LCD L Ambulance (Ground) Services - Posted for Notice

Transcription

1 (J12) LCD L Ambulance (Ground) Services - Posted for Notice (Effective 04/12/2... Page 1 of 25 LCD L Ambulance (Ground) Services - Posted for Notice Contractor Information Contractor Name: Novitas Solutions, Inc. Contractor Number(s): 12102, 12202, 12302, 12501, 12301, 12201, 12401, 12402, 12101, 12502, Contractor Type: MAC Part A & B Go to Top LCD Information Document Information LCD ID Number L32252 LCD Title Ambulance (Ground) Services - Posted for Notice Contractor s Determination Number L32252 AMA CPT/ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. Primary Geographic Jurisdiction Pennsylvania, Maryland, District of Columbia, New Jersey, Delaware Oversight Region Central Office Original Determination Effective Date For services performed on or after 04/12/2012 Original Determination Ending Date N/A Revision Effective Date For services performed on or after N/A Revision Ending Date N/A CMS National Coverage Policy Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury. Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations. Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim. Title XVIII of the Social Security Act, Section 1861(s)(7), Ambulance Service Title XVIII of the Social Security Act, Section 1861 (v)(1)(k)(ii), Bona Fide Emergency Services CMS Internet-Only Manual (IOM), Publication (Pub.) , Medicare Benefit Policy Manual, Chapter 10, Ambulance Services CMS IOM Pub , Medicare Claims Processing Manual, Chapter 15, Ambulance

2 (J12) LCD L Ambulance (Ground) Services - Posted for Notice (Effective 04/12/2... Page 2 of 25 Indications and Limitations of Coverage and/or Medical Necessity Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits. The Medicare payment benefit for ambulance services is very restricted. Ambulance suppliers must understand the benefit and refrain from seeking Medicare payment for services that do not conform to the limited benefit requirements as stated in regulation. Physicians and others who order and certify medical necessity of ambulance services must also understand and abide by the limitations of Medicare coverage of ambulance services. This LCD includes, for reference only, portions of CMS national payment policy as found in relevant Internet-Only Manual (IOM) sections and regulations. This LCD further provides limited coverage diagnosis to procedure edit requirements for ambulance suppliers who choose to submit ICD-9-CM codes on their claims. The LCD also contains utilization guidelines for the purpose of automated ambulance claim denial by the contractor in its jurisdictions. CMS National Payment Policy Medicare covers ambulance services only if furnished to a beneficiary whose medical condition at the time of transport is such that transportation by other means would endanger the patient s health. A patient whose condition permits transport in any type of vehicle other than an ambulance does not qualify for Medicare payment. Medicare payment for ambulance transportation depends on the patient s condition at the actual time of the transport regardless of the patient s diagnosis. To be deemed medically necessary for payment, the patient must require both the transportation and the level of service provided. Medicare covers both emergency ambulance transportation and non-emergency ambulance transportation as follows: Medical Necessity Ambulance transportation is covered when the patient s condition requires the vehicle itself and/or the specialized services of the trained ambulance personnel. A requirement of coverage is that the needed services of the ambulance personnel were provided and clear clinical documentation in the patient s medical record validates their medical need and their provision. The patient s condition, as well as changes in that condition and the treatment provided, must be in the record of the ambulance service (usually the run sheet). Emergency Ambulance Services 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 complies with all State and local laws governing an emergency transportation vehicle. Emergency response means responding immediately at the Basic Life Support (BLS), Advanced Life Support 1 (ALS1) level of service or Advanced Life Support 2 (ALS-2 emergency) to a 911 call or the equivalent. An immediate response is one in which the ambulance supplier begins as quickly as possible to take the steps necessary to respond to the call. Application: The determination to respond emergently with a BLS or ALS1 ambulance must be in accord with the local 911 or equivalent service dispatch protocol (ALS2 has additional requirements). If the call came in directly to the ambulance provider/supplier, then the provider s/supplier s dispatch protocol 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 the protocol must meet, at a minimum, the standards of a dispatch protocol in another similar jurisdiction within the State or, if there is no similar jurisdiction within the State, then the standards of any other dispatch protocol within the State. Where the dispatch was inconsistent with this 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. Non-Emergency Ambulance Service

3 (J12) LCD L Ambulance (Ground) Services - Posted for Notice (Effective 04/12/2... Page 3 of 25 Ambulance services are covered in the absence of an emergency condition in either of the two general categories of circumstances that follow: The patient being transported has, at the time of ground transport, a condition such that all other methods of ground transportation (e.g., taxi, private automobile, wheelchair van or other vehicle) are contraindicated. In this circumstance, contraindicated means that the patient cannot be transported by any other means from the origin to the destination without endangering the individual s health. Having or having had a serious illness, injury or surgery does not necessarily justify Medicare payment for ambulance transportation. Thus, a thorough assessment and documented description of the patient s current state by the treating provider is essential for coverage. All statements about the patient s medical condition must be validated in the documentation using contemporaneous objective observations and findings. See Table I of medical conditions below for examples of findings required for coverage of ambulance transportation. The patient is bed-confined before, during and after transportation. For the purposes of this LCD, "bed-confined" means the patient must meet all of the following three criteria: Unable to get up from bed without assistance, Unable to ambulate, and Unable to sit in a chair (including a wheelchair). Statements about the patient s bed-bound status must be validated in the record of the ordering provider with contemporaneous objective observations and findings as to the patient s functional physical and/or mental limitations that have rendered him/her bed-bound. Non-emergency ambulance transportation is not covered for patients who are restricted to bed rest by a physician s instructions but who do not meet the above three criteria. If some means of transportation other than an ambulance (i.e., private car, wheelchair van, etc.) could be utilized without endangering the individual s health, regardless if such other transportation is actually available, no payment may be made for ambulance service. Non-emergency ambulance services may be those that are scheduled in advance scheduled services being either repetitive or non-repeating. Non-emergency ambulance transportation is not covered if transportation is provided for the patient to receive a service that could have been safely and effectively provided in the point of origin (residence, Skilled Nursing Facility (SNF), hospital, etc.). Such transportation is not covered even if the patient could only have gone for the service by ambulance. Ambulance transportation for services excluded from SNF consolidated billing must meet the reasonable and necessary criteria as indicated above. Ambulance transports to or from an Independent Diagnostic Testing Facility (IDTF) are considered paid in the SNF Prospective Payment System (PPS) rate when the beneficiary is in a covered Part A stay and may not be paid separately as Part B services. The ambulance transport is included in the SNF PPS rate if the first or second character (origin or destination) of any HCPCS code ambulance modifier is D (diagnostic or therapeutic site other than P or H ), and the other modifier (origin or destination) is N (SNF). In this instance, the SNF is responsible for the costs of the transport. The D origin/destination modifier includes cancer treatment centers, wound care centers, radiation therapy centers, and all other diagnostic or therapeutic sites. Destination 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 hospital care necessary to manage 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. The fact that a more distant institution may be better equipped (either subjectively or quantitatively) does not mean that the closer institution does not have appropriate facilities. In the case of a hospital, it also means that a physician or a physician specialist is available to provide the necessary care required to treat the patient s condition. However, the fact that a particular physician does or does not have staff privileges in a hospital is not a consideration in determining whether the hospital has appropriate facilities. Thus,

4 (J12) LCD L Ambulance (Ground) Services - Posted for Notice (Effective 04/12/2... Page 4 of 25 ambulance service to a more distant hospital solely to avail a patient of the service of a specific physician or physician specialist does not make the hospital in which the physician has staff privileges the nearest hospital with appropriate facilities. However, a legal impediment that bars the patient s admission would preclude that institution from having appropriate facilities. For example, if the nearest appropriate specialty hospital is in another state and that state s law precludes admission of nonresidents, that facility is not an appropriate facility. An institution is also not considered an appropriate facility if there is no bed available. The contractor, however, will presume there are beds available at the local institutions unless the claimant furnished evidence that none of these institutions had a bed available at the time the ambulance service was provided. 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. Covered destinations for emergency ambulance services include: Hospitals. Physician s office only if during an emergency transportation to a hospital the ambulance stops at a physician s office en route due to a dire need for professional attention and thereafter continues to the hospital. In such cases, the patient is deemed not to have been transported to the physician s office and payment may be made for the entire trip. Covered destinations for non-emergency transports include: Hospitals ( appropriate facility ). Skilled nursing facilities. Dialysis facilities Ambulance services furnished to a maintenance dialysis patient only when the patient s condition at the time of transport requires ambulance services. From an SNF to the nearest supplier of medically necessary services not available at the SNF where the beneficiary is a resident, including the return trip (for instance, cardiac catheterization; specialized diagnostic imaging procedures such as computerized axial tomography or magnetic resonance imaging; surgery performed in an operating room; specialized wound care; cancer treatments) when the patient s condition at the time of transport requires ambulance services. The patient s residence only if the transport is to return from an appropriate facility and the patient s condition at the time of transport requires ambulance services. Physician Certification Statement (PCS) For scheduled and non-scheduled non-emergency ambulance transports, providers of ambulance transportation must obtain a written statement (PCS) from the patient s attending physician, PA, NP, CNS, RN or discharge planner certifying that medical necessity requirements for ambulance transportation are met. The signature of the medical professional completing the PCS must be legible (or accompanied by a typed or printed name) and include credentials. Furthermore, signatures on the PCS must be dated at the time they are completed. A PCS is not required for emergency transports or for non-scheduled non-emergency transports of patients residing at home or in facilities where they are not under the direct care of a physician. It is important to note that the mere presence of the signed provider certification statement does not, by itself, demonstrate that the transport was medically necessary and does not absolve the ambulance provider from meeting all other coverage and documentation criteria. For non-repetitive non-emergency transports, the following apply: If the ambulance provider is unable to obtain the PCS from the attending physician within 48 hours of transport, the ambulance provider may submit a claim if a certification has been obtained from a Physician Assistant (PA), Nurse Practitioner (NP), Clinical Nurse Specialist (CNS), Registered Nurse (RN) or discharge planner who is knowledgeable about the patient s condition and who is employed by either the attending physician or the facility in which the patient is admitted. Alternatively, the provider may submit the claim after 21 days if there is documentation of attempt(s) to obtain the order and certification. The ambulance supplier must document efforts to obtain certification. When the PCS cannot be obtained in accordance with 42 CFR , the provider/supplier may send a letter via U.S. Postal Service certified mail with return receipt and/or proof of mailing and/or other similar service (FedEx, UPS) demonstrating delivery of the letter as evidence of the attempt to obtain the PCS.

5 (J12) LCD L Ambulance (Ground) Services - Posted for Notice (Effective 04/12/2... Page 5 of 25 For repetitive non-emergency transports, the following apply: A PCS for repetitive transports must be signed by the patient s attending provider. The PCS must be dated no earlier than 60 days in advance of the transport for those patients who require repetitive ambulance services and whose transportation is scheduled in advance. Tables of Medical Conditions The following diagnoses tables illustrate the severity of the patient s condition to justify payment for ambulance transportation services when all other coverage and payment conditions are met. Though not all-inclusive, the following table lists medical conditions for which ambulance transportation is commonly required and can be used to judge relative severity of conditions not listed. The run report must include a description of the patient s symptoms and physical findings in sufficient detail as to demonstrate conditions such as those described in the tables. I. Medical Conditions Complaint or Symptom Condition Requirement Examples of Systems and Findings Necessary (and Documented) For Coverage Abdominal pain Accompanied by other signs or symptoms Associated symptoms include nausea, vomiting, fainting. Associated signs include tender or pulsatile mass, distention, rigidity, rebound tenderness on exam, guarding. Abnormal cardiac rhythm/cardiac dysrhythmia Abnormal skin signs Alcohol or drug intoxication Allergic reaction Animal bites/sting/ envenomation Sexual assault Blood glucose Back pain (see general pain listing below) Symptomatic or potentially lifethreatening arrhythmia Severe intoxication Potentially life-threatening manifestations Potentially life- or limbthreatening With significant external and/or internal injuries Abnormal <80 or >250 with symptoms Sudden onset, severe nontraumatic pain suggestive of cardiac or vascular origin or requiring special positioning only available by ambulance Necessary symptoms include syncope or near syncope, chest pain and dyspnea. Signs required include severe bradycardia or tachycardia (rate < 60 or > 120), signs of congestive heart failure. Examples include junctional and ventricular rhythms, non-sinus tachycardias, PVCs > 6/min, biand trigeminy, ventricular tachyarrhythmias, PEA, asystole. Patients are expected to have conditions that require monitoring during and after transportation. Includes diaphorhesis, cyanosis, delayed capillary refill, diminished skin turgor, mottled skin. Presence of other emergency conditions Unable to care for self. Unable to ambulate. Altered level of consciousness. Airway may or may not be at risk. Includes rapidly progressive symptoms, prior history of anaphylaxis, wheezing, oral/facial/laryngeal edema Symptoms of specific envenomation, significant face, neck, trunk and extremity involvement. Special handling and/or monitoring required. Presence of other emergency conditions. Signs include altered mental status (altered beyond baseline function), vomiting, significant volume contraction, significant cardiac dysfunction on 10-point severity scale. Neurologic symptoms and/or signs, absent leg pulses, pulsatile abdominal mass, concurrent chest or abdominal pain

6 (J12) LCD L Ambulance (Ground) Services - Posted for Notice (Effective 04/12/2... Page 6 of 25 Complaint or Symptom Condition Requirement Examples of Systems and Findings Necessary (and Documented) For Coverage Respiratory arrest Includes apnea or hypoventilation requiring ventilatory assistance and airway management Respiratory distress, shortness of breath, need for supplemental oxygen Cardiac arrest with resuscitation in progress Chest pain (nontraumatic) Choking episode Cold exposure Altered level of consciousness (nontraumatic) Convulsions/seizures Non-traumatic headache Objective evidence of abnormal respiratory function Cardiac origin suspected. Obvious non-emergent cause not identified Respiratory or neurologic impairment Potentially life- or limbthreatening Neurologic dysfunction in addition to any baseline abnormality Active seizing or immediate post-seizure at risk of repeated seizure and requires medical monitoring/observation Associated neurologic signs and/or symptoms or abnormal vital signs Includes tachypnea, labored respiration, hypoxemia requiring oxygen administration. Includes patients who require advanced airway management such as ventilator management, apnea monitoring for possible intubation and deep airway suctioning. Includes patients who require positioning not possible in other conveyance vehicles. Note that oxygen administration absent signs or symptoms of respiratory distress is, by itself, inadequate reason to justify ambulance transportation in a patient capable of selfadministration of oxygen. Patient must require oxygen therapy and be so frail as to require assistance of medically trained personnel. Pain characterized as severe, tight, dull or crushing, substernal, epigastric, left-sided chest pain. Especially with associated pain of the jaw, left arm, neck, back, GI symptoms (such as nausea, vomiting), arrhythmias, palpitations, difficulty breathing, pallor, diaphoresis, alteration of consciousness. Atypical pain accompanied by nausea and vomiting, severe weakness, feeling of impending doom or abnormal vital signs. Findings include temperature < 95º F, signs of deep frost bite or presence of other emergency conditions. Acute condition with Glasgow Coma Scale <15 or transient symptoms of dizziness associated with neurologic or cardiovascular symptoms and/or signs or abnormal vital signs Conditions include new onset or untreated seizures or history of significant change in baseline control of seizure activity. Findings include ongoing seizure activity, post-ictal neurologic dysfunction. Heat exposure Potentially life-threatening Findings include hot and dry skin, core temperature >105º, neurologic dysfunction, muscle cramps, profuse sweating, severe fatigue. Hemorrhage Potentially life-threatening Includes uncontrolled bleeding with signs of shock and active severe bleeding (quantity identified) ongoing or recent with potential for immediate rebleeding. Infectious diseases requiring isolation procedures/public health risk The nature of the infection or the behavior of the patient must be such that failure to isolate Infections in this category are limited to those infections for which isolation is provided both before and after transportation.

7 (J12) LCD L Ambulance (Ground) Services - Posted for Notice (Effective 04/12/2... Page 7 of 25 Complaint or Symptom Condition Requirement Examples of Systems and Findings Necessary (and Documented) For Coverage poses significant risk of spread of a contagious disease. Hazardous substance exposure Medical device failure Neurologic dysfunction Pain not otherwise specified in this table Poisons ingested, injected, inhaled or absorbed, alcohol or drug intoxication Complication of pregnancy/childbirth and postoperative procedure complications Psychiatric/behavioral Fever The nature of the exposure should be such that potential injury is likely. Life- or limb-threatening malfunction, failure or complication Acute or unexplained neurologic dysfunction in addition to any baseline abnormality Pain is the reason for the transport. Acute onset or bedconfining. Potentially life-threatening Requires special handling for transport Is expressing active signs and/or symptoms of uncontrolled psychiatric condition or acute substance withdrawal. Is a threat to self or others requiring restraint (chemical or physical) or monitoring and/or intervention of trained medical personnel during transport for patient and crew safety. Transport is required by state law/court order. Significantly high fever unresponsive to pharmacologic intervention or fever with associated symptoms Toxic fume or liquid exposure via inhalation, absorption, oral, radiation, smoke inhalation Malfunction of ventilator, internal pacemaker, internal defibrillator, implanted drug delivery device, O 2 supply malfunction, orthopedic device failure Signs include facial drooping, loss of vision without ophthalmologic explanation, aphasia, dysphasia, difficulty swallowing, numbness, tingling extremity, stupor, delirium, confusion, hallucinations, paralysis, paresis (focal weakness), abnormal movements, vertigo, unsteady gait/balance. Pain is severity of 7 10 on 10-point severity scale despite pharmacologic intervention. Patient needs specialized handling to be moved. Other emergency conditions are present or reasonably suspected. Signs of other life- or limb-threatening conditions are present. Associated cardiopulmonary, neurologic, or peripheral vascular signs and symptoms are present. Requires cardiopulmonary and/or neurologic monitoring and support and/or urgent pharmacologic intervention. Includes circumstances in which quantity and identity of agent known to be life-threatening; instances in which quantity and identity of agent are not known but there are signs and symptoms of neurologic dysfunction, abnormal vital signs, or abnormal cardiopulmonary function. Also, includes circumstances in which quantity and identity of agent are not known but life-threatening poisoning reasonably suspected. Includes major wound dehiscence, evisceration, organ prolapse, hemorrhage or orthopedic appliance failure Includes disorientation, suicidal ideations, attempts and gestures, homicidal behavior, hallucinations, violent or disruptive behavior, sign/symptoms or DTs, drug withdrawal signs/symptoms, severe anxiety, acute episode or exacerbation of paranoia. Refer to definition of restraints in the CFR, Section (e). For behavioral or cognitive risk such that patient requires attendant to assure patient does not try to exit the ambulance prematurely, see CFR, Section (f)(2) for definition. Temperature after pharmacologic intervention >102º (adult) Temperature after pharmacologic intervention >104º (child) Associated neurologic or cardiovascular symptoms/signs, other abnormal vital signs

8 (J12) LCD L Ambulance (Ground) Services - Posted for Notice (Effective 04/12/2... Page 8 of 25 Complaint or Symptom Condition Requirement Examples of Systems and Findings Necessary (and Documented) For Coverage Gastrointestinal distress Accompanied by other signs or symptoms Severe nausea and vomiting or severe, incapacitating diarrhea with evidence of volume depletion, abnormal vital signs or neurologic dysfunction General mobility issues and bed confinement Patient s physical condition is such that patient risks injury during vehicle movement despite restraints or positioning and/or record demonstrates specialized handling required and provided This may be due to any or multiple of the conditions listed above. All conditions that contribute to general mobility issues must be adequately described. Includes conditions such as: Decubitus ulcers on sacrum or buttocks that are grade 3 or greater for transfers requiring more than 60 minutes of sitting. Lower extremity contractures that are of sufficient degree as to prohibit sitting in a wheelchair (severe fixed contractures at or proximal to the knee). Unstable joints. Includes flail weight-bearing joints following joint surgery. Includes other patients who, in the expressed opinion of the operating surgeon, must absolutely bear no weight on a postoperative joint or patients who are incapable of protecting the joint without the assistance of the trained medical ambulance personnel. Patients who have undergone successful weight bearing joint repair/replacement and those who have successfully undergone long-bone fracture repair (and who are not otherwise immobilized in casts that prohibit sitting) will generally not be included. Severely debilitating chronic neurological conditions such as degenerative conditions or strokes with severe sequelae. Neurological deficits must be described. Morbid obesity (as a sole qualifying condition) causing the patient to meet the regulatory definition of bed-confined. Medicare does not expect this to occur with persons whose BMI is <80. II. Conditions Trauma On-Scene Condition (General) On-Scene Condition (Specific) Comments and Examples (Not All-Inclusive) Major trauma Other trauma Hemorrhage As defined by ACS Field Triage Decision Scheme Need to monitor or maintain airway or immobilize head/neck Potentially life-threatening hemorrhage Trauma with one of the following: Glasgow < 14; systolic BP < 90; RR < 10 or > 29; all penetrating injuries to head, neck, torso, extremities proximal to elbow or knee; flail chest; combination of trauma and burns; pelvic fracture; two or more long-bone fractures; open or depressed skull fracture; paralysis; severe mechanism of injury including: ejection, death of another passenger in same patient compartment, falls > 20 feet, 20-inch deformity in vehicle or 12-inch deformity of patient compartment, auto pedestrian/bike, pedestrian thrown/run over, motorcycle accident at speeds > 20 miles per hour and rider separated from vehicle Decreased level of consciousness, bleeding into airway, significant trauma to head, face or neck Includes uncontrolled bleeding with signs of shock and active severe bleeding

9 (J12) LCD L Ambulance (Ground) Services - Posted for Notice (Effective 04/12/2... Page 9 of 25 On-Scene Condition (General) On-Scene Condition (Specific) Comments and Examples (Not All-Inclusive) (quantity identified), ongoing or recent, with potential for immediate rebleeding Suspected fractures/dislocations Suspected fracture or dislocation requires splinting/immobilization and renders patient unable to be transported by another vehicle Includes suspected fractures or dislocations of spine and long bones and joints proximal to knee and elbow. The record will demonstrate history of significant trauma and or findings to support such suspicions. Penetrating extremity injuries Life-or limb-threatening injury Uncontrolled hemorrhage, compromised neurovascular supply, uncontrollable pain requiring pharmacologic intervention Traumatic amputations Life-threatening injury or reattachment opportunity exists Suspected internal, head, chest or abdominal injuries Burns Lightning Electrocution Near-drowning Eye injuries Major: per American Burn Association (ABA) Acute vision loss or blurring, severe pain or chemical exposure, penetrating, severe lid lacerations Signs of closed head injury, open head injury, pneumothorax, hemothorax, abdominal bruising, positive abdominal signs on exam, internal bleeding criteria, evisceration Partial thickness burns > 10 percent Total Body Surface Area (TBSA); involvement of face, hands, feet, genitalia, perineum or major joints; third-degree burns; electrical, chemical, inhalation burns with pre-existing medical disorders; burns and trauma Patients Transported to and From Hemodialysis Centers Only a fraction (approximately 10 percent) of End Stage Renal Disease (ESRD) patients on chronic hemodialysis require ambulance transportation to and from hemodialysis sessions. The presence of ESRD and the requirement for hemodialysis do not alone qualify a patient for ambulance transportation. To be considered reasonable and necessary, patients transported to and from hemodialysis centers must have other conditions such as those described in the tables above and adequate documentation of those conditions must be in the ambulance supplier s run reports and in the medical records of other providers involved with the patient s care. Special Considerations Regarding Beneficiary Death Payment for ambulance services in circumstances in which the beneficiary dies is based on the time of the beneficiary s death related to the time of the call for service and transport. In cases where the beneficiary is pronounced dead after the ambulance is called but before the ambulance arrives at the scene, payment may be made for a BLS service. Neither mileage nor a rural adjustment would be paid. The blended rate amount will otherwise apply. In cases where the beneficiary is pronounced dead after being loaded into the ambulance (regardless of whether the pronouncement is made during or subsequent to the transport), payment is made following the

10 Page 10 of 25 usual rules of payment as if the beneficiary had not died. This scenario includes a determination of Dead on Arrival (DOA) at the facility to which the beneficiary was transported. Limitations Medicare does not cover the following services: Transportation in Ambi-buses, ambulettes (Mobility Assistance Vehicle (MAV)), Medi-cabs, vans, privately owned vehicles, taxicabs. Transportation via Mobile Intensive Care Unit (MICU) (if billed under Medicare Part A). Parking fees. Tolls for bridges, tunnels and highways. Medicare does not provide payment for Ambulance response and treatment, no transport (A0998). Coding Information Bill Type Codes Go to Top 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. 011x Hospital Inpatient (Including Medicare Part A) 012x 013x 083x 085x Hospital Inpatient (Medicare Part B only) Hospital Outpatient Ambulatory Surgery Center 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. 054X Ambulance - General Classification CPT/HCPCS Codes Italicized and/or quoted material is excerpted from the American Medical Association, Current Procedural Terminology (CPT) codes. A0425 A0426 A0427 A0428 A0429 GROUND MILEAGE, PER STATUTE MILE AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, NON-EMERGENCY TRANSPORT, LEVEL 1 (ALS 1) AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, EMERGENCY TRANSPORT, LEVEL 1 (ALS1-EMERGENCY) AMBULANCE SERVICE, BASIC LIFE SUPPORT, NON-EMERGENCY TRANSPORT, (BLS) AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY TRANSPORT (BLS-EMERGENCY)

11 Page 11 of 25 A0433 ADVANCED LIFE SUPPORT, LEVEL 2 (ALS 2) A0434 SPECIALTY CARE TRANSPORT (SCT) The following CPT/HCPCS code is Non-Covered: A0888 NONCOVERED AMBULANCE MILEAGE, PER MILE (E.G., FOR MILES TRAVELED BEYOND CLOSEST APPROPRIATE FACILITY) ICD-9 Codes that Support Medical Necessity It is the provider s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-9-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted. 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). 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 prior to the effective date of this policy, ambulance suppliers were not required to submit ICD-9-CM codes on their claims if filing on a 1500 claim form or utilizing an electronic version other than the 5010 version of the 837P. The CPT/HCPCS codes included in this LCD will be subjected to procedure to diagnosis editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a claim contains one or more ICD-9-CM diagnoses but a covered diagnosis code is not on the claim, the edit will deny the service. It is expected that ambulance transportation from acute care facilities will not routinely be reported with the same diagnosis codes reported for the emergent visit to the facility. For HCPCS codes A0425, A0426, A0427, A0428, A0429, A0433 and A0434: Covered for Ambulance Transportation Services to the Site of Medical Care: DIABETES WITH KETOACIDOSIS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED - DIABETES WITH KETOACIDOSIS, TYPE I [JUVENILE TYPE], UNCONTROLLED DIABETES WITH HYPEROSMOLARITY, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED - DIABETES WITH HYPEROSMOLARITY, TYPE I [JUVENILE TYPE], UNCONTROLLED DIABETES WITH OTHER COMA, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED - DIABETES WITH OTHER COMA, TYPE I [JUVENILE TYPE], UNCONTROLLED DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED - DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED

12 Page 12 of HYPOGLYCEMIC COMA - OTHER SPECIFIED HYPOGLYCEMIA ALCOHOL WITHDRAWAL DELIRIUM ALCOHOL WITHDRAWAL DRUG WITHDRAWAL PATHOLOGICAL DRUG INTOXICATION 293.0* DELIRIUM DUE TO CONDITIONS CLASSIFIED ELSEWHERE 293.1* SUBACUTE DELIRIUM 298.8* OTHER AND UNSPECIFIED REACTIVE PSYCHOSIS * OTHER DISORDERS OF IMPULSE CONTROL ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL SUBSEQUENT EPISODE OF CARE TRUE POSTERIOR WALL INFARCTION EPISODE OF CARE UNSPECIFIED - TRUE POSTERIOR WALL INFARCTION SUBSEQUENT EPISODE OF CARE SUBENDOCARDIAL INFARCTION EPISODE OF CARE UNSPECIFIED - SUBENDOCARDIAL INFARCTION SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE SUBSEQUENT EPISODE OF CARE PRINZMETAL ANGINA IATROGENIC PULMONARY EMBOLISM AND INFARCTION OTHER PULMONARY EMBOLISM AND INFARCTION CARDIAC TAMPONADE

13 Page 13 of ATRIOVENTRICULAR BLOCK COMPLETE RIGHT BUNDLE BRANCH BLOCK AND LEFT POSTERIOR FASCICULAR BLOCK - TRIFASCICULAR BLOCK PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA - PAROXYSMAL VENTRICULAR TACHYCARDIA ATRIAL FIBRILLATION - ATRIAL FLUTTER VENTRICULAR FIBRILLATION - VENTRICULAR FLUTTER CARDIAC ARREST UNSPECIFIED SYSTOLIC HEART FAILURE - ACUTE ON CHRONIC SYSTOLIC HEART FAILURE UNSPECIFIED DIASTOLIC HEART FAILURE - ACUTE ON CHRONIC DIASTOLIC HEART FAILURE UNSPECIFIED COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE - ACUTE ON CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE 431 INTRACEREBRAL HEMORRHAGE CEREBRAL THROMBOSIS WITHOUT CEREBRAL INFARCTION - CEREBRAL THROMBOSIS WITH CEREBRAL INFARCTION CEREBRAL EMBOLISM WITHOUT CEREBRAL INFARCTION - CEREBRAL EMBOLISM WITH CEREBRAL INFARCTION CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITHOUT CEREBRAL INFARCTION - CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITH CEREBRAL INFARCTION UNSPECIFIED TRANSIENT CEREBRAL ISCHEMIA HEMIPLEGIA AFFECTING UNSPECIFIED SIDE - HEMIPLEGIA AFFECTING NONDOMINANT SIDE MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE PHLEBITIS AND THROMBOPHLEBITIS OF FEMORAL VEIN (DEEP) (SUPERFICIAL) HYPOTENSION UNSPECIFIED HEMORRHAGE UNSPECIFIED ASTHMA UNSPECIFIED TYPE WITH STATUS ASTHMATICUS - ASTHMA UNSPECIFIED WITH (ACUTE) EXACERBATION 496* CHRONIC AIRWAY OBSTRUCTION NOT ELSEWHERE CLASSIFIED 514 PULMONARY CONGESTION AND HYPOSTASIS ACUTE EDEMA OF LUNG UNSPECIFIED TRANSFUSION RELATED ACUTE LUNG INJURY (TRALI) STRICTURE AND STENOSIS OF ESOPHAGUS

14 Page 14 of INTESTINAL OR PERITONEAL ADHESIONS WITH OBSTRUCTION (POSTOPERATIVE) (POSTINFECTION) OTHER SPECIFIED INTESTINAL OBSTRUCTION HEMORRHAGE OF GASTROINTESTINAL TRACT UNSPECIFIED OTHER SPECIFIED COMPLICATIONS OF PREGNANCY UNSPECIFIED AS TO EPISODE OF CARE PRESSURE ULCER, LOWER BACK - PRESSURE ULCER, BUTTOCK PRESSURE ULCER, STAGE III - PRESSURE ULCER, STAGE IV CONTRACTURE OF JOINT SITE UNSPECIFIED - CONTRACTURE OF JOINT OF MULTIPLE SITES * PAIN IN JOINT INVOLVING MULTIPLE SITES COMA - PERSISTENT VEGETATIVE STATE ALTERATION OF CONSCIOUSNESS OTHER HALLUCINATIONS - SYNCOPE AND COLLAPSE COMPLEX FEBRILE CONVULSIONS POST TRAUMATIC SEIZURES OTHER CONVULSIONS * HYPOTHERMIA NOT ASSOCIATED WITH LOW ENVIRONMENTAL TEMPERATURE FUNCTIONAL QUADRIPLEGIA ALTERED MENTAL STATUS * ABNORMALITY OF GAIT - TRANSIENT PARALYSIS OF LIMB MENINGISMUS CYANOSIS APHASIA GANGRENE SHOCK UNSPECIFIED - SEPTIC SHOCK OTHER SHOCK WITHOUT TRAUMA * RESPIRATORY ABNORMALITY OTHER UNSPECIFIED CHEST PAIN - PAINFUL RESPIRATION ABDOMINAL RIGIDITY UNSPECIFIED SITE - ABDOMINAL RIGIDITY GENERALIZED ABDOMINAL RIGIDITY OTHER SPECIFIED SITE ASPHYXIA - HYPOXEMIA RESPIRATORY ARREST APPARENT LIFE THREATENING EVENT IN INFANT

15 Page 15 of OTHER CLOSED SKULL FRACTURE WITHOUT INTRACRANIAL INJURY WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER CLOSED SKULL FRACTURE WITHOUT INTRACRANIAL INJURY WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION OTHER CLOSED SKULL FRACTURE WITHOUT INTRACRANIAL INJURY WITH CONCUSSION UNSPECIFIED OTHER CLOSED SKULL FRACTURE WITH CEREBRAL LACERATION AND CONTUSION WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER CLOSED SKULL FRACTURE WITH CEREBRAL LACERATION AND CONTUSION WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION OTHER CLOSED SKULL FRACTURE WITH CEREBRAL LACERATION AND CONTUSION WITH CONCUSSION UNSPECIFIED OTHER CLOSED SKULL FRACTURE WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER CLOSED SKULL FRACTURE WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION OTHER CLOSED SKULL FRACTURE WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED OTHER CLOSED SKULL FRACTURE WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH STATE OF UNCONSCIOUSNESS UNSPECIFIED - OTHER CLOSED SKULL FRACTURE WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION OTHER CLOSED SKULL FRACTURE WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED OTHER CLOSED SKULL FRACTURE WITH INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER SITE OF CLOSED SKULL FRACTURE WITH INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION OTHER SITE OF CLOSED SKULL FRACTURE WITH INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH CONCUSSION UNSPECIFIED OTHER OPEN SKULL FRACTURE WITHOUT INJURY WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER OPEN SKULL FRACTURE WITHOUT INTRACRANIAL INJURY WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION OTHER OPEN SKULL FRACTURE WITHOUT INTRACRANIAL INJURY WITH CONCUSSION UNSPECIFIED OTHER OPEN SKULL FRACTURE WITH CEREBRAL LACERATION AND CONTUSION WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER OPEN SKULL FRACTURE WITH CEREBRAL LACERATION AND CONTUSION WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION OTHER OPEN SKULL FRACTURE WITH CEREBRAL LACERATION AND CONTUSION WITH CONCUSSION UNSPECIFIED OTHER OPEN SKULL FRACTURE WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS

16 Page 16 of 25 UNSPECIFIED - OTHER OPEN SKULL FRACTURE WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION OTHER OPEN SKULL FRACTURE WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED OTHER OPEN SKULL FRACTURE WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER OPEN SKULL FRACTURE WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION OTHER OPEN SKULL FRACTURE WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED OTHER OPEN SKULL FRACTURE WITH INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER OPEN SKULL FRACTURE WITH INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION OTHER OPEN SKULL FRACTURE WITH INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH CONCUSSION UNSPECIFIED CLOSED FRACTURE OF CERVICAL VERTEBRA UNSPECIFIED LEVEL - CLOSED FRACTURE OF MULTIPLE CERVICAL VERTEBRAE OPEN FRACTURE OF CERVICAL VERTEBRA UNSPECIFIED LEVEL - OPEN FRACTURE OF MULTIPLE CERVICAL VERTEBRAE CLOSED FRACTURE OF DORSAL (THORACIC) VERTEBRA WITHOUT SPINAL CORD INJURY - OPEN FRACTURE OF UNSPECIFIED PART OF VERTEBRAL COLUMN WITHOUT SPINAL CORD INJURY CLOSED FRACTURE OF C1-C4 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - CLOSED FRACTURE OF C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY OPEN FRACTURE OF C1-C4 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - OPEN FRACTURE OF C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY CLOSED FRACTURE OF T1-T6 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - CLOSED FRACTURE OF T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY OPEN FRACTURE OF T1-T6 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - OPEN FRACTURE OF T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY CLOSED FRACTURE OF LUMBAR SPINE WITH SPINAL CORD INJURY - OPEN FRACTURE OF LUMBAR SPINE WITH SPINAL CORD INJURY CLOSED FRACTURE OF SACRUM AND COCCYX WITH UNSPECIFIED SPINAL CORD INJURY - CLOSED FRACTURE OF SACRUM AND COCCYX WITH OTHER CAUDA EQUINA INJURY CLOSED FRACTURE OF SACRUM AND COCCYX WITH OTHER SPINAL CORD INJURY

17 Page 17 of OPEN FRACTURE OF SACRUM AND COCCYX WITH UNSPECIFIED SPINAL CORD INJURY - OPEN FRACTURE OF SACRUM AND COCCYX WITH OTHER CAUDA EQUINA INJURY OPEN FRACTURE OF SACRUM AND COCCYX WITH OTHER SPINAL CORD INJURY CLOSED FRACTURE OF UNSPECIFIED VERTEBRA WITH SPINAL CORD INJURY - OPEN FRACTURE OF UNSPECIFIED VERTEBRA WITH SPINAL CORD INJURY CLOSED FRACTURE OF ACETABULUM - OPEN FRACTURE OF PUBIS CLOSED FRACTURE OF ILIUM - MULTIPLE CLOSED PELVIC FRACTURES WITH DISRUPTION OF PELVIC CIRCLE CLOSED FRACTURE OF OTHER SPECIFIED PART OF PELVIS OPEN FRACTURE OF ILIUM - MULTIPLE OPEN PELVIC FRACTURES WITH DISRUPTION OF PELVIC CIRCLE OPEN FRACTURE OF OTHER SPECIFIED PART OF PELVIS UNSPECIFIED CLOSED FRACTURE OF PELVIS - UNSPECIFIED OPEN FRACTURE OF PELVIS OPEN FRACTURE OF CLAVICLE UNSPECIFIED PART - OPEN FRACTURE OF ACROMIAL END OF CLAVICLE FRACTURE OF UNSPECIFIED PART OF UPPER END OF HUMERUS OPEN - FRACTURE OF GREATER TUBEROSITY OF HUMERUS OPEN OTHER OPEN FRACTURE OF UPPER END OF HUMERUS FRACTURE OF UNSPECIFIED PART OF HUMERUS OPEN - FRACTURE OF SHAFT OF HUMERUS OPEN FRACTURE OF UNSPECIFIED PART OF LOWER END OF HUMERUS OPEN - FRACTURE OF UNSPECIFIED CONDYLE(S) OF HUMERUS OPEN OTHER FRACTURE OF LOWER END OF HUMERUS OPEN ILL-DEFINED OPEN FRACTURES OF UPPER LIMB MULTIPLE CLOSED FRACTURES INVOLVING BOTH UPPER LIMBS AND UPPER LIMB WITH RIB(S) AND STERNUM - MULTIPLE OPEN FRACTURES INVOLVING BOTH UPPER LIMBS AND UPPER LIMB WITH RIB(S) AND STERNUM FRACTURE OF UNSPECIFIED INTRACAPSULAR SECTION OF NECK OF FEMUR CLOSED - FRACTURE OF BASE OF NECK OF FEMUR CLOSED OTHER TRANSCERVICAL FRACTURE OF FEMUR CLOSED FRACTURE OF UNSPECIFIED INTRACAPSULAR SECTION OF NECK OF FEMUR OPEN - FRACTURE OF BASE OF NECK OF FEMUR OPEN OTHER TRANSCERVICAL FRACTURE OF FEMUR OPEN FRACTURE OF UNSPECIFIED TROCHANTERIC SECTION OF FEMUR CLOSED - FRACTURE OF SUBTROCHANTERIC SECTION OF FEMUR CLOSED

18 Page 18 of FRACTURE OF UNSPECIFIED TROCHANTERIC SECTION OF FEMUR OPEN - FRACTURE OF SUBTROCHANTERIC SECTION OF FEMUR OPEN FRACTURE OF UNSPECIFIED PART OF NECK OF FEMUR CLOSED - FRACTURE OF UNSPECIFIED PART OF NECK OF FEMUR OPEN FRACTURE OF UNSPECIFIED PART OF FEMUR CLOSED - FRACTURE OF SHAFT OF FEMUR CLOSED FRACTURE OF UNSPECIFIED PART OF FEMUR OPEN - FRACTURE OF SHAFT OF FEMUR OPEN FRACTURE OF LOWER END OF FEMUR UNSPECIFIED PART CLOSED - SUPRACONDYLAR FRACTURE OF FEMUR CLOSED OTHER FRACTURE OF LOWER END OF FEMUR CLOSED FRACTURE OF LOWER END OF FEMUR UNSPECIFIED PART OPEN - SUPRACONDYLAR FRACTURE OF FEMUR OPEN OTHER FRACTURE OF LOWER END OF FEMUR OPEN OPEN FRACTURE OF PATELLA OPEN FRACTURE OF UPPER END OF TIBIA - OPEN FRACTURE OF UPPER END OF FIBULA WITH TIBIA OPEN FRACTURE OF SHAFT OF TIBIA - OPEN FRACTURE OF SHAFT OF FIBULA WITH TIBIA OPEN FRACTURE OF UNSPECIFIED PART OF TIBIA - OPEN FRACTURE OF UNSPECIFIED PART OF FIBULA WITH TIBIA CLOSED DISLOCATION OF HIP UNSPECIFIED SITE - OTHER CLOSED ANTERIOR DISLOCATION OF HIP OPEN DISLOCATION OF HIP UNSPECIFIED SITE - OTHER OPEN ANTERIOR DISLOCATION OF HIP DISLOCATION OF KNEE UNSPECIFIED PART OPEN - LATERAL DISLOCATION OF TIBIA PROXIMAL END OPEN OTHER DISLOCATION OF KNEE OPEN CLOSED DISLOCATION CERVICAL VERTEBRA UNSPECIFIED - CLOSED DISLOCATION MULTIPLE CERVICAL VERTEBRAE OPEN DISLOCATION CERVICAL VERTEBRA UNSPECIFIED - OPEN DISLOCATION MULTIPLE CERVICAL VERTEBRAE CLOSED DISLOCATION LUMBAR VERTEBRA - CLOSED DISLOCATION THORACIC VERTEBRA OPEN DISLOCATION LUMBAR VERTEBRA - OPEN DISLOCATION THORACIC VERTEBRA CLOSED DISLOCATION VERTEBRA UNSPECIFIED SITE CLOSED DISLOCATION SACRUM OPEN DISLOCATION VERTEBRA UNSPECIFIED SITE - OPEN DISLOCATION SACRUM CLOSED DISLOCATION OTHER LOCATION

19 Page 19 of OPEN DISLOCATION STERNUM OPEN DISLOCATION OTHER LOCATION CLOSED DISLOCATION MULTIPLE AND ILL-DEFINED SITES - OPEN DISLOCATION MULTIPLE AND ILL-DEFINED SITES INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITHOUT OPEN INTRACRANIAL WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED - INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITHOUT OPEN INTRACRANIAL WOUND WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITHOUT OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH OPEN INTRACRANIAL WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED - INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH OPEN INTRACRANIAL WOUND WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED LACERATION OF EYELID FULL-THICKNESS NOT INVOLVING LACRIMAL PASSAGES - PENETRATING WOUND OF ORBIT WITH FOREIGN BODY OCULAR LACERATION WITHOUT PROLAPSE OF INTRAOCULAR TISSUE - UNSPECIFIED OCULAR PENETRATION UNSPECIFIED OPEN WOUND OF EYEBALL FOREIGN BODY IN LARYNX FOREIGN BODY IN RESPIRATORY TREE UNSPECIFIED BURN OF UNSPECIFIED SITE UNSPECIFIED DEGREE - DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE UNSPECIFIED SITE WITH LOSS OF A BODY PART OTHER AND UNSPECIFIED INJURY TO HEAD OTHER AND UNSPECIFIED INJURY TO FACE AND NECK OTHER INJURY OF CHEST WALL - OTHER INJURY OF ABDOMEN OTHER AND UNSPECIFIED INJURY OF OTHER SITES OF TRUNK * OTHER AND UNSPECIFIED INJURY TO HIP AND THIGH - OTHER AND UNSPECIFIED INJURY TO UNSPECIFIED SITE POISONING BY UNSPECIFIED DRUG OR MEDICINAL SUBSTANCE HYPOTHERMIA EFFECTS OF LIGHTNING - DROWNING AND NONFATAL SUBMERSION ASPHYXIATION AND STRANGULATION - ELECTROCUTION AND NONFATAL EFFECTS OF ELECTRIC CURRENT OTHER ANAPHYLACTIC REACTION OTHER DRUG ALLERGY

20 Page 20 of UNSPECIFIED ADVERSE EFFECT OF OTHER DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE DISRUPTION OF EXTERNAL OPERATION (SURGICAL) WOUND DISRUPTION OF TRAUMATIC INJURY WOUND REPAIR V07.0 NEED FOR ISOLATION V15.6 PERSONAL HISTORY OF POISONING PRESENTING HAZARDS TO HEALTH V15.89 V45.88 V V46.12 OTHER SPECIFIED PERSONAL HISTORY PRESENTING HAZARDS TO HEALTH STATUS POST ADMINISTRATION OF TPA (RTPA) IN A DIFFERENT FACILITY WITHIN THE LAST 24 HOURS PRIOR TO ADMISSION TO CURRENT FACILITY DEPENDENCE ON RESPIRATOR, STATUS - ENCOUNTER FOR RESPIRATOR DEPENDENCE DURING POWER FAILURE V46.14 MECHANICAL COMPLICATION OF RESPIRATOR [VENTILATOR] V49.84 BED CONFINEMENT STATUS V49.87 PHYSICAL RESTRAINTS STATUS *Notes: Use code to denote chemical restraint. Use code to denote patient safety: danger to self and others monitoring other and unspecified reactive psychosis. Use code to denote patient safety: danger to self and others seclusion (flight risk). Use code if behavior is such that restraints were required to ensure patient safety. Use code 496 to denote suctioning required en route or need for titrated oxygen therapy. Use code to denote specialized handling en route position requires specialized handling. Use code to denote airway control/positioning required en route. Use code to report a fall with injuries and other multiple injury conditions such as injuries sustained in motor vehicle accidents. Covered for Ambulance Services for Return Transportation Following Receipt of Medical Care: * OTHER DISORDERS OF IMPULSE CONTROL 436 ACUTE BUT ILL-DEFINED CEREBROVASCULAR DISEASE COGNITIVE DEFICITS HEMIPLEGIA AFFECTING UNSPECIFIED SIDE - HEMIPLEGIA AFFECTING NONDOMINANT SIDE MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE PRESSURE ULCER, LOWER BACK - PRESSURE ULCER, BUTTOCK PRESSURE ULCER, STAGE III - PRESSURE ULCER, STAGE IV CONTRACTURE OF JOINT SITE UNSPECIFIED - CONTRACTURE OF JOINT OF MULTIPLE SITES COMA - PERSISTENT VEGETATIVE STATE