Chapter 9Ambulance 9 9.1 Enrollment........................................................ 9-2 9.2 Emergency Ground Ambulance Transportation.............................. 9-2 9.2.1 Benefits, Limitations, and Authorization Requirements................... 9-2 9.2.2 Claims Information............................................. 9-3 9.3 Emergency Air Ambulance Transportation.................................. 9-4 9.3.1 Benefits, Limitations, and Authorization Requirements................... 9-4 9.3.2 Claims Information............................................. 9-4 9.4 Nonemergency Ground Ambulance Transportation........................... 9-5 9.4.1 Benefits, Limitations, and Authorization Requirements................... 9-5 9.4.2 Claims Information............................................. 9-6 9.5 Origin and Destination Modifiers........................................ 9-7 9.6 Place of Service and Claims Form Instructions.............................. 9-8 9.6.1 Place of Service (POS) Coding..................................... 9-8 9.6.2 CMS-1500 Paper Claim Form Instructions............................. 9-8 9.7 Reimbursement.................................................... 9-8 9.8 TMHP-CSHCN Services Program Contact Center............................. 9-8 CPT only copyright 2009 American Medical Association. All rights reserved.
Chapter 9 9.1 Enrollment To enroll in the CSHCN Services Program, ambulance providers must be actively enrolled in Texas Medicaid, have a valid Provider Agreement with the CSHCN Services Program, have completed the CSHCN Services Program enrollment process, and comply with all applicable state laws and requirements. Providers may enroll online or download enrollment forms at www.tmhp.com. A hospital-operated ambulance provider must enroll as an ambulance provider and submit claims using the ambulance provider identifier, not the hospital provider identifier. Out-of-state ambulance and air ambulance providers must meet all these conditions and be located in the United States within 50 miles of the Texas state border. Ambulance and air ambulance providers must submit a copy of their permit or license from the Department of State Health Services (DSHS). Important: CSHCN Services Program providers are responsible for knowing, understanding, and complying with the laws, administrative rules, and policies of the CSHCN Services Program and Texas Medicaid. By enrolling in the CSHCN Services Program, providers are charged not only with knowledge of the adopted CSHCN Services Program agency rules published in Title 25 Texas Administrative Code (TAC), but also with knowledge of the adopted Medicaid agency rules published in 1 TAC, Part 15, and specifically including the fraud and abuse provisions contained in Chapter 371. CSHCN Services Program providers also are required to comply with all applicable laws, administrative rules, and policies that apply to their professions or to their facilities. Specifically, it is a violation of program rules when a provider fails to provide health-care services or items to recipients in accordance with accepted medical community standards and standards that govern occupations, as explained in 1 TAC 371.1617(6) for Medicaid providers, which also applies to CSHCN Services Program providers as set forth in 25 TAC 38.6(b)(1). Accordingly, CSHCN Services Program providers can be subject to sanctions for failure to deliver, at all times, health-care items and services to recipients in full accordance with all applicable licensure and certification requirements. These include, without limitation, requirements related to documentation and record maintenance, such that a CSHCN Services Program provider can be subject to sanctions for failure to create and maintain all records required by his or her profession or their facility, as well as those required by the CSHCN Services Program and Texas Medicaid. Refer to: Section 2.1, Provider Enrollment, on page 2-2 for more detailed information about CSHCN Services Program provider enrollment procedures. 9.2 Emergency Ground Ambulance Transportation The CSHCN Services Program may reimburse emergency ground ambulance transportation for eligible clients. The procedure codes and the description of the services provided that are reported on the claim submitted must correspond with the circumstances at the time of service and are classified according to emergency criteria. 9.2.1 Benefits, Limitations, and Authorization Requirements Emergency ambulance transport services may be reimbursed if the client s condition meets the definition of an emergency. The CSHCN Services Program defines an emergency as the sudden onset of a life-threatening situation in which a severe debilitating condition or death would result if immediate medical care is not provided. When the condition of the client is life-threatening and requires use of special equipment, life support systems, and close monitoring by trained attendants while en route to the nearest appropriate facility, the ambulance transport is considered an emergency service. The following procedure codes are considered for reimbursement for emergency ground ambulance transportation: Service Procedure Codes Mileage and transport A0425 with modifier ET A0429 Additional items and services A0382 A0422 A0424 9 2 CPT only copyright 2009 American Medical Association. All rights reserved.
Ambulance The CSHCN Services Program may reimburse for disposable supplies (procedure code A0382) and for oxygen supplies (procedure code A0422) separately from the established global fee for the ambulance transport. Reimbursement is limited to one of each code per trip during emergency ambulance transports. The CSHCN Services Program may reimburse for an extra attendant (procedure code A0424). Reimbursement is limited to emergency ground transport, and documentation of the medical necessity of the advance life-support services must be provided on the claim. Only one extra attendant is considered for reimbursement. The CSHCN Services Program does not reimburse for the return trip of an empty ambulance, for an ambulance call that does not result in transport, or for any other contingencies. Important: Hospitals are allowed to release a client s protected health information (PHI) to a transporting emergency medical services provider for treatment, payment, and health-care operations. Authorization is not required for emergency ground ambulance transportation. 9.2.2 Claims Information Emergency ambulance claims must include the appropriate procedure code(s) and all of the following additional information to be considered for reimbursement: Nature of the emergency necessitating the transport (a detailed description must be provided) Distance of transport Time of transport Acuity of client, origin or destination modifier, and relevant vital signs. Refer to: Section 9.5, Origin and Destination Modifiers, on page 9-7 for more information. Ambulance providers must use an appropriate International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code on the claim form to document the client s condition and the reason for the transport. Emergency ambulance claims submitted without the ICD-9-CM diagnosis code are denied. If a diagnosis is not known at the time of the transport, providers must use the diagnosis code that most closely represents the client s physical signs and symptoms at the time of the transport. If the above documentation does not indicate an emergency, the claim is denied. If procedure code A0425 with the ET modifier is billed on the claim for emergency ambulance services, the claim must include the number of loaded miles traveled (i.e., the number of miles traveled between the time the client is loaded on to the ambulance and the time the client is unloaded from the ambulance). If mileage (procedure code A0425 with ET modifier) is not indicated on the claim, only the base rate (procedure code A0429) may be reimbursed. Ambulance claims must be submitted to TMHP in an approved electronic format or on the CMS-1500 paper claim form. Providers may purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms. When completing a CMS-1500 paper claim form, all required information must be included on the claim, as information is not keyed from attachments. Superbills, or itemized statements, are not accepted as claim supplements. Emergency ambulance claims must include the appropriate ICD-9-CM diagnosis code in Block 21 of the CMS-1500 paper claim form or electronic equivalent. Providers billing electronically can enter the data supporting the necessity for the emergency transport in the Comments field or the Purpose of Stretcher field of the electronic claim. Providers using the CMS-1500 paper claim form can enter relevant vital signs and detailed narrative in Block 19 or 21 of the claim form. Run sheets, medical records, or emergency room records are not required to be submitted with the claim submission. If, however, documentation is submitted with the claim, an emergency medical technician s signature is required on all of the documents. 9 CPT only copyright 2009 American Medical Association. All rights reserved. 9 3
Chapter 9 Note: Providers must maintain any documentation that substantiates the medical need for the transport and must ensure that the documentation is available to the CSHCN Services Program or its designee upon request. Refer to: Chapter 37, TMHP Electronic Data Interchange (EDI), on page 37-1 for information on electronic claims submissions. Chapter 5, Claims Filing, Third-Party Resources, and Reimbursement, on page 5-1 for general information about claims. Section 5.7.1.3, CMS-1500 Paper Claim Form Instructions, on page 5-22 for instructions on completing paper claims. 9.3 Emergency Air Ambulance Transportation The CSHCN Services Program may reimburse emergency air ambulance transportation for eligible clients. The procedure codes and description of services provided that are reported on the claim must correspond with the circumstances at the time of service and are classified according to emergency criteria. 9.3.1 Benefits, Limitations, and Authorization Requirements CSHCN Services Program benefits for emergency air ambulance transport are limited to instances where the client s pickup point is inaccessible by ground transport or when great distance interferes with the immediate admission to a medical treatment facility appropriate for the client s condition. The following procedure codes are considered for reimbursement for emergency air ambulance transportation: Service Procedure Codes Fixed-wing air transport and A0430 A0435 mileage Rotary-wing air transport and A0431 A0436 mileage Additional items and services A0382 A0422 The CSHCN Services Program may reimburse for disposable supplies (procedure code A0382) and for oxygen supplies (procedure code A0422) separately from the established global fee for the ambulance transport. Reimbursement is limited to one of each code per trip during emergency ambulance transports. Prior authorization is not required for emergency air ambulance transports. 9.3.2 Claims Information Procedure codes A0430 (transport) and A0325 (mileage) must be billed together; procedure codes A0431 (transport) and A0436 (mileage) must be billed together. Emergency air ambulance claims must include the appropriate procedure code(s) and all of the following additional information to be considered for reimbursement: Distance of transport Time of transport Acuity of client, origin or destination modifier, and relevant vital signs Refer to: Section 9.5, Origin and Destination Modifiers, on page 9-7 for more information. Ambulance claims must be submitted to TMHP in an approved electronic format or on the CMS-1500 paper claim form. Providers may purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms. When completing a CMS-1500 paper claim form, all required information must be included on the claim, as information is not keyed from attachments. Superbills, or itemized statements, are not accepted as claim supplements. 9 4 CPT only copyright 2009 American Medical Association. All rights reserved.
Ambulance Emergency ambulance claims must include the appropriate ICD-9-CM diagnosis code in Block 21 of the CMS-1500 paper claim form or electronic equivalent. Providers billing electronically can enter the data supporting the necessity for the emergency transport in the Comments field or the Purpose of Stretcher field of the electronic claim. Providers using the CMS-1500 paper claim form can enter relevant vital signs and detailed narrative in Block 19 or 21 of the claim form. For ambulance transfers where the destination is a hospital, enter the name and address of the facility in Block 32. Run sheets, medical records, or emergency room records are not required to be submitted with the claim submission. If, however, documentation is submitted with the claim, an emergency medical technician s signature is required on all of the documents. Note: Providers must maintain any documentation that substantiates the medical need for the transport and must ensure that the documentation is available to the CSHCN Services Program or its designee upon request. Refer to: Chapter 37, TMHP Electronic Data Interchange (EDI), on page 37-1 for information on electronic claims submissions. Chapter 5, Claims Filing, Third-Party Resources, and Reimbursement, on page 5-1 for general information about claims. Section 5.7.1.3, CMS-1500 Paper Claim Form Instructions, on page 5-22 for instructions on completing paper claims. Blocks that are not referenced are not required for processing by TMHP and may be left blank. 9.4 Nonemergency Ground Ambulance Transportation The CSHCN Services Program may reimburse nonemergency ground transportation for eligible clients. The procedure codes and the description of the services provided that are reported on the claim submitted must correspond with the circumstances at the time of service and are classified according to nonemergency criteria. 9 9.4.1 Benefits, Limitations, and Authorization Requirements When the client has a medical problem requiring treatment in another location and is so severely disabled that the use of an ambulance is the only appropriate means of transport, the ambulance transport is considered a nonemergency service. The definition of a severely disabled client is one whose physical handicap limits their mobility to the extent that they must be transported by litter or requires life-support systems, and an ambulance is the most appropriate means of transport. A nonemergency ambulance transport must be to or from a scheduled medical appointment at the nearest appropriate facility for medically necessary care that is approved by the CSHCN Services Program. The following procedure codes are considered for reimbursement for nonemergency ground ambulance transportation: Service Mileage and transport Additional items and services Procedure Codes A0425 A0428 A0382 A0420 A0422 Important: Hospitals are allowed to release a client s protected health information (PHI) to a transporting emergency medical services provider for treatment, payment and health-care operations. If the ambulance provider must wait for the client for more than 30 minutes at the pick-up location, the ambulance provider may bill for the waiting time using procedure code A0420. Procedure code A0420 may be billed with up to a maximum quantity of 2 units (up to 1 hour) when it is the general billing practice of local ambulance companies to charge for unusual waiting time (over 30 minutes). The circumstances necessitating a wait time and the exact time involved must be documented on the claim form. The amount charged for waiting time must not exceed the charge for a one-way transport. CPT only copyright 2009 American Medical Association. All rights reserved. 9 5
Chapter 9 The CSHCN Services Program may reimburse for disposable supplies (procedure code A0382) and for oxygen supplies (procedure code A0422) separately from the established global fee for the ambulance transport. Reimbursement is limited to one of each code per trip during nonemergency ambulance transports. The CSHCN Services Program does not reimburse for the return trip of an empty ambulance, for an ambulance call that does not result in transport, or for any other contingencies. Authorization is not required for nonemergency ground ambulance transportation. 9.4.2 Claims Information All nonemergency ambulance claims must include the appropriate procedure codes and all of the following additional information to be considered for reimbursement: Detailed description of the client s medical condition necessitating the transport Distance of transport Time of transport Acuity of client, origin and destination modifier, and relevant vital signs Refer to: Section 9.5, Origin and Destination Modifiers, on page 9-7 for more information. The ambulance provider is responsible for the integrity of the information about the client s condition necessitating the transport and the medical necessity of the transport. The ambulance provider may be sanctioned, including exclusion from the CSHCN Services Program, for completing or signing a claim form that includes a false or misleading representation of the client s condition or of the medical necessity of the transport. Ambulance claims must be submitted to TMHP in an approved electronic format or on the CMS-1500 paper claim form. Providers may purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms. When completing a paper CMS-1500 claim form, all required information must be included on the claim, as information is not keyed from attachments. Superbills, or itemized statements, are not accepted as claim supplements. Ambulance providers must use an appropriate ICD-9-CM diagnosis code on the claim form to document the client s condition and the reason for the transport. If a diagnosis is not known at the time of the transport, providers must use the diagnosis code that most closely represents the client s physical signs and symptoms at the time of the transport. If the above documentation does not indicate an emergency, the claim is denied. If procedure code A0425 is billed on the claim for ambulance services, the claim must include the number of loaded miles traveled (i.e. the number of miles traveled between the time the client is loaded on to the ambulance and the time the client is unloaded from the ambulance). If mileage (procedure code A0425) is not indicated on the claim, only the base rate (procedure code A0428) may be reimbursed. Providers billing electronically can enter the data supporting the necessity for the nonemergency transport in the Comments field or the Purpose of Stretcher field of the electronic claim. Providers using the CMS-1500 paper claim form can enter relevant vital signs and detailed narrative in Block 19 or 21 of the claim form. For ambulance transfers where the destination is a hospital, enter the name and address of the facility in Block 32. For transfers from hospital-to-hospital, indicate in Block 19 the services needed at the second facility that were unavailable at the first facility. Run sheets, medical records, or emergency room records are not required to be submitted with the claim submission. If, however, documentation is submitted with the claim, an emergency medical technicians signature is required on all of the documents. 9 6 CPT only copyright 2009 American Medical Association. All rights reserved.
Ambulance Note: Providers must maintain any documentation that substantiates the medical need for the transport and must ensure that the documentation is available to the CSHCN Services Program or its designee upon request. Refer to: Chapter 37, TMHP Electronic Data Interchange (EDI), on page 37-1 for information on electronic claims submissions. Chapter 5, Claims Filing, Third-Party Resources, and Reimbursement, on page 5-1 for general information about claims. Section 5.7.1.3, CMS-1500 Paper Claim Form Instructions, on page 5-22 for instructions on completing paper claims. Blocks that are not referenced are not required for processing by TMHP and may be left blank. 9.5 Origin and Destination Modifiers All claims submitted on paper or electronically must include the 2-digit origin and destination codes. The origin is the first digit, and the destination is the second digit. The following are the origin and destination codes accepted by the CSHCN Services Program: Origin and Destination Code D E G H I J N P R S X Description Diagnostic or therapeutic site, or freestanding facility (e.g., radiation therapy center) other than H or P Residential, domiciliary, or custodial facility (unskilled facility) Hospital-based dialysis facility (hospital or hospital-related) Hospital (inpatient or outpatient) Site of transfer (e.g., airport or helicopter pad) between modes of ambulance transport Nonhospital-based dialysis facility Skilled nursing facility (includes HMO and nonhospital facility) Physician s office (includes HMO and nonhospital facility) Residence (client s home or any residence) Scene of accident or acute event Intermediate stop at physician s office en route to the hospital (destination code only) 9 Providers must submit one of the following modifiers to indicate the origin and destination of the transport. Ambulance Modifiers DD DE DG DH DI DJ DN DP DR DX ED EG EH EI EJ EN EP ER EX GD GE GH GI GJ GN GP GR GX HD HE HG HH HI HJ HN HP HR ID IE IG IH II IJ IN IR JD JE JG JH JI JJ JN JP JR JX ND NE NG NH NI NJ NN NP NR NX PD PE PG PH PI PJ PN PP PR PX RD RE RG RH RI RJ RN RP RR RX SD SG SH SI SJ SN SP SX CPT only copyright 2009 American Medical Association. All rights reserved. 9 7
Chapter 9 9.6 Place of Service and Claims Form Instructions All claims submitted must include a Place of Service (POS) code in block 24b of the CMS-1500 paper claim form. 9.6.1 Place of Service (POS) Coding The POS identifies where services are performed. Indicate the POS by using the appropriate numeric code for each service listed on the claim. The following POS codes must be used: Two-Digit Numeric Codes Place of Service (Electronic Billers) Office 11, 65, 71, 72 1 Home 12 2 Inpatient hospital 21, 51, 52, 55, 56, 61 3 Outpatient hospital 22, 23, 24, 62 5 Other location 26, 34, 53, 99 9 Independent lab 81 6 Destination of ambulance Indicate destination using above codes One-Digit Numeric Codes (Paper Billers) Indicate destination using above codes 9.6.2 CMS-1500 Paper Claim Form Instructions The following instructions describe the information that must be entered in block 24d of the CMS-1500 paper claim form. Block No. Description Guidelines 24b Place of service Select the appropriate POS code from the POS code table above. 24d Fully describe procedures, medical services, or supplies furnished for each date given. Enter the appropriate procedure codes and modifier for all services billed. Include in this block the Origin and Destination modifier from the table in Section 9.5. 9.7 Reimbursement Ambulance providers may be reimbursed the lower of the billed amount or the amount allowed by Texas Medicaid. For fee information, providers can refer to the Online Fee Lookup (OFL) on the TMHP website at www.tmhp.com. 9.8 TMHP-CSHCN Services Program Contact Center The TMHP-CSHCN Services Program Contact Center at 1-800-568-2413 is available Monday through Friday from 7 a.m. to 7 p.m., Central Time, and is the main point of contact for the CSHCN Services Program provider community. 9 8 CPT only copyright 2009 American Medical Association. All rights reserved.