Trailblazer Ambulance Services (Ground Ambulance)

Transcription

1 Trailblazer Ambulance Services (Ground Ambulance) LCD ID: 3316 LCD/LMRP Article Comment Summary Additional Information Add Comments/Feedback Effective Date:4/14/2009 Status:Active Revision Date:10/1/2011 LCD Title Ambulance Services (Ground Ambulance) 4T-3AB-R7 Contractor s Determination Number 4T-3AB (L28627) Contractor Name TrailBlazer Health Enterprises Contractor Number (04101, 04201, 04301, 04401, 04901) (04102, 04202, 04302, 04402). Contractor Type MAC Part A. MAC Part B. AMA CPT/ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2010 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. CMS National Coverage Policy This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determination (NCDs) or payment policy rules and regulations for non-emergency ground ambulance services. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for non-emergency ground ambulance services and must

2 properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies regarding non-emergency ground ambulance services are found in the following Internet-Only Manuals (IOMs) published on the CMS Web site: Medicare Benefit Policy Manual Pub Medicare National Coverage Determinations Manual Pub Medicare Provider Integrity Manual Pub Correct Coding Initiative Medicare Contractor Beneficiary and Provider Communications Manual Pub , Chapter 5. Federal Register, Vol. 66, No. 233, December 4, Federal Register, Vol. 67, No. 39, February 27, CFR Social Security Act (Title XVIII) Standard References, Sections: o 1862 (a)(1)(a) Medically Reasonable & Necessary. o 1833 (e) Incomplete Claim. o 1861 (s)(7) Ambulance Service. o 1861 (v)(1)(k)(ii) Bona Fide Emergency Services. Primary Geographic Jurisdiction o CO. NM. OK. TX: o Indian Health Service. End Stage Renal Disease (ESRD) facilities. o Skilled Nursing Facilities (SNFs). o Rural Health Clinics (RHCs). Transitioned WPS legacy providers. Oversight Region Region IV. Region VI. Original Determination Effective Date 04/14/2009 Original Determination Ending Date N/A Revision Effective Date 10/01/2011 Revision Ending Date N/A Indications and Limitations of Coverage and/or Medical Necessity

3 Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier (see Coding Guidelines section in the attached article for instructions). 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 TrailBlazer 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 validates their medical need and their provision in the record of the 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 is licensed by the state. Emergency response means responding immediately at the Basic Life Support (BLS) or Advanced Life Support 1 (ALS1) level of service 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. The patient s condition is an emergency that renders the patient unable to go safely to the hospital by other means. Emergency ambulance services are services provided after the sudden onset of a medical condition. For the purposes of this LCD, acute signs and/or symptoms of sufficient severity must manifest the emergency medical condition such that the absence of immediate medical attention could reasonably be expected to result in one or more of the following: Place the patient s health in serious jeopardy. Cause serious impairment to bodily functions. Cause serious dysfunction of any body organ or part. Non-Emergency Ambulance Service

4 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 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 before, during and after transportation, bed-confined. For the purposes of this LCD, bed-confined means the patient must meet all of the following three criteria: o Unable to get up from bed without assistance. o Unable to ambulate. o Unable to sit in a chair (including a wheelchair). As stated in the bullet above, statements about the patient s bed-bound status must be validated in the record with contemporaneous objective observations and findings as to the patient s functional physical and/or mental limitations that have rendered him 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, whether 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 who is transported 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 criteria as reasonable and necessary 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

5 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, 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 non-residents, that facility is not an appropriate facility. An institution is also not considered an appropriate facility if there is no bed available. The carrier, 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 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 physician 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.

6 For non-repetitive non-emergency transports, the following apply: The PCS must be obtained from the attending physician within 48 hours after the transport. If the ambulance provider is unable to obtain the PCS from the attending physician within 48 hours of transport, the 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 a good faith effort 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 or other similar service demonstrating delivery of the letter as evidence of the attempt to obtain the PCS. For repetitive non-emergency transports, the following apply: A PCS for repetitive transports must be signed by the patient s attending physician. 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 tables illustrate Medicare s expectations with respect to 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. Medicare requires the run report to 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. Special Note Regarding Patients Transported to and From Hemodialysis Centers: Only a fraction (approximately 10 percent) ESRD patients on chronic hemodialysis requires 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. Medicare payment requires patients transported to and from hemodialysis centers to have other conditions such as those described in the tables below and requires adequate documentation of those conditions in the ambulance supplier s run reports and in the medical records of other providers involved with the patient s care. I. Medical Conditions Complaint or Symptom Abdominal pain Abnormal cardiac rhythm/cardiac Condition Requirement Accompanied by other signs or symptoms Symptomatic or potentially lifethreatening arrhythmia Examples of Systems and Findings Necessary (and Documented) For Coverage Associated symptoms include nausea, vomiting, fainting. Associated signs include tender or pulsatile mass, distention, rigidity, rebound tenderness on exam, guarding. Necessary symptoms include syncope or near syncope, chest pain and

7 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) Respiratory arrest Respiratory distress, shortness of breath need for supplemental of oxygen Severe intoxication Potentially life-threatening manifestations Potentially life- or limb- threatening With significant external and/or internal injuries Abnormal <80 or >250 with symptoms Sudden onset, severe non-traumatic pain suggestive of cardiac or vascular origin or requiring special positioning only available by ambulance Objective evidence of abnormal respiratory function 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, bi- and 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 Includes apnea or hypoventilation requiring ventilatory assistance and airway management 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

8 Cardiac arrest with resuscitation in progress Chest pain (nontraumaticemergent cause not Cardiac origin suspected. Obvious non- identified capable of self-administration 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. Choking episode Respiratory or neurologic impairment Cold exposure Potentially life- or limb- threatening Findings include temperature < 95º F, signs of deep frost bite or presence of other emergency conditions. Altered level of consciousness (nontraumatic) Convulsions/seizures Neurologic dysfunction in addition to any baseline abnormality Active seizing or immediate postseizure at risk of repeated seizure and requires medical monitoring/observation 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. Non-traumatic headache Associated neurologic signs and/or symptoms or abnormal vital signs 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 The nature of the infection or the behavior of the patient must be such Infections in this category are limited to those infections for which isolation procedures/public health that failure to isolate poses significant is provided both before and after risk risk of spread of a contagious disease. transportation. Hazardous substance exposure Medical device failure The nature of the exposure should be such that potential injury is likely. Life- or limb-threatening malfunction, failure or complication 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

9 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 Acute or unexplained neurologic dysfunction in addition to any baseline abnormality Pain is the reason for the transport. Acute onset or bed-confining. 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 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 limbthreatening 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 lifethreatening 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)

10 Temperature after pharmacologic intervention >104º (child) Gastrointestinal distress General mobility issues and bed confinement Accompanied by other signs or symptoms 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 Associated neurologic or cardiovascular symptoms/signs, other abnormal vital signs Severe nausea and vomiting or severe, incapacitating diarrhea with evidence of volume depletion, abnormal vital signs or neurologic dysfunction 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

11 regulatory definition of bedconfined. Medicare does not expect this to occur with persons whose BMI is <80. On-Scene Condition (General) Major trauma Other trauma Hemorrhage Suspected fractures/dislocations Penetrating extremity injuries Traumatic amputations Suspected internal, head, chest or abdominal injuries Burns Lightning Electrocution Near-drowning Eye injuries II. Conditions Trauma On-Scene Condition (Specific) As defined by ACS Field Triage Decision Scheme Need to monitor or maintain airway or immobilize head/neck Potentially life-threatening hemorrhage Suspected fracture or dislocation requires splinting/immobilization and renders patient unable to be transported by another vehicle Life-or limb-threatening injury Life-threatening injury or reattachment opportunity exists Major: per American Burn Association (ABA) Acute vision loss or blurring, Comments and Examples (Not All- Inclusive) 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 (quantity identified), ongoing or recent, with potential for immediate rebleeding 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. Uncontrolled hemorrhage, compromised neurovascular supply, uncontrollable pain requiring pharmacologic intervention 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

12 severe pain or chemical exposure, penetrating, severe lid lacerations 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 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). Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules. As published in CMS IOM , Section , in order to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is: Safe and effective. Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, that meet the requirements of the Clinical Trials NCD are considered reasonable and necessary). Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is: o Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient s condition or to improve the function of a malformed body member. o Furnished in a setting appropriate to the patient s medical needs and condition. o Ordered and furnished by qualified personnel. o One that meets, but does not exceed, the patient s medical needs. o At least as beneficial as an existing and available medically appropriate alternative.

13 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. 12X, 13X, 22X, 23X, 83X, 85X 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. Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual Publication , Claims Processing Manual, for further guidance. 054X CPT/HCPCS Codes Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web. A0425 Ground mileage, per statute mile A0426 Ambulance service, ALS, non-emergency transport, level 1 A0427 Ambulance service, ALS, emergency transport, level 1 A0428 Ambulance service, BLS, non-emergency transport A0429 Ambulance service, BLS, emergency transport A0433 Advanced life support, level 2 (ALS2) A0434 Specialty Care Transport (SCT) A0888 Non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) A0999 Unlisted ambulance service ICD-9-CM Codes that Support Medical Necessity 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). It is the provider s responsibility to supply the contractor with information describing the condition of the patient that necessitated ambulance transportation. Medicare recognizes limitations of usual ambulance personnel for establishing a diagnosis and recognizes, therefore, that diagnosis coding of a

14 patient s condition using ICD-9-CM codes when reporting ambulance services may be less specific than for services reported by other professional providers. Also, selected ICD-9-CM diagnosis codes from the CMS condition code list are included with instructions to use them in a manner that is contrary to usual ICD-9-CM coding conventions. Providers who submit ICD-9-CM diagnosis codes should choose the code that best describes the patient s condition at the time of transport. As a reminder to providers of ambulance services, rule out or suspected diagnoses should not be reported using specific ICD-9-CM codes. In such instances where a diagnosis is not confirmed, it is more correct to use a symptom, finding or injury code. 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. TrailBlazer recognizes that ambulance suppliers are currently 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, though their doing so facilitates timely claim adjudication. 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 automatically deny the service as not medically necessary. Claims without an ICD-9-CM diagnosis code are adjudicated manually utilizing the information contained in the claim s narrative field and/or medical records (the trip report and any other records supplied to Medicare by the provider upon our request). Ambulance suppliers utilizing the 5010 version of the 837P are required to submit ICD-9-CM diagnosis code(s). Medicare is establishing the following limited coverage for HCPCS codes A0425, A0426, A0427, A0428, A0429, A0433 and A0434: Table 1 Covered for Ambulance Transportation Services to the Site of Medical Care: Bacterial infection, unspecified Note: Use code to denote special handling in route isolation Brain tumor Malignant neoplasm without specification of site Diabetes mellitus, uncontrolled (without mention of complication) Diabetes mellitus, uncontrolled (with ketoacidosis) Diabetes mellitus, uncontrolled (with hyperosmolar coma) Diabetes mellitus, uncontrolled (with other coma) Diabetes mellitus, uncontrolled (with renal manifestations) Diabetes mellitus, uncontrolled (with ophthalmologic manifestations) Diabetes mellitus, uncontrolled (with neurologic manifestations) Diabetes mellitus, uncontrolled (with peripheral circulatory manifestations) Diabetes mellitus, with other specified manifestations Other disorders of pancreatic secretions Disorders of fluid, electrolytes, and acid-base balance Delirium tremens Alcohol withdrawal psychosis Drug withdrawal Pathologic drug intoxication Delirium due to conditions classified elsewhere Note: Use code to denote chemical restraint Subacute delirium Note: Use code to denote patient safety: danger to self and others monitoring other and unspecified reactive psychosis Other and unspecified reactive psychosis Note: Use code to denote patient safety: danger to self and others seclusion

15 (flight risk) Drunkenness and other drug intoxicated states Combativeness Note: Use code if behavior is such that restraints were required to ensure patient safety Acute myocardial infarction of anterolateral wall Acute myocardial infarction of other anterior wall Acute myocardial infarction of inferolateral wall Acute myocardial infarction of inferoposterior wall Acute myocardial infarction of other inferior wall Acute myocardial infarction of other lateral wall Acute myocardial infarction, true posterior wall infarction Acute myocardial infarction, subendocardial infarction Acute myocardial infarction of other specified site Acute myocardial infarction of unspecified site Angina pectoris Iatrogenic pulmonary embolism and infarction Saddle embolus of pulmonary artery Pulmonary embolism, other Cardiac tamponade Atrioventricular block, complete Left bundle branch block Right bundle branch block Bundle branch block, other and unspecified Paroxysmal tachycardia, supraventricular and ventricular Atrial fibrillation and flutter Ventricular fibrillation and flutter Cardiac or cardiopulmonary arrest Ventricular premature beats Bradycardia Heart failure, congestive and left heart Systolic heart failure Diastolic heart failure Combined systolic and diastolic heart failure Heart failure, unspecified Note: Use code to denote cardiac/hemodynamic monitoring required en route. 431 Intracerebral hemorrhage Cerebral thrombosis Cerebral embolism Cerebral artery occlusion, unspecified Transient cerebral ischemia 436 Stroke Late effects of cerebrovascular disease, cognitive deficits Late effects of cerebrovascular disease, hemiplegia/hemiparesis Late effects of cerebrovascular disease, monoplegia of lower limb Phlebitis and thrombophlebitis, femoral vein (deep)(superficial) Phlebitis and thrombophlebitis of deep vessels of lower extremities, other Hypotension Hemorrhage, unspecified Asthma, unspecified, with status asthmaticus/acute exacerbation 496 Chronic obstructive pulmonary disease, not elsewhere classified Note: Use code 496 to denote suctioning required en route, need for titrated oxygen therapy or IV fluid(s). 514 Pulmonary congestion and hypostasis Acute pulmonary edema, acute Transfusion related acute lung injury (TRALI) Stricture and stenosis of esophagus, esophageal obstruction Intestinal or peritoneal adhesions with obstruction (postoperative)(postinfection) Intestinal or peritoneal adhesions with obstruction, other

16 578.9 Hemorrhage of gastrointestinal tract, unspecified Other specified complications of pregnancy, unspecified as to episode of care or not applicable Pressure ulcer Pressure ulcer Contracture of joints Pain in joint, multiple sites Note: Use code to denote specialized handling en route position requires specialized handling Pain in thoracic spine Lumbago Backache unspecified Swelling of limb Alterations of consciousness Alterations of consciousness General symptoms Complex febrile convulsions Post traumatic seizures Other convulsions (seizures) Fever Hypothermia not associated with low environmental temperature Note: Use of diagnosis codes and alone will not be sufficient to allow ambulance transportation. Use an additional diagnosis to indicate the associated condition of the patient that necessitates ambulance transportation of a febrile person Functional quadriplegia Altered mental status Symptoms involving nervous and musculoskeletal systems Note: Use code to denote patient safety risk of falling off wheelchair or stretcher while in motion Meningismus Cyanosis Headache Aphasia Symptoms involving cardiovascular system Gangrene Shock without mention of trauma Shock without mention of trauma, other Dyspnea and respiratory abnormalities (respiratory distress), other Note: Use code to denote airway control/positioning required en route Chest pain Nausea with vomiting Vomiting Abdominal pain Abdominal pain, other specified site Abdominal or pelvic swelling, mass or lump Abdominal or pelvic swelling, mass or lump Abdominal rigidity Abdominal rigidity Abdominal tenderness (rebound tenderness) Abdominal tenderness (rebound tenderness) Elevated blood pressure reading without diagnosis of hypertension Other ill-defined and unknown causes of morbidity and mortality, asphyxia (hypoxemia) Respiratory arrest Apparent life threatening event in infant Closed skull fracture without mention of intracranial injury Closed skull fracture without mention of intracranial injury Closed skull fracture with cerebral laceration and contusion

17 Closed skull fracture with cerebral laceration and contusion Closed skull fracture with subarachnoid, subdural and extradural hemorrhage Closed skull fracture with subarachnoid, subdural and extradural hemorrhage Closed skull fracture with other and unspecified intracranial hemorrhage Closed skull fracture with other and unspecified intracranial hemorrhage Closed skull fracture with intracranial injury of other and unspecified nature Closed skull fracture with intracranial injury of other and unspecified nature Open skull fracture without mention of intracranial injury Open skull fracture without mention of intracranial injury Open skull fracture with cerebral laceration and contusion Open skull fracture with cerebral laceration and contusion Open skull fracture with subarachnoid, subdural and extradural hemorrhage Open skull fracture with subarachnoid, subdural and extradural hemorrhage Open skull fracture with other and unspecified intracranial hemorrhage Open skull fracture with other and unspecified intracranial hemorrhage Open skull fracture with intracranial injury of other and unspecified nature Open skull fracture with intracranial injury of other and unspecified nature Fracture, closed, cervical spine, without mention of spinal cord injury Fracture, open, cervical spine, without mention of spinal cord injury Fracture of vertebral column without mention of spinal cord injury, open/closed Fracture, cervical spine, with spinal cord injury, closed Fracture, cervical spine, with spinal cord injury, open Fracture, dorsal (thoracic) spine, with spinal cord injury, closed Fracture, dorsal (thoracic) spine, with spinal cord injury, open Fracture, lumbar spine, with spinal cord injury, closed/open Fracture, sacrum and coccyx, with spinal cord injury, closed Fracture, sacrum and coccyx, with spinal cord injury, closed Fracture, sacrum and coccyx, with spinal cord injury, open Fracture, sacrum and coccyx, with spinal cord injury, open Fracture, unspecified vertebral, with spinal cord injury, closed/open Fracture, pelvis (acetabulum/pubis), closed/open Fracture, pelvis (other specified part), closed Fracture, pelvis (other specified part), closed Fracture, pelvis (other specified part), open Fracture, pelvis (other specified part), open Fracture, pelvis (unspecified part), closed/open Fracture, clavicle, open Fracture of humerus, upper end, open Fracture of humerus, upper end, open Fracture of humerus, shaft or unspecified part, closed Fracture of humerus, shaft or unspecified part, open Fracture of humerus, lower end, open Fracture of humerus, lower end, open Ill-defined fractures of upper limb, open Multiple fractures involving both upper limbs, and upper limb with rib(s) and sternum Fracture of neck of femur, transcervical, closed Fracture of neck of femur, transcervical, closed Fracture of neck of femur, transcervical, open Fracture of neck of femur, transcervical, open Fracture of neck of femur, pertrochanteric, closed Fracture of neck of femur, pertrochanteric, open Fracture of neck of femur, unspecified part, closed/open Fracture of shaft or unspecified part of femur, open Fracture of shaft or unspecified part of femur, open Fracture of lower end of femur, closed Fracture of lower end of femur, closed Fracture of lower end of femur, open Fracture of lower end of femur, open Fracture of patella, open

18 Fracture of tibia and fibula, upper end, closed Fracture of tibia and fibula, upper end, open Fracture of tibia and fibula, shaft, open Fracture of tibia and fibula, unspecified part, open Dislocation of hip, closed dislocation Dislocation of hip, open dislocation Dislocation, other, of knee, closed Dislocation, other, of knee, closed Dislocation, other, of knee, open Dislocation, other, of knee, open Dislocation, closed, cervical spine Dislocation, open, cervical spine Dislocation, closed, thoracic and lumbar spine Dislocation, open, thoracic and lumbar spine Dislocation, closed, unspecified vertebra Dislocation, closed, sacrum Dislocation, other vertebra, open Dislocation, closed, other location (pelvis) Dislocation, open, other location (sternum) Dislocation, open, other location Multiple and ill-defined dislocations Intracranial injury of other and unspecified nature, without mention of open intracranial wound (closed head injury) Intracranial injury of other and unspecified nature, without mention of open intracranial wound (closed head injury) Intracranial injury of other and unspecified nature, with open intracranial wound (open head injury) Intracranial injury of other and unspecified nature, with open intracranial wound (open head injury) Open wound of ocular adnexa Open wound of eyeball Open wound of eyeball Late effect of spinal cord injury Note: Use code to denote special handling en route to reduce pain Foreign body in larynx (choking) Foreign body in respiratory tree Burn, unspecified Head injury, unspecified Injury of face and neck Other injury of trunk Other injury of other sites of trunk Injury to hip/thigh, knee/leg/ankle/foot, other specified/multiple, and unspecified site Note: Use code to report a fall with injuries and other multiple injury conditions such as injuries sustained in motor vehicle accidents Poisoning by unspecified drugs and medicinal substances (drug overdose) Effects of reduced temperature (hypothermia) Effects of other external causes Effects of other external causes Other anaphylactic reaction Other drug allergy Unspecified adverse effect of other drug, medicinal and biological substance Allergy, unspecified Adult maltreatment, unspecified (This code may be used to report assaults.) Disruption of wound, unspecified Disruption of external operation (surgical) wound Disruption of traumatic injury wound repair V07.0 Isolation (need for) V15.6 Personal history of poisoning V15.89 Other specified personal history presenting hazards to health

19 V45.88 Status post-administration of tpa (rtpa) in a different facility within the last 24 hours prior to admission to current facility V46.11 V46.12 Dependence on respirator (ventilator) V46.14 Mechanical complication of respirator (ventilator) V46.2 Other dependence on machines, supplemental oxygen Note: Use code V46.2 to indicate that transportation was necessary due to administration of medically necessary oxygen or required IV medications when the patient is incapable of self-administration. V49.75 V49.76 Lower limb amputation status V49.84 Cannot sit in a chair and cannot stand and cannot get up from bed without assistance V49.87 Physical restraints status Table 2 Covered for Ambulance Services for Return Transportation Following Receipt of Medical Care: Brain tumor Malignant neoplasm without specification of site Combativeness Note: Use code if behavior is such that restraints were required to ensure patient safety. 436 Acute, but ill-defined, cerebrovascular disease (stroke) Late effects of cerebrovascular disease, cognitive deficits Late effects of cerebrovascular disease, hemiplegia/hemiparesis Late effects of cerebrovascular disease, monoplegia of lower limb Pressure ulcer Pressure ulcer Contracture of joints Alterations of consciousness Alterations of consciousness Symptoms involving nervous musculoskeletal systems Note: Use code to denote patient safety risk of falling off wheelchair or stretcher while in motion Fracture, cervical spine, with spinal cord injury, closed Fracture, cervical spine, with spinal cord injury, open Fracture, dorsal (thoracic) spine, with spinal cord injury, closed Fracture, dorsal (thoracic) spine, with spinal cord injury, open Fracture, lumbar spine, with spinal cord injury, closed/open Fracture, sacrum and coccyx, with spinal cord injury, closed Fracture, sacrum and coccyx, with spinal cord injury, closed Fracture, sacrum and coccyx, with spinal cord injury, open Fracture, sacrum and coccyx, with spinal cord injury, open Fracture, unspecified vertebral, with spinal cord injury, closed/open Fracture, pelvis (acetabulum/pubis), closed/open Fracture, pelvis (other specified part), closed Fracture, pelvis (other specified part), closed Fracture, pelvis (other specified part), open Fracture, pelvis (other specified part), open Fracture, pelvis (unspecified part), closed/open Fracture of neck of femur, transcervical, closed Fracture of neck of femur, transcervical, closed Fracture of neck of femur, transcervical, open Fracture of neck of femur, transcervical, open Fracture of neck of femur, pertrochanteric, closed Fracture of neck of femur, pertrochanteric, open Fracture of neck of femur, unspecified part, closed/open Fracture of shaft or unspecified part of femur, closed Fracture of shaft or unspecified part of femur, open Fracture of lower end of femur, closed

20 Fracture of lower end of femur, closed Fracture of lower end of femur, open Fracture of lower end of femur, open Head injury, unspecified Other injury of trunk Other injury of other sites of trunk V46.11 V46.12 Dependence on respirator (ventilator) V46.14 Mechanical complication of respirator (ventilator) V46.2 Other dependence on machines, supplemental oxygen Note: Use code V46.2 to indicate that transportation was necessary due to administration of medically necessary oxygen when the patient is incapable of selfadministration. V49.75 V49.76 Lower limb amputation status V49.84 Cannot sit in a chair and cannot stand and cannot get up from bed without assistance V49.87 Physical restraints status Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims. Diagnoses that Support Medical Necessity N/A ICD-9-CM Codes that DO NOT Support Medical Necessity N/A Diagnoses that DO NOT Support Medical Necessity All diagnoses not listed in the ICD-9-CM Codes That Support Medical Necessity section of this LCD for those HCPCS codes where limited coverage was established. Documentation Requirements It is the responsibility of the ambulance supplier to maintain (and furnish to Medicare upon demand) complete and accurate documentation of the beneficiary s condition to demonstrate the ambulance service being furnished meets the medical necessity criteria. Documentation must be legible. The documents required for this Medicare purpose include the following: A PCS (for those services for which the physician certification is required - see Physician s Certification Statement section). The certification itself is not the sole factor used in determining whether payment for ambulance services will be allowed: o The PCS may be completed and signed by the following medical professionals: the patient s attending physician (MD or DO), or for instances in which the physician signature is not available, a PA, NP, CNS, Registered Nurse (RN), or discharge planner employed by the hospital or facility where the beneficiary is treated with knowledge of the beneficiary s condition at the time the transport was ordered or the service was rendered. This is applicable to non-emergency, non-scheduled transports. Repetitive non-emergency scheduled transports must be signed by the attending physician. o A particular form or format is not required for the certification. Suppliers and physicians may develop their own certification form. o Ambulance company employees should not complete forms on behalf of these individuals. o For repetitive services, the PCS may include the expected length of time ambulance transport would be required but may not exceed 60 days. o Signature of the medical professional completing the PCS must also be legible (or accompanied by a typed or printed name) and include credentials.

21 o Signatures on the PCS must be dated at the time they are completed. Trip record must include: o A detailed description of the patient s condition at the time of transport. Coverage will not be allowed if the trip record contains an insufficient description of the patient s condition at the time of transfer for Medicare to reasonably determine that other means of transportation are contraindicated. Coverage will not be allowed if the description of the patient s condition is limited to conclusory statements and/or opinions, such as the following: Patient is non-ambulatory. Patient moved by drawsheet. Patient could only be moved by stretcher. Patient is bed-confined. Patient is unable to sit, stand or walk. o The trip record must paint a picture of the patient s condition and must be consistent with documentation found in other supporting medical record documentation (including the physician s certification). The trip record must include the following: A concise explanation of symptoms reported by the patient and/or other observers and details of the patient s physical assessments that clearly demonstrate that the patient requires ambulance transportation and cannot be safely transported by an alternate mode. An objective description of the patient s physical condition in sufficient detail to demonstrate that the patient s condition or functional status at the time of transport meets Medicare limitation of coverage for ambulance services. Description of the traumatic event when trauma is the basis for suspected injuries. A detailed description of existing safety issues. A detailed description of special precautions taken (if any) and explanation of the need for such precautions. A description of specific monitoring and treatments required, ordered and performed/administered. That a treatment (such as oxygen) and/or monitoring (such as cardiac rhythm monitoring) were performed absent sufficient description of the patient's condition (to demonstrate that the treatment and/or monitoring was medically necessary) is inadequate on its own merit to justify payment for the ambulance service. For example, when oxygen is supplied as a basis for ambulance transportation, the patient's pretreatment capillary blood oxygen saturation and clinical respiratory description must be recorded. The two must be consistent with oxygen need. o Statements such as the following, absent supporting information in relevant bullets above, are insufficient to justify Medicare payment for ambulance services: Patient complained of shortness of breath. History of stroke. Past history of knee replacement. Hypertension. Chest pain. Generalized weakness. Is bed-confined. o Signatures, including credentials, from the provider(s) who renders the services documented: Services provided/ordered must be authenticated by the author. The method used must be a handwritten or electronic signature: If the signature is found to be illegible or missing from the medical documentation, a signature log or attestation statement to determine the identity of the author may be requested: A signature log includes the typed or printed name and usual signature of the author associated with initials or an illegible signature. An attestation statement is required when a signature is missing from the documentation; it must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary, date of service and be specific to the service documented. Providers should not add late signatures to the documentation.

22 o Point of pick-up/destination (identify place and complete address). o For hospital-to-hospital transports, the trip record must clearly indicate the precise treatment or procedure (or medical specialist) that is available only at the receiving hospital. Non-specific or vague statements such as needs cardiac care or needs higher level of care are insufficient. Any additional available documentation that supports medical necessity of ambulance transport (for example, emergency room report, SNF record, End Stage Renal Disease (ESRD) facility record, hospital record). Dispatch record. Documentation supporting the number of loaded miles billed. Appendices N/A Utilization Guidelines Most patients who require ambulance transportation have a short-term need due to an acute illness or injury. Longer term repetitive or frequent ambulance transportation is medically necessary for relatively few patients. Medicare expects that more than eight covered ambulance trips per year will rarely be medically necessary for an individual beneficiary and will cover no more than 12 ambulance trips per beneficiary per year without review of the patient s medical record. Notice: This LCD imposes utilization guideline limitations that support automated frequency denials. Despite Medicare s allowing up to these maximums, each patient s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services. Sources of Information and Basis for Decision Other Contractor Local Coverage Determinations Ambulance Services (Ground Ambulance), TrailBlazer LCD (04001 and 04002) L Ambulance Services (Ground Ambulance), TrailBlazer LCD (00400) L14259, (00900) L Advisory Committee Meeting Notes This LCD does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this LCD was developed in cooperation with advisory groups, which include representatives from various specialties. Advisory Committee meeting dates: TX October 8, CO October 30, NM October 23, OK October 15, Start Date of Comment Period 10/31/2008

23 Ending Date of Comment Period 12/15/2008 Start Date of Notice Period 02/27/2009 Revision History Number Date Explanation R7 10/01/2011 Per CR 7454 (annual ICD-9-CM diagnosis code update) added diagnosis codes , , , , and to CPT/HCPCS codes A0425, A0426, A0427, A0428, A0429, A0433 and A0434 in Table 1, and added diagnosis codes , , and to CPT/HCPCS codes A0425, A0426, A0427, A0428, A0429, A0433 and A0434 in Table 2 of the ICD-9-CM Codes that Support Medical Necessity section of the LCD. Effective date: 10/01/2011. R6 07/01/2011 Per CR 7228, notice of automatic denial for claims line(s) items with a GZ modifier added to definition of GZ modifier in "Coding Guidelines" section of related Article. Effective date: 07/01/2011. R5 04/14/2009 Per provider request, updated text under Documentation Requirements section of LCD to further clarify bullet regarding documentation for number of loaded miles. Effective date: 04/14/2009 R4 01/01/2011 Updated the text under ICD-9-CM Codes that Support Medical Necessity to include information for the new 5010 electronic format requirements. Effective date: 01/01/2011 Per CR 6698, updated text under Physician Certification Statement and Documentation Requirements section to clarify signature requirements. Effective date: 03/01/2010 Per provider request, updated text under Documentation Requirements regarding trip record for number of loaded miles. Effective date: 04/14/2009. Text modified in numerous sections in LCD to clarify clinical requirements for benefit coverage. Effective date: 04/14/2009. R3 01/01/2011 Per CR 7121 (annual HCPCS update), description changed for the GA modifier. Effective date: 01/01/2011. R2 10/18/2010 Use of LCD and related article made applicable to providers transitioning from WPS to TrailBlazer with addition of contractor number Effective date: dates of service on or after 10/18/2010. Per CR 7006 (Annual ICD-9-CM Diagnosis Coding Update), diagnosis code was added to limited coverage table 1 and code V49.87 was added to tables 1 and 2. Effective date: 10/01/2010. R1 10/01/2009 Per CR 6520 (Annual ICD-9-CM Diagnosis Coding Update), added new diagnosis code to (Table 1) HCPCS codes A0425, A0426, A0427, A0428, A0429, A0433, A0434 and A0999. Effective date: 10/01/2009. Article Title Ambulance Services (Ground Ambulance) 4T-3AB-R7

24 Contractor s Determination Number 4T-3AB Contractor Name TrailBlazer Health Enterprises Contractor Number (04101, 04201, 04301, 04401, 04901) (04102, 04202, 04302, 04402). Contractor Type MAC Part A. MAC Part B. AMA CPT/ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2010 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 o CO. NM. OK. TX: o Indian Health Service. End Stage Renal Disease (ESRD) facilities. o Skilled Nursing Facilities (SNFs). o Rural Health Clinics (RHCs). Transitioned WPS legacy providers. Oversight Region Region IV. Region VI. Original Article Effective Date 04/14/2009 Article Revision Effective Date 10/01/2011

25 Article Ending Effective Date N/A Article Text Abstract 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. Ambulance services involve the assessment and administration of emergency care by medically trained personnel (see definition below) and transportation of patients within an appropriate, safe and monitored environment. Ambulance transportation is a covered service under Medicare when the patient s condition is such that the use of any other method of transportation would endanger the patient s health. Medicare coverage for ambulance transportation is limited by CMS national policy in accordance with federal law. For the purposes of the related LCD, the following definitions apply: Medically trained personnel refers to individuals who have fulfilled state training and educational requirements and are certified or licensed by their respective state to provide Basic Life Support (BLS) and/or Advanced Life Support (ALS) Emergency Medical Technician (EMT)- level services. The vehicle used as an ambulance must be specially designed or equipped for transportation of the sick or injured and have customary patient care equipment. At a minimum, the ambulance must contain a stretcher, linens, emergency medical supplies, oxygen equipment and other lifesaving emergency medical equipment, and be equipped with emergency warning lights, sirens and telecommunications equipment as required by state or local law. This should include, at a minimum, one two-way voice radio or wireless telephone. Definitions of Levels of Service BLS Basic Life Support: Medically necessary transportation by ground ambulance vehicle and medically necessary supplies and services, plus the provision of BLS ambulance services. The ambulance must be staffed by an individual who is qualified in accordance with state and local laws as an Emergency Medical Technician-Basic (EMT-Basic). These laws may vary from state to state. For example, only in some states is an EMT-Basic permitted to operate limited equipment on board the vehicle, assist more qualified personnel in performing assessments and interventions, and establish a peripheral intravenous (IV) line. ALS Assessment Advanced Life Support Assessment: An assessment performed by an ALS crew as part of an emergency response that was necessary because the patient s reported condition at the time of dispatch was such that only an ALS crew was qualified to perform the assessment. An ALS assessment does not necessarily result in a determination that the patient requires an ALS level of service. ALS Intervention Advanced Life Support Intervention: A procedure that is, in accordance with state and local laws, beyond the scope of practice of an EMT-Basic. ALS1 Advanced Life Support, Level 1: Where medically necessary, transportation by ground ambulance vehicle providing medically necessary supplies and services, and either an ALS assessment by ALS personnel or the provision of at least one ALS intervention. EMT-

26 Intermediate scope includes but is not limited to: o Administration of IV fluids (except blood or blood products). o Peripheral venous puncture. o Blood drawing. o Monitoring IV solutions during transport, which contain potassium. o Administration of approved medications, IV, Sub Q, sublingual, nebulizer inhalation, IM (limited to deltoid and thigh sites only). ALS2 Advanced Life Support, Level 2: Medically necessary ground ambulance vehicle transportation providing medically necessary supplies and services along with at least one of the following: o Three separate administrations of one or more medications by intravenous push/bolus or by continuous infusion excluding crystalloids (hypotonic, isotonic and hypertonic solutions) such as dextrose, normal saline or ringer s lactate. o Manual defibrillation/cardioversion. o Endotracheal intubation. o Central venous line o Cardiac pacing. o Chest compression. o Surgical airway. o Intraosseous line. SCT Specialty Care Transport: Specialty care transport is the interfacility transportation of a critically injured or ill beneficiary by a ground ambulance vehicle, including the provision of medically necessary supplies and services beyond the scope of the EMT-Paramedic. SCT is necessary when a beneficiary s condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area, for example, emergency or critical care nursing, emergency medicine, respiratory care, cardiovascular care, or a paramedic with additional training. Part A Program Instructions Reasons for Denial All other indications not listed in the Indications and Limitations of Coverage and/or Medical Necessity section of this LCD. The medical record does not verify that the service described by the HCPCS code was provided. The claim includes ICD-9-CM diagnosis codes but does not include a covered diagnosis code from the covered list above. Documentation contains an insufficient description of the patient s condition at the time of transfer for Medicare to reasonably determine that other means of transportation are contraindicated. Description of the patient s condition is limited to conclusory opinions, such as the following: o Patient is non-ambulatory. o Patient moved by drawsheet. o Patient could only be moved by stretcher. o Patient is bed-confined. o Patient is unable to sit, stand, or walk. Documentation in the trip record conflicts with other supporting medical records (including physician s certification). Failure to obtain appropriate physician order and/or certification (as defined and required in this LCD). Transfer from a hospital or Skilled Nursing Facility (SNF), which has appropriate facilities, to a second hospital or SNF. The patient is not transported (see exception regarding patient death). The patient is ambulatory, there is no emergency, and there is no other condition that contraindicates transport by other means. Transportation is to a non-covered destination.

27 Transportation is for purposes of obtaining a non-covered service. If the transport was medically appropriate but the beneficiary could have been treated at a closer hospital than the one to which he was transported, the transport payment is limited to the rate for the distance from the point of pick up to that closer hospital. Transport was to a funeral home. The ambulance was used solely because other means of transportation were unavailable. The individual merely needed assistance in getting from his room or home to a vehicle. The service does not follow the guidelines of this LCD. Coding Guidelines Refer to the Correct Coding Initiative (CCI) for correct coding guidelines and specific applicable code combinations prior to billing Medicare. Provisions of this LCD do not take precedence over CCI edits. Ambulance providers may submit claims using a covered ICD-9-CM code as listed in the LCD to report services for patients whose conditions warrant Medicare payment for ambulance transportation. Report a diagnosis code that best describes the patient s condition at the time of transport. As a reminder to providers of ambulance services, rule out or suspected diagnoses should not be reported using specific ICD-9-CM codes. In such instances where a diagnosis is not confirmed, it is more correct to use a symptom, finding or injury code. Modifiers: o GM: Multiple patients on one ambulance trip. o QM: Ambulance service provided under arrangement by a provider of services (Part A only). o QN: Ambulance services furnished directly by a provider of services (Part A only). o QL: Patient pronounced dead after ambulance called. o GA: Waiver of liability statement issued as required by payer policy, individual case. (Use for patients who do not meet the covered indications and limitations of this LCD and for whom an ABN is on file.) (ABN does not have to be submitted but must be made available upon request.) o GW: Service not related to hospice patient s terminal condition. o GY: Item or service is statutorily excluded or does not meet the definition of any Medicare benefit. Use modifier GY to report ambulance services for patients whose condition does not meet the requirements of this LCD or for whom ambulance transportation is noncovered. o GZ: Item or service expected to be denied as not reasonable and necessary. (Use for patients who do not meet the covered indications and limitations of this LCD and who did not sign an ABN and the provider expects the item/service to be denied. All claim line items submitted with the GZ modifier will be denied automatically and will not be subject to complex medical review.) See also Bill Type and Revenue Code sections below. Origin/destination: Providers must report an origin and destination modifier for each ambulance trip provided. Origin and destination modifiers used for ambulance services are created by combining two alpha characters. Each alpha character, with the exception of X, represents an origin code or a destination code. The pair of alpha codes creates one modifier. The first position alpha code equals origin; the second alpha code equals destination: o o D Diagnostic or therapeutic site other than P or H when these are used as origin codes o E Residential, domiciliary, custodial facility (other than an 1819 facility) o G Hospital-based dialysis facility (hospital or hospital-related) o H Hospital I Site of transfer (e.g., airport or helicopter pad) between modes of ambulance transport

28 o o J Non-hospital-based dialysis facility o N Skilled Nursing Facility (SNF)(1819 facility) o P Physician s office o R Residence o S Scene of accident or acute event X (Destination code only) Intermediate stop at physician s office on the way to the hospital For additional information on modifiers, see the modifier section of the Ambulance Manual: Part B Program Instructions Reasons for Denial All other indications not listed in the Indications and Limitations of Coverage and/or Medical Necessity section of this LCD. The medical record does not verify that the service described by the HCPCS code was provided. The claim includes ICD-9-CM diagnosis codes but does not include a covered diagnosis code from the covered list above. Documentation contains an insufficient description of the patient s condition at the time of transfer for Medicare to reasonably determine that other means of transportation are contraindicated. Description of the patient s condition is limited to conclusory opinions, such as the following: o Patient is non-ambulatory. o Patient moved by drawsheet. o Patient could only be moved by stretcher. o Patient is bed-confined. o Patient is unable to sit, stand, or walk. Documentation in the trip record conflicts with other supporting medical records (including physician s certification). Failure to obtain appropriate physician order and/or certification (as defined and required in this LCD). Transfer from a hospital or Skilled Nursing Facility (SNF), which has appropriate facilities, to a second hospital or SNF. The patient is not transported (see exception regarding patient death). The patient is ambulatory, there is no emergency, and there is no other condition that contraindicates transport by other means. Transportation to a non-covered destination. Transportation is for purposes of obtaining a non-covered service. If the transport was medically appropriate but the beneficiary could have been treated at a nearer hospital than the one to which he was transported, the transport payment is limited to the rate for the distance from the point of pick up to that nearer hospital. Transport was to a funeral home. The ambulance was used solely because other means of transportation were unavailable. The individual merely needed assistance in getting from his room or home to a vehicle. The service does not follow the guidelines of this LCD. Coding Guidelines Refer to the Correct Coding Initiative (CCI) for correct coding guidelines and specific applicable code combinations prior to billing Medicare. Provisions of this LCD do not take precedence over CCI edits.

29 Ambulance providers may submit claims using a covered ICD-9-CM code as listed in the LCD to report services for patients whose conditions warrant Medicare payment for ambulance transportation. Report a diagnosis code that best describes the patient s condition at the time of transport. As a reminder to providers of ambulance services, rule out or suspected diagnoses should not be reported using specific ICD-9-CM codes. In such instances where a diagnosis is not confirmed, it is more correct to use a symptom, finding or injury code. Modifiers: o GM: Multiple patients on one ambulance trip. o QL: Patient pronounced dead after ambulance called. o CR Catastrophe/Disaster related. o GA: Waiver of liability statement issued as required by payer policy, individual case. (Use for patients who do not meet the covered indications and limitations of this LCD and for whom an ABN is on file.) (ABN does not have to be submitted but must be made available upon request.) o GW: Service not related to hospice patient s terminal condition. o GY: Item or service is statutorily excluded or does not meet the definition of any Medicare benefit. Use modifier GY to report ambulance services for patients whose condition does not meet the requirements of this LCD or for whom ambulance transportation is noncovered. o GZ: Item or service expected to be denied as not reasonable and necessary. (Use for patients who do not meet the covered indications and limitations of this LCD and who did not sign an ABN and the provider expects the item/service to be denied. All claim line items submitted with the GZ modifier will be denied automatically and will not be subject to complex medical review.) Bill Type and Revenue Codes below DO NOT apply to Part B. Origin/destination: Providers must report an origin and destination modifier for each ambulance trip provided. Origin and destination modifiers used for ambulance services are created by combining two alpha characters. Each alpha character, with the exception of X, represents an origin code or a destination code. The pair of alpha codes creates one modifier. The first position alpha code equals origin; the second alpha code equals destination: o o D Diagnostic or therapeutic site other than P or H when these are used as origin codes o E Residential, domiciliary, custodial facility (other than an 1819 facility) o G Hospital-based dialysis facility (hospital or hospital-related) o H Hospital I Site of transfer (e.g., airport or helicopter pad) between modes of ambulance transport o J Non-hospital-based dialysis facility o N Skilled Nursing Facility (SNF)(1819 facility) o P Physician s office o R Residence o S Scene of accident or acute event o X (Destination code only) Intermediate stop at physician s office on the way to the hospital For additional information on modifiers, see the modifier section of the Ambulance Manual: 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

30 should be assumed to apply equally to all claims. 12X, 13X, 22X, 23X, 83X, 85X 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. Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual Publication , Claims Processing Manual, for further guidance. 054X CPT/HCPCS Codes Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web. A0425 Ground mileage, per statute mile A0426 Ambulance service, ALS, non-emergency transport, level 1 A0427 Ambulance service, ALS, emergency transport, level 1 A0428 Ambulance service, BLS, non-emergency transport A0429 Ambulance service, BLS, emergency transport A0433 Advanced life support, level 2 (ALS2) A0434 Specialty Care Transport (SCT) A0888 Non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) A0999 Unlisted ambulance service Other Comments Multiple-patient transports A single payment allowance for mileage will be prorated by the number of patients on board. Downcoding from air to ground ambulance is a denial under Section 1862 (a)(1)(a) (Program Integrity Manual (PIM) Chapter 6, 12B). ABN is required. Aspirin alone does not qualify as an indication that an ALS-2-level service has been supplied. Oxygen alone, even at high-flow rates, does not qualify as an indication that an ALS-2-level has been supplied. IV fluids even with a fluid challenge do not qualify as an indication that an ALS-2-level service has been supplied. Nitroglycerin administered as an assist to the patient s own nitroglycerin does not qualify as an indication that an ALS-2-level service has been supplied. Nitroglycerin administered from the ambulance stock under a physician s telephonic order or standing orders does qualify as an indication (as one of three medications) that an ALS-2-level service has been supplied. Ambulance fee schedule payment covers both the transport of the beneficiary to the nearest appropriate facility and all items and services associated with such transport. Such items and services include but are not limited to oxygen, drugs and extra attendants, but only when such

31 items and services are both medically necessary and covered by Medicare under the ambulance benefit. 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 billing the service. LCD Comment and Notice Summary Report LCD Title: Ambulance Services (Ground Ambulance) 4T-3AB LCD Lead: DLP Comment Topic #1 Commentator Suggestion(s): Add ICD-9-CM codes with notation to use to denote patient safety to Table 2 as is present in Virginia policy (Texas policy prior to transition). Pre-Finalization Recommendation Add codes. Finalization Recommendation Add codes. Comment Topic #2 Commentator Suggestion(s): Exert care if implementing utilization guidelines so as not to limit access to deserving patients and not have financial impact on ambulance providers. Pre-Finalization Recommendation We acknowledge that access of qualified patients to receive necessary ambulance transportation is essential. Finalization Recommendation Implementation will be done with due care. Comment Topic #3 Commentator Suggestion(s): Add explanation for limited coverage in light of the non-mandatory nature of ICD-9-CM diagnosis reporting by ambulance suppliers. Pre-Finalization Recommendation Will add.

32 Finalization Recommendation Add. Finalization Committee Recommendation Proceed with finalization of Ambulance Services (Ground Ambulance) 4T-3AB for CO/NM/OK/TX Part B and Part A, with changes as suggested above. [No additional information has been specified for this record] Comments are closed. This content pertains to... Programs: Part A,Part B Topics: Facility Types, Policies, Special Provider Types, Specialty Services Subtopics: Ambulance, ASC, CAH, Indian Health, Inpatient Acute, Local Coverage Determinations, OPPS, SNF