow 75 percent of the payment allowance for the base rate applicable to the level of care furnished to that beneficiary plus 50 percent of the total mileage payment allowance for the entire trip. If three or more patients are transported to the same destination simultaneously, then the payment allowance for the Medicare beneficiary (or each of them) is equal to 60 percent of the base rate applicable to the level of care furnished to the beneficiary. However, a single payment allowance for mileage will be prorated by the number of patients onboard. This policy applies to both ground and air transports. Facility providers must report value code 32 (multiple patient ambulance transport) and the number of patients transported in the amount field as a whole number to the left of the delimiter. Providers/suppliers may not report additional ambulance services on a claim that contains a multiple ambulance transport, even if the point of pickup zip code is the same. A separate claim must be submitted for additional ambulance services.

18 3. Multiple arrivals - When multiple units respond to a call for services, the entity that provides the transport for the beneficiary should be the only provider/supplier billing the service. 4. Downcoding from air to ground ambulance is an 1862 (a)(1)(a) denial. 5. The following do not qualify to validate as an indicator that an ALS-2 level has been supplied: A. Aspirin B. Oxygen C. IV Fluids Sources of Information and Basis for Decision The law, the regulations, and the coverage in interpretive manuals that apply to Ambulance (see the CMS National Coverage Policy Section of this LCD). Other Medicare Contractors' LCDs Revision History Information Associated Documents Attachments Related Local Coverage Documents Related National Coverage Documents Public Version(s) Updated on 04/14/2014 with effective dates 10/01/2015 -

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