BULLETIN. Medical. Assis. Programs. ssistance. AMBULANCE PROVIDER Policy and Procedure Update ELIMINATION OF LOCAL CODES

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1 July 2003 Kansas Medical Assis ssistance Programs AMBULANCE PROVIDER Policy and Procedure Update ELIMINATION OF LOCAL CODES BULLETIN Effective with dates of service on and after July 14, 2003, all Ambulance local codes will be non-covered. See the attached manual and appendix pages for covered codes. AMBULANCE PROVIDER MANUAL REVISIONS Remove: Replace With: A1 A1 If you have any questions, please contact the Medical Assistance Customer Service Center at or (785) between 7:30 a.m. - 5:30 p.m., Monday through Friday. Bulletins and manuals constitute proof of notification of program changes to Kansas Medical Assistance providers. Please read these publications carefully and keep them for future reference. is the fiscal agent and administrator of the Kansas Medical Assistance Program for the Kansas Department of Social and Rehabilitation Services

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3 BENEFITS AND LIMITATIONS COPAYMENT Non-emergency ambulance transportation requires a copayment from the beneficiary of $3.00 per date of service. When procedure code A0426, or A0428 (non-emergency transport) is billed in conjunction with the non-emergency procedure code S0215 for the same dates of service, copayment will be collected from the beneficiary only once. Bill all services occurring on the same date on the same claim form. If multiple claims are submitted for the same date(s) of service, the $3.00 copayment requirement will be deducted for each claim submitted. Do not reduce the charges or balance due by the copayment amount. This reduction will be made automatically during claim processing. AMBULANCE PROVIDER MANUAL 07/03 8-1

4 BENEFITS AND LIMITATIONS MEDIKAN Only the following emergency transportation procedure codes are covered under the MediKan program. A Ambulance service, neonatal transport, base rate, emergency transport, one way A BLS mileage, per mile A ALS mileage, per mile A Ambulance service, ALS, emergency transport, level 1 A Ambulance service, BLS emergency transport A Ambulance service, conventional air service, transport one way (fixed wing) A Ambulance service, conventional air services, transport one way (rotary wing) A Advanced life support, level 2 (ALS) A Specialty Care Transport A Fixed wing air mileage, per statute mile A Rotary wing mileage, per statute mile AMBULANCE PROVIDER MANUAL 07/03 8-2

5 BENEFITS AND LIMITATIONS MEDICAID Benefits: Covered Services Emergency ambulance transportation provided by Basic Life Support (BLS)/Advanced Life Support (ALS) services. Non-emergency ambulance transportation with the exception of adult care home residents (see page 8-4) for the following: Discharge from hospital to residence or other less expensive care. Trips from residence to closest available medically necessary services. Trips from one institution to another to receive a medical service not available in the first institution. Waiting Time Limitations: The medical condition of the consumer must necessitate ambulance transportation: Emergency situations in which services are performed after the providers response to the onset of a medical condition manifested by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to: Place the consumer's health in serious jeopardy; Seriously impair bodily functions; or Result in serious dysfunction of any bodily organ or part Trips that could have been scheduled are not considered emergencies. Non-emergency transportation when the consumer's condition is such that a car or van cannot be used, e.g.: Consumer unconscious Consumer cannot sit up Oxygen or other life support required Extreme obesity or position of cast(s) Restraints required AMBULANCE PROVIDER MANUAL 05/03 8-3

6 8400. Ambulance transportation for a deceased person is covered only if the person was pronounced dead while enroute to or upon arrival at destination. If the person was pronounced dead after the ambulance was called, but before pickup, the service to the point of pickup is covered. Supplies may not be billed in addition to A0426, A0427, A0428, A0429, A0433. When an ambulance responds to a '911' call that is determined upon patient assessment to be non-emergent and the patient is transported, the ambulance provider must bill one of the non-emergency ambulance transportation procedure codes. Emergency '911' calls that do not result in transporting the patient are not covered and may be billed to the patient. Licensing Requirements and Restrictions: Ambulance providers must be licensed by the state to provide the level of service for which reimbursement is being requested. Services Requiring Medical Necessity: Medical necessity documentation (Section 4100) must be attached to the claim form when billing for non-emergency transports, waiting time, multiple patients on one ambulance trip, and air ambulance transportation. When the consumer is Kansas Medical Assistance Program eligible plus QMB and Medicare allows the service, medical necessity (MN) need not be attached to the claim; however, it must be available in the provider's file. The documentation must be printed and legible. MN for non-emergency ambulance transportation must state the reason the trip is required (hospital discharge or medical service) and the medical reason the consumer could not be transported by car or van. MN for air ambulance transportation must indicate the consumer's medical condition required immediate and rapid ambulance transportation that could not have been provided by land ambulance, and the point of pickup is inaccessible by land vehicle; or great distances or other obstacles are involved in getting the consumer to the nearest hospital with appropriate facilities; or the consumer's condition is such that the time needed to transport by land, or the instability of transportation by land, poses a threat to the consumer's survival or seriously endangers the consumer's health. If a determination is made that transport by ambulance was necessary, however, land ambulance service would have sufficed, payment for the air ambulance service will be the lesser of the billed charges and the maximum allowable for ground ambulance. AMBULANCE PROVIDER MANUAL 07/03 8-4

7 8400. Air Ambulance Guidelines: Time: If time is a critical factor in the patient s recovery or survival, or duration of ground transport would be excessive and potentially detrimental, air transport may be indicated. In general, if the ground ambulance can arrive at the destination institution within 20 minutes, it is the preferred mode of transport. Expertise: If the health care institution does not possess the expertise to provide the definitive care required to stabilize the patient (i.e., advanced life support) and the ground ambulance providers in the near vicinity cannot provide assistance in providing that care, air transport may be indicated. Coverage: If ground ambulance utilization leaves the service area without adequate ground coverage and patient outcome will be compromised by arranging other ground transport, air transport may be indicated. Documentation: The above guidelines serve as a guide to documentation which is necessary to determine proper reimbursement and must specify the indication and justification for air transport. If guidelines are not met, or are met but not documented, the billed transportation will be reimbursed at ground ambulance rates or denied altogether. Transportation of ACH Residents: The cost of transporting a current adult care home resident for nonemergent services (either by ambulance or commercial non-ambulance medical transportation) is a responsibility of the nursing facility. This includes new admissions to the nursing facility. The cost of transporting residents and new admissions to the nursing facility is a cost nursing facilities will incur. Transportation Services for Hospice Consumers: Medically necessary ambulance transportation services provided to hospice consumers are covered. The coverage requirement for these services is the same as for any Kansas Medical Assistance Program consumer. In the instance that prior authorization (PA) is required, the transportation provider should contact the hospice for any medical information that may be needed to obtain PA. AMBULANCE PROVIDER MANUAL 05/03 8-5

8 8400. Emergency Medical Services For Aliens (SOBRA): In addition to inpatient hospital and emergency room hospital, emergency services performed in outpatient facilities and related physician, lab, and x-ray services will be allowed for the following places of service: office, outpatient hospital, Federally Qualified Health Clinics, state or local public health clinics, rural health clinics, ambulance, and lab for SOBRA claims. Inpatient hospital reimbursement will not be limited to 48 hours. Follow-up care will not be allowed once the emergent condition has been stabilized. Refer to Section 2040 of the General Provider Manual for specific information. AMBULANCE PROVIDER MANUAL 05/03 8-6

9 APPENDIX I PROCEDURE CODES AND NOMENCLATURE The following codes represent an all inclusive list of ambulance services billable to the Kansas Medical Assistance Program. Procedures not listed here are considered non-covered. MN = Medical necessity documentation is required. COVERAGE INDICATORS COV. CODE NOMENCLATURE MN A0426 Ambulance service, ALS, non-emergency transport, level 1 (ALS 1) MN A0428 Ambulance service, BLS, non-emergency transport, (BLS) MN S0215 Non-emergency transportation mileage MN A0420 Ambulance waiting time (ALS or BLS), one half (1/2) hour increments A0427 Ambulance service, ALS, emergency transport A0390 ALS mileage, per mile A0429 Ambulance service, BLS, emergency transport A0380 BLS mileage, per mile A0433 Advanced life support, level 2 (ALS 2) A0422 Ambulance (ALS or BLS) oxygen and oxygen supplies, life sustaining situation A0424 Extra ambulance attendant, ground (ALS or BLS)or Air (fixed or rotary wing) REQUIRES MEDICAL REVIEW, Pertinent documentation required when this code is reported A0434 A0225 Specialty care transport Ambulance service, neonatal transport, base rate, emergency transport, one way MN A0430 Ambulance service, conventional air services, transport, one way (fixed wing) MN A0435 Fixed wing air mileage, per statute mile MN A0431 Ambulance service, conventional air services, transport, one way (rotary wing) MN A0436 Rotary wing air mileage, per statute mile NOTE: The modifier, GM - (multiple patients on one ambulance trip) may be used with the following procedure codes: A0427, A0429, A0225, A0433, A0430, or A0431. AMBULANCE PROVIDER MANUAL 07/03 APPENDIX A-1