Local Coverage Determination (LCD): Non- Emergency Ground Ambulance Services (L33383)

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1 Local Coverage Determination (LCD): Non- Emergency Ground Ambulance Services (L33383) Contractor Information Contractor Name First Coast Service Options, Inc. LCD Information Document Information LCD ID L33383 Original ICD-9 LCD ID L29916 LCD Title Non- Emergency Ground Ambulance Services 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 medicine or dispense medical services. The AMA assumes no liability for data contained or 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 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 Language quoted from CMS National Coverage Determination (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR [b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See 1869(f)(1)(A)(i) of the Social Security Act. Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: Title XVIII of the Social Security Act, 1861(s)(7) defines 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 of the Social Security Act, 1862 (a)(1)(a). allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Medicare Benefit Policy Manual (Pub ) Chapter 10 Medicare Claims Processing Manual (Pub ) Chapter 15 Medicare Program Integrity Manual (Pub ) Chapter 1, Section 1.1.2

3 Change request 5442, Pub , Medicare Claims Processing, transmittal 1185, dated February 7, 2007 Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity INDICATIONS Medical necessity is established when the patient s condition is such that use of any other method of transportation is contraindicated. In any case in which some means of transportation other than an ambulance could be used without endangering the individual s health, whether or not such other transportation is actually available, no payment may be made for ambulance services. In all cases, the appropriate documentation must be kept on file and, upon request, presented to the carrier/intermediary. It is important to note that the presence or absence of a physician s order for transport by ambulance does not necessarily prove (or disprove) whether the transport was medically necessary. The ambulance service must meet all program coverage criteria in order for payment to be made. Reasons to allow non-emergency ground ambulance services include: The beneficiary is bed confined* before and after the ambulance trip and meets the above criteria. There is risk of physical injury to the patients or others requiring observation during transport. The patient requires ongoing IV meds/fluids (and a heparin/saline lock is contraindicated) during transport Medical treatment and/or observation during transport is required to prevent endangering of the beneficiary s health. * Bed confined is defined as the inability to get up from bed without assistance, the inability to ambulate and the inability to sit in a chair, including a wheelchair. All three components must be met in order for the patient to meet the requirements of the definition of bed confined. Bed confined is not synonymous with bed rest or nonambulatory. Bed confinement, by itself is neither sufficient nor is it necessary to determine coverage for Medicare ambulance benefits. LIMITATIONS In addition to meeting the criteria in the Indications section of this LCD, non-emergency ambulance services will not be covered for the following reasons: Transportation to a funeral home Transfer from one residence to another

4 Transfer from a hospital which has appropriate facilities and staff for treatment to another hospital Transportation via ambi-buses, ambulettes, stretcher vans, wheelchair vans, mobility assistance vehicle (MAV), medicabs, vans, privately owned vehicles, and taxicabs Transportation to a dialysis facility for routine maintenance dialysis, unless the patient s condition justifies the medical necessity of the transport The patient refuses to be transported 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. 012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 022x Skilled Nursing - Inpatient (Medicare Part B only) 023x Skilled Nursing - Outpatient 085x 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

5 Group 1 Paragraph: Group 1 Codes: A0425 GROUND MILEAGE, PER STATUTE MILE AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, NON-EMERGENCY A0426 TRANSPORT, LEVEL 1 (ALS 1) AMBULANCE SERVICE, BASIC LIFE SUPPORT, NON-EMERGENCY A0428 TRANSPORT, (BLS) A0999 UNLISTED AMBULANCE SERVICE ICD-10 Codes that Support Medical Necessity Group 1 Paragraph: The presence of one of these two ICD-10-CM codes on the claim for HCPCS codes A0426 and A0428, is intended to indicate that the patient s condition was such that transportation by any other means is contraindicated. If one of these two covered diagnoses is not on the claim, the service will be denied. Group 1 Codes: Show entries for Group 1 ICD-10 Codes that Support Medical Necessity: Group 1Codes ICD-10 Code Description Z74.01* Bed confinement status Z78.9* Other specified health status Group 1 Medical Necessity ICD-10 Codes Asterisk Explanation: ** The use ICD-10-CM code Z74.01 indicates that the patient is bed confined and transportation by any other means is contraindicated due to the medical condition of the patient. * The use of ICD-10-CM code Z78.9 indicates that transportation by any other means is contraindicated due to the medical condition of the patient. The use of one of these two ICD-10-CM codes does not prohibit the inclusion of additional ICD-10-CM codes on the claim to indicate the specific condition and/or signs/symptoms requiring ambulance transport. The ambulance fee schedule medical conditions list located in the Medicare Claims Processing Manual, Pub , Chapter 15, section 40 can also be used as an educational guideline for determining appropriate medical conditions and applicable ICD-10-CM codes related to ambulance transports. The intent of the medical conditions list is primarily as an educational guideline and although it will help ambulance suppliers to communicate the patient s condition, use of the codes does not guarantee payment of the claim or payment for a certain level of service.

6 Showing 1 to 2 of 2 entries in Group 1 ICD-10 Codes that DO NOT Support Medical Necessity Additional ICD-10 Information General Information Associated Information Documentation Requirements The medical record should include documentation of dispatch instructions, patient s condition, other on-scene information, and details of the transport (e.g., medications administered, changes in the patient s condition and mileage). Documentation should also include the physician certification statement when required. (See Coding Guidelines) Medical records must include a trip record which documents: A detailed description of the patient s condition at the time of transport for Medicare to reasonably determine that other means of transportation are contraindicated. A description of specific monitoring and/or treatments ordered and performed/administered during transport. Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to medical review. Sources of Information and Basis for Decision FCSO reference LCD numbers L29920, L29953, L29955 Palmetto GBA LCD for Ambulance Services (L933) Trailblazer Health Enterprises, LLC LCD for Ambulance services (Ground ambulance)

7 Wisconsin Physicians Service Insurance Corporation LCD for ambulance Services (L26601) Revision History Information Associated Documents Attachments Coding guidelines efec 10/1/11 opens in new window Related Local Coverage Documents Related National Coverage Documents Public Version(s) Updated on 07/01/2014 with effective dates 10/01/ Updated on 03/26/2014 with effective dates 10/01/ Keywords Read the LCD Disclaimer opens in new window FIRST COAST SERVICE OPTIONS MAC PART A/B CODING GUIDELINES LCD Database ID Number L33383 Contractor Name First Coast Service Options, Inc. Contractor Number

8 09101 Florida Puerto Rico/Virgin Islands Florida Puerto Rico Virgin Islands LCD Title Non-emergency Ground Ambulance Services Coding Guidelines VEHICLE AND CREW REQUIREMENTS Medicare Benefit Policy Manual (Pub ) Chapter 10, outlines vehicle and crew requirements. THE DESTINATION Medicare Benefit Policy Manual (Pub , Chapter 10, 10.3 outlines destination requirements. Medicare covers ambulance transports (that meet all other program requirements for coverage) only to the following destinations: Hospitals ( appropriate facility ). Appropriate facility 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. Critical Access Hospital (CAH) Skilled nursing facilities (SNF) Dialysis facilities Ambulance services furnished to a maintenance dialysis patient must show that the patient s condition requires ambulance services. Beneficiary s home A physician s office is not a covered destination. However, under special circumstances an ambulance transport may temporarily stop at a physician s office without affecting the coverage status of the transport. As a general rule, only local transportation by ambulance is covered, and therefore, only mileage to the nearest appropriate facility equipped to treat the patient is covered. However, if two or more facilities that meet the destination requirements can treat the patient appropriately and the locality (see below) of each facility encompasses the place where the ambulance transportation of the patient began, then the full mileage to any one of the facilities to which the beneficiary is taken is covered. Because all duly licensed hospitals and SNFs are presumed to be appropriate sources of health care, only in exceptional situations where the ambulance transportation originates beyond the locality of the institution to which the beneficiary was transported, may full payment for mileage be considered. And then, only if the evidence clearly establishes that the destination institution was the nearest one with appropriate facilities under the particular circumstances. (See below.) The institution to which a patient is transported need not be a participating institution but must meet at least the

9 requirements of 1861(e)(1) or 1861(j)(1) of the Social Security Act (the Act.) (See Pub Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, "Definitions," for an explanation of these requirements.) When ambulance services are used for transportation of patients in situations where transportation by other means is not contraindicated, the provider/supplier would not append one of the two covered ICD-10-CM codes identified in the LCD and a benefit category denial will result. The provider/supplier may issue a Notice of Exclusion from Medicare Benefits (NEMB) CMS form to alert a beneficiary in advance that Medicare does not cover certain items and services because the item or service does not meet the definition of a benefit, or because the item or service is specially excluded by law. (Refer to the Beneficiary Notices Initiative (BNI) webpage on and IOM Publication , Chapter 30 Financial Liability Protections.) Physician Certification Statement 42 CFR outlines physician certification requirements for non-emergency, scheduled, repetitive ambulance services. Medicare covers medically necessary non-emergency, scheduled, repetitive ambulance services if one of the following criteria are met and all other coverage criteria regarding the patient s condition being such that use of any other method of transportation is contraindicated: The ambulance provider or supplier, before furnishing the service to the beneficiary, obtains a written order dated no earlier than 60 days before the date the service is furnished, from the beneficiary s attending physician certifying that services are medically necessary as defined in the indications and limitations section of the LCD A resident of a facility who is under the care of a physician if the ambulance provider or supplier obtains a written order from the beneficiary s attending physician, within 48 hours after the transport, certifying that the resident meets medical necessity requirements as defined in the indications and limitations section of the LCD A PCS is not required for non-scheduled emergency transport of beneficiaries residing at home or in facilities who are not under the direct care of a physician. If the ambulance provider or 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), 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; or, If the ambulance provider or supplier is unable to obtain the required certification within 21 calendar days following the date of the service, the ambulance supplier must document its attempts to obtain the requested certification and may then submit the claim. Acceptable documentation includes a signed return receipt from the U.S. Postal Service or other similar service that evidences that the ambulance supplier attempted to obtain the required signature from the beneficiary s attending physician or one of the above- mentioned individual. Note: Effective for dates of service on or after April 1, 2012, based on CMS Transmittal 2383, Change Request 7557 (FISS Claims Processing Updates for Ambulance Services), non-emergency trips (i.e., HCPCS codes A0426 and A0428 [when A0428 is billed without modifier QL]) require an NPI in the Attending Physician field. Comments

10

11 Revision History Date Revision 10/01/2014 This Coding Guideline replaces all previous Coding Guidelines to comply with ICD-10-CM based on Change Request The effective date of this Coding Guideline is based on date of service. 04/01/ Based on CMS Transmittal 2383, Change Request 7557 (FISS Claims Processing Updates for Ambulance Services) the coding guidelines attachment has been revised to add the following statement: non-emergency trips (i.e., HCPCS codes A0426 and A0428 [when A0428 is billed without modifier QL]) require an NPI in the Attending Physician field. The effective date of this revision is for claims processed on or after 04/02/2012 for dates of service on or after 04/01/ /30/2009 Original Document formatted: 05/09/2013 (DA/mp)

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