Local Coverage Determination (LCD) for Ambulance Services (Ground Ambulance) 4T-3AB-R7 (L28627)

Lcal Cverage Determinatin (LCD) fr Ambulance Services (Grund Ambulance) 4T-3AB-R7 (L28627) Cntractr Infrmatin Cntractr Name TrailBlazer Health Enterprises, LLC LCD Infrmatin Dcument Infrmatin LCD ID Number L28627 LCD Title Ambulance Services (Grund Ambulance) 4T-3AB-R7 Oversight Regin Regin IV Cntractr's Determinatin Number 4T-3AB AMA CPT/ADA CDT Cpyright Statement CPT cdes, descriptins and ther data nly are cpyright 2011 American Medical Assciatin (r such ther date f publicatin f CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminlgy, (CDT) (including prcedure cdes, nmenclature, descriptrs and ther data cntained therein) is cpyright by the American Dental Assciatin. 2002, 2004 American Dental Assciatin. All rights reserved. Applicable FARS/DFARS apply. CMS Natinal Cverage Plicy Original Determinatin Effective Date Fr services perfrmed n r after 04/14/2009 Original Determinatin Ending Date Revisin Effective Date Fr services perfrmed n r after 10/01/2011 Revisin Ending Date

This LCD supplements but des nt replace, mdify r supersede existing Medicare applicable Natinal Cverage Determinatins (NCDs) r payment plicy rules and regulatins fr nn-emergency grund ambulance services. Federal statute and subsequent Medicare regulatins regarding prvisin and payment fr medical services are lengthy. They are nt repeated in this LCD. Neither Medicare payment plicy rules nr this LCD replace, mdify r supersede applicable state statutes regarding medical practice r ther health practice prfessins acts, definitins and/r scpes f practice. All prviders wh reprt services fr Medicare payment must fully understand and fllw all existing laws, regulatins and rules fr Medicare payment fr nn-emergency grund ambulance services and must prperly submit nly valid claims fr them. Please review and understand them and apply the medical necessity prvisins in the plicy within the cntext f the manual rules. Relevant CMS manual instructins and plicies regarding nn-emergency grund ambulance services are fund in the fllwing Internet- Only Manuals (IOMs) published n the CMS Web site: Medicare Benefit Plicy Manual Pub. 100-02. Medicare Natinal Cverage Determinatins Manual Pub. 100-03. Medicare Prvider Integrity Manual Pub. 100-08. Crrect Cding Initiative Medicare Cntractr Beneficiary and Prvider Cmmunicatins Manual Pub. 100-09, Chapter 5. Federal Register, Vl. 66, N. 233, December 4, 2001. Federal Register, Vl. 67, N. 39, February 27, 2002. 42 CFR 410.40. Scial Security Act (Title XVIII) Standard References, Sectins: 1862 (a)(1)(a) Medically Reasnable & Necessary. 1833 (e) Incmplete Claim. 1861 (s)(7)ambulance Service. 1861 (v)(1)(k)(ii) Bna Fide Emergency Services. Indicatins and Limitatins f Cverage and/r Medical Necessity Ntice: It is nt apprpriate t bill Medicare fr services that are nt cvered (as described by this entire LCD) as if they are cvered. When billing fr nn-cvered services, use the apprpriate mdifier (see Cding Guidelines sectin in the attached article fr instructins). The Medicare payment benefit fr ambulance services is very restricted. Ambulance suppliers must understand the benefit and refrain frm seeking Medicare payment fr services that d nt cnfrm t the limited benefit requirements as stated in regulatin. Physicians and thers wh rder and certify medical necessity f ambulance services must als understand and abide by the limitatins f Medicare cverage f ambulance services. This LCD includes, fr reference nly, prtins f CMS natinal payment plicy as fund in relevant Internet-Only Manual (IOM) sectins and regulatins. This LCD

further prvides limited cverage diagnsis t prcedure edit requirements fr ambulance suppliers wh chse t submit ICD-9-CM cdes n their claims. The LCD als cntains utilizatin guidelines fr the purpse f autmated ambulance claim denial by TrailBlazer in its jurisdictins. CMS Natinal Payment Plicy Medicare cvers ambulance services nly if furnished t a beneficiary whse medical cnditin at the time f transprt is such that transprtatin by ther means wuld endanger the patient s health. A patient whse cnditin permits transprt in any type f vehicle ther than an ambulance des nt qualify fr Medicare payment. Medicare payment fr ambulance transprtatin depends n the patient s cnditin at the actual time f the transprt regardless f the patient s diagnsis. T be deemed medically necessary fr payment, the patient must require bth the transprtatin and the level f service prvided. Medicare cvers bth emergency ambulance transprtatin and nn-emergency ambulance transprtatin as fllws: Medical Necessity Ambulance transprtatin is cvered when the patient s cnditin requires the vehicle itself and/r the specialized services f the trained ambulance persnnel. A requirement f cverage is that the needed services f the ambulance persnnel were prvided and clear clinical dcumentatin validates their medical need and their prvisin in the recrd f the service (usually the run sheet). Emergency Ambulance Services Medicare will cver emergency ambulance services when the services are medically necessary, meet the destinatin limits f clsest apprpriate facilities and are prvided by an ambulance service that is licensed by the state. Emergency respnse means respnding immediately at the Basic Life Supprt (BLS) r Advanced Life Supprt 1 (ALS1) level f service t a 911 call r the equivalent. An immediate respnse is ne in which the ambulance supplier begins as quickly as pssible t take the steps necessary t respnd t the call. The patient s cnditin is an emergency that renders the patient unable t g safely t the hspital by ther means. Emergency ambulance services are services prvided after the sudden nset f a medical cnditin. Fr the purpses f this LCD, acute signs and/r symptms f sufficient severity must manifest the emergency medical cnditin such that the absence f immediate medical attentin culd reasnably be expected t result in ne r mre f the fllwing: Place the patient s health in serius jepardy.

Cause serius impairment t bdily functins. Cause serius dysfunctin f any bdy rgan r part. Nn-Emergency Ambulance Service Ambulance services are cvered in the absence f an emergency cnditin in either f the tw general categries f circumstances that fllw: The patient being transprted has, at the time f grund transprt, a cnditin such that all ther methds f grund transprtatin (e.g., taxi, private autmbile, wheelchair van r ther vehicle) are cntraindicated. In this circumstance, cntraindicated means that the patient cannt be transprted by any ther means frm the rigin t the destinatin withut endangering the individual s health. Having r having had a serius illness, injury r surgery des nt necessarily justify Medicare payment fr ambulance transprtatin, thus a thrugh assessment and dcumented descriptin f the patient s current state is essential fr cverage. All statements abut the patient s medical cnditin must be validated in the dcumentatin using cntempraneus bjective bservatins and findings. See Table I f medical cnditins belw fr examples f findings required fr cverage f ambulance transprtatin. The patient is befre, during and after transprtatin, bed-cnfined. Fr the purpses f this LCD, bed-cnfined means the patient must meet all f the fllwing three criteria: Unable t get up frm bed withut assistance. Unable t ambulate. Unable t sit in a chair (including a wheelchair). As stated in the bullet abve, statements abut the patient s bed-bund status must be validated in the recrd with cntempraneus bjective bservatins and findings as t the patient s functinal physical and/r mental limitatins that have rendered him bed-bund. Nn-emergency ambulance transprtatin is nt cvered fr patients wh are restricted t bed rest by a physician s instructins but wh d nt meet the abve three criteria. If sme means f transprtatin ther than an ambulance (i.e., private car, wheelchair van, etc.) culd be utilized withut endangering the individual s health, whether such ther transprtatin is actually available, n payment may be made fr ambulance service.

Nn-emergency ambulance services may be thse that are scheduled in advance scheduled services being either repetitive r nn-repeating. Nn-emergency ambulance transprtatin is nt cvered if transprtatin is prvided fr the patient wh is transprted t receive a service that culd have been safely and effectively prvided in the pint f rigin (residence, Skilled Nursing Facility (SNF), hspital, etc.). Such transprtatin is nt cvered even if the patient culd nly have gne fr the service by ambulance. Ambulance transprtatin fr services excluded frm SNF cnslidated billing must meet the criteria as reasnable and necessary indicated abve. Ambulance transprts t r frm an Independent Diagnstic Testing Facility (IDTF) are cnsidered paid in the SNF Prspective Payment System (PPS) rate when the beneficiary is in a cvered Part A stay and may nt be paid separately as Part B services. The ambulance transprt is included in the SNF PPS rate if the first r secnd character (rigin r destinatin) f any HCPCS cde ambulance mdifier is D (diagnstic r therapeutic site ther than P r H ), and the ther mdifier (rigin r destinatin) is N (SNF). In this instance, the SNF is respnsible fr the csts f the transprt. The D rigin/destinatin mdifier includes cancer treatment centers, wund care centers, radiatin therapy centers, and all ther diagnstic r therapeutic sites. Destinatin Fr ambulance services t be a cvered benefit, the transprt must be t the nearest institutin with apprpriate facilities fr the treatment f the illness r injury invlved. The term apprpriate facilities means that the institutin is generally equipped t prvide hspital care necessary t manage the illness r injury invlved. It is the institutin, its equipment, its persnnel and its capability t prvide the services necessary t supprt the required medical care that determine whether it has apprpriate facilities. The fact that a mre distant institutin may be better equipped (either subjectively r quantitatively) des nt mean that the clser institutin des nt have apprpriate facilities. In the case f a hspital, it als means that a physician r a physician specialist is available t prvide the necessary care required t treat the patient s cnditin. Hwever, the fact that a particular physician des r des nt have staff privileges in a hspital is nt a cnsideratin in determining whether the hspital has apprpriate facilities. Thus, ambulance service t a mre distant hspital slely t avail a patient f the service f a specific physician r physician specialist des nt make the hspital in which the physician has staff privileges the nearest hspital with apprpriate facilities. Hwever, a legal impediment that bars the patient s admissin wuld preclude that institutin frm having apprpriate facilities. Fr example, if the nearest apprpriate specialty hspital is in anther state and that state s law precludes admissin f nn-residents, that facility is nt an apprpriate facility.

An institutin is als nt cnsidered an apprpriate facility if there is n bed available. The carrier, hwever, will presume there are beds available at the lcal institutins unless the claimant furnished evidence that nne f these institutins had a bed available at the time the ambulance service was prvided. In the case f ambulance services t a facility ther than the clsest apprpriate facility, nly thse miles t the clsest facility are eligible fr cverage. Cvered destinatins fr emergency ambulance services include: Hspitals. Physician s ffice nly if during an emergency transprtatin t a hspital the ambulance stps at a physician s ffice en rute due t a dire need fr prfessinal attentin and thereafter cntinues t the hspital. In such cases, the patient is deemed nt t have been transprted t the physician s ffice and payment may be made fr the entire trip. Cvered destinatins fr nn-emergency transprts include: Hspitals ( apprpriate facility ). Skilled nursing facilities. Dialysis facilities Ambulance services furnished t a maintenance dialysis patient nly when the patient s cnditin at the time f transprt requires ambulance services. Frm an SNF t the nearest supplier f medically necessary services nt available at the SNF where the beneficiary is a resident, including the return trip (fr instance, cardiac catheterizatin; specialized diagnstic imaging prcedures such as cmputerized axial tmgraphy r magnetic resnance imaging; surgery perfrmed in an perating rm; specialized wund care; cancer treatments) when the patient s cnditin at the time f transprt requires ambulance services. The patient s residence nly if the transprt is t return frm an apprpriate facility and the patient s cnditin at the time f transprt requires ambulance services. Physician Certificatin Statement (PCS) Fr scheduled and nn-scheduled nn-emergency ambulance transprts,

prviders f ambulance transprtatin must btain a written statement (PCS) frm the patient s attending physician certifying that medical necessity requirements fr ambulance transprtatin are met. The signature f the medical prfessinal cmpleting the PCS must be legible (r accmpanied by a typed r printed name) and include credentials. Furthermre, signatures n the PCS must be dated at the time they are cmpleted. A PCS is nt required fr emergency transprts r fr nn-scheduled nn-emergency transprts f patients residing at hme r in facilities where they are nt under the direct care f a physician. It is imprtant t nte that the mere presence f the signed physician certificatin statement des nt, by itself, demnstrate that the transprt was medically necessary and des nt abslve the ambulance prvider frm meeting all ther cverage and dcumentatin criteria. Fr nn-repetitive nn-emergency transprts, the fllwing apply: The PCS must be btained frm the attending physician within 48 hurs after the transprt. If the ambulance prvider is unable t btain the PCS frm the attending physician within 48 hurs f transprt, the prvider may submit a claim if a certificatin has been btained frm a Physician Assistant (PA), Nurse Practitiner (NP), Clinical Nurse Specialist (CNS), Registered Nurse (RN) r discharge planner wh is knwledgeable abut the patient s cnditin and wh is emplyed by either the attending physician r the facility in which the patient is admitted. Alternatively, the prvider may submit the claim after 21 days if there is dcumentatin f a gd faith effrt t btain the rder and certificatin. The ambulance supplier must dcument effrts t btain certificatin. When the PCS cannt be btained in accrdance with 42 CFR 410.40, the prvider/supplier may send a letter via U.S. Pstal Service certified mail with return receipt and/r prf f mailing r ther similar service demnstrating delivery f the letter as evidence f the attempt t btain the PCS. Fr repetitive nn-emergency transprts, the fllwing apply: A PCS fr repetitive transprts must be signed by the patient s attending physician. The PCS must be dated n earlier than 60 days in advance f the transprt fr thse patients wh require repetitive ambulance services and whse transprtatin is scheduled in advance.

Tables f Medical Cnditins The attached tables illustrate Medicare s expectatins with respect t the severity f the patient s cnditin t justify payment fr ambulance transprtatin services when all ther cverage and payment cnditins are met. Thugh nt allinclusive, the fllwing table lists medical cnditins fr which ambulance transprtatin is cmmnly required and can be used t judge relative severity f cnditins nt listed. Medicare requires the run reprt t include a descriptin f the patient s symptms and physical findings in sufficient detail as t demnstrate cnditins such as thse described in the tables. Special Nte Regarding Patients Transprted t and Frm Hemdialysis Centers: Only a fractin (apprximately 10 percent) ESRD patients n chrnic hemdialysis requires ambulance transprtatin t and frm hemdialysis sessins. The presence f ESRD and the requirement fr hemdialysis d nt alne qualify a patient fr ambulance transprtatin. Medicare payment requires patients transprted t and frm hemdialysis centers t have ther cnditins such as thse described in the tables belw and requires adequate dcumentatin f thse cnditins in the ambulance supplier s run reprts and in the medical recrds f ther prviders invlved with the patient s care. See 4T-3AB Table f Cnditins.htm attachment fr medical cnditins. Special Cnsideratins Regarding Beneficiary Death Payment fr ambulance services in circumstances in which the beneficiary dies is based n the time f the beneficiary s death related t the time f the call fr service and transprt. In cases where the beneficiary is prnunced dead after the ambulance is called but befre the ambulance arrives at the scene, payment may be made fr a BLS service. Neither mileage nr a rural adjustment wuld be paid. The blended rate amunt will therwise apply. In cases where the beneficiary is prnunced dead after being laded int the ambulance (regardless f whether the prnuncement is made during r subsequent t the transprt), payment is made fllwing the usual rules f payment as if the beneficiary had nt died. This scenari includes a determinatin f Dead n Arrival (DOA) at the facility t which the beneficiary was transprted. Limitatins

Medicare des nt cver the fllwing services: Transprtatin in Ambi-buses, ambulettes (Mbility Assistance Vehicle (MAV)), Medi-cabs, vans, privately wned vehicles, taxicabs. Transprtatin via Mbile Intensive Care Unit (MICU) (if billed under Medicare Part A). Parking fees. Tlls fr bridges, tunnels and highways. Medicare des nt prvide payment fr Ambulance respnse and treatment, n transprt (A0998). Ntice: This LCD impses diagnsis limitatins that supprt diagnsis t prcedure cde autmated denials. Hwever, services perfrmed fr any given diagnsis must meet all f the indicatins and limitatins stated in this plicy, the general requirements fr medical necessity as stated in CMS payment plicy manuals, any and all existing CMS natinal cverage determinatins, and all Medicare payment rules. As published in CMS IOM 100-08, Sectin 13.5.1, in rder t be cvered under Medicare, a service shall be reasnable and necessary. When apprpriate, cntractrs shall describe the circumstances under which the prpsed LCD fr the service is cnsidered reasnable and necessary under Sectin 1862(a)(1)(A). Cntractrs shall cnsider a service t be reasnable and necessary if the cntractr determines that the service is: Safe and effective. Nt experimental r investigatinal (exceptin: rutine csts f qualifying clinical trial services with dates f service n r after September 19, 2000, that meet the requirements f the Clinical Trials NCD are cnsidered reasnable and necessary). Apprpriate, including the duratin and frequency that is cnsidered apprpriate fr the service, in terms f whether it is: Furnished in accrdance with accepted standards f medical practice fr the diagnsis r treatment f the patient's cnditin r t imprve the functin f a malfrmed bdy member.

Furnished in a setting apprpriate t the patient's medical needs and cnditin. Ordered and furnished by qualified persnnel. One that meets, but des nt exceed, the patient's medical needs. At least as beneficial as an existing and available medically apprpriate alternative. Back t Tp Cding Infrmatin Bill Type Cdes: Cntractrs may specify Bill Types t help prviders identify thse Bill Types typically used t reprt this service. Absence f a Bill Type des nt guarantee that the plicy des nt apply t that Bill Type. Cmplete absence f all Bill Types indicates that cverage is nt influenced by Bill Type and the plicy shuld be assumed t apply equally t all claims. 012x Hspital Inpatient (Medicare Part B nly) 013x Hspital Outpatient 022x Skilled Nursing - Inpatient (Medicare Part B nly) 023x Skilled Nursing - Outpatient 083x Ambulatry Surgery Center 085x Critical Access Hspital Revenue Cdes: Cntractrs may specify Revenue Cdes t help prviders identify thse Revenue Cdes typically used t reprt this service. In mst instances Revenue Cdes are purely advisry; unless specified in the plicy services reprted under ther Revenue Cdes are equally subject t this cverage determinatin. Cmplete absence f all Revenue Cdes indicates that cverage is nt influenced by Revenue Cde and the plicy shuld be assumed t apply equally t all Revenue Cdes. Nte: TrailBlazer has identified the Bill Type and Revenue Cdes applicable fr use with the CPT/HCPCS cdes included in this LCD. Prviders are reminded that nt all CPT/HCPCS cdes listed can be billed with all Bill Type and/r Revenue Cdes listed.

CPT/HCPCS cdes are required t be billed with specific Bill Type and Revenue Cdes. Prviders are encuraged t refer t the CMS Internet-Only Manual (IOM), Publicatin 100-04, Claims Prcessing Manual, fr further guidance. 054X Ambulance - General Classificatin CPT/HCPCS Cdes Nte: Prviders are reminded t refer t the lng descriptrs f the CPT cdes in their CPT bk. The American Medical Assciatin (AMA) and the Centers fr Medicare & Medicaid Services (CMS) require the use f shrt CPT descriptrs in plicies published n the Web. A0425 Grund mileage A0426 Als 1 A0427 ALS1-emergency A0428 bls A0429 BLS-emergency A0433 als 2 A0434 Specialty care transprt A0888 Nncvered ambulance mileage A0999 Unlisted ambulance service ICD-9 Cdes that Supprt Medical Necessity Nte: Prviders shuld cntinue t submit ICD-9-CM diagnsis cdes withut decimals n their claim frms and electrnic claims. Medical necessity and cverage f ambulance services are nt based slely n the presence f a specific diagnsis. Medicare payment fr ambulance transprtatin may be made nly fr thse patients whse cnditin at the time f transprt is such that ambulance transprtatin is necessary. Fr example, it is insufficient that a patient merely has a diagnsis such as pneumnia, strke r fracture t justify ambulance transprtatin. In each f thse instances, the cnditin f the patient must be such that transprtatin by any ther means is medically cntraindicated. In the case f ambulance transprtatin, the cnditin necessitating transprtatin is ften that an accident r injury has ccurred giving rise t a clinical suspicin that a specific cnditin exists (fr instance, fractures may be strngly suspected based n clinical examinatin and histry f a specific injury). It is the prvider s respnsibility t supply the cntractr with infrmatin describing the cnditin f the patient that necessitated ambulance transprtatin. Medicare recgnizes limitatins f usual ambulance persnnel fr establishing a diagnsis and recgnizes, therefre, that diagnsis cding f a patient s cnditin using ICD-9-CM cdes when reprting ambulance services may be less specific than fr services reprted by ther

prfessinal prviders. Als, selected ICD-9-CM diagnsis cdes frm the CMS cnditin cde list are included with instructins t use them in a manner that is cntrary t usual ICD-9-CM cding cnventins. Prviders wh submit ICD-9-CM diagnsis cdes shuld chse the cde that best describes the patient s cnditin at the time f transprt. As a reminder t prviders f ambulance services, rule ut r suspected diagnses shuld nt be reprted using specific ICD-9-CM cdes. In such instances where a diagnsis is nt cnfirmed, it is mre crrect t use a symptm, finding r injury cde. Reprting ambulance services using a cde frm the list belw certifies t Medicare that the ambulance prvider believes the cde descriptin reasnably reflects the cnditin f the patient at the time f transprt and that the patient s cnditin was cnsistent with the requirements f the Medicare ambulance transprtatin benefit. TrailBlazer recgnizes that ambulance suppliers are currently nt required t submit ICD-9-CM cdes n their claims if filing n a 1500 claim frm r utilizing an electrnic versin ther than the 5010 versin f the 837P, thugh their ding s facilitates timely claim adjudicatin. The CPT/HCPCS cdes included in this LCD will be subjected t prcedure t diagnsis editing. The fllwing lists include nly thse diagnses fr which the identified CPT/HCPCS prcedures are cvered. If a claim cntains ne r mre ICD-9-CM diagnses but a cvered diagnsis cde is nt n the claim, the edit will autmatically deny the service as nt medically necessary. Claims withut an ICD-9-CM diagnsis cde are adjudicated manually utilizing the infrmatin cntained in the claim s narrative field and/r medical recrds (the trip reprt and any ther recrds supplied t Medicare by the prvider upn ur request). Ambulance suppliers utilizing the 5010 versin f the 837P are required t submit ICD-9-CM diagnsis cde(s). Medicare is establishing the fllwing limited cverage fr HCPCS cdes A0425, A0426, A0427, A0428, A0429, A0433 and A0434: Table 1 Cvered fr Ambulance Transprtatin Services t the Site f Medical Care: 041.9* BACTERIAL INFECTION UNSPECIFIED IN CONDITIONS CLASSIFIED ELSEWHERE AND OF UNSPECIFIED SITE 191.9 MALIGNANT NEOPLASM OF BRAIN UNSPECIFIED SITE 199.1-199.2 250.02-250.03 250.12-250.13 OTHER MALIGNANT NEOPLASM OF UNSPECIFIED SITE - MALIGNANT NEOPLASM ASSOCIATED WITH TRANSPLANT ORGAN DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED - DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE I [JUVENILE TYPE], UNCONTROLLED DIABETES WITH KETOACIDOSIS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED - DIABETES WITH KETOACIDOSIS, TYPE I [JUVENILE TYPE], UNCONTROLLED

250.22-250.23 250.32-250.33 250.42-250.43 250.52-250.53 250.62-250.63 250.72-250.73 250.80-250.83 DIABETES WITH HYPEROSMOLARITY, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED - DIABETES WITH HYPEROSMOLARITY, TYPE I [JUVENILE TYPE], UNCONTROLLED DIABETES WITH OTHER COMA, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED - DIABETES WITH OTHER COMA, TYPE I [JUVENILE TYPE], UNCONTROLLED DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED - DIABETES WITH RENAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED - DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED - DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED - DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE I [JUVENILE TYPE], UNCONTROLLED DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED 251.0-251.1 HYPOGLYCEMIC COMA - OTHER SPECIFIED HYPOGLYCEMIA 276.50 - VOLUME DEPLETION, UNSPECIFIED - HYPOVOLEMIA 276.52 291.0 ALCOHOL WITHDRAWAL DELIRIUM 291.81 ALCOHOL WITHDRAWAL 292.0 DRUG WITHDRAWAL 292.2 PATHOLOGICAL DRUG INTOXICATION 293.0* DELIRIUM DUE TO CONDITIONS CLASSIFIED ELSEWHERE 293.1* SUBACUTE DELIRIUM 298.8* OTHER AND UNSPECIFIED REACTIVE PSYCHOSIS NONDEPENDENT ALCOHOL ABUSE UNSPECIFIED DRINKING 305.00 - BEHAVIOR - NONDEPENDENT OTHER MIXED OR UNSPECIFIED 305.92 DRUG ABUSE EPISODIC USE 312.39* OTHER DISORDERS OF IMPULSE CONTROL 410.00-410.02 ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL SUBSEQUENT EPISODE OF CARE

410.10-410.12 410.20-410.22 410.30-410.32 410.40-410.42 410.50-410.52 410.60-410.62 410.70-410.72 410.80-410.82 410.90-410.92 ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL SUBSEQUENT EPISODE OF CARE TRUE POSTERIOR WALL INFARCTION EPISODE OF CARE UNSPECIFIED - TRUE POSTERIOR WALL INFARCTION SUBSEQUENT EPISODE OF CARE SUBENDOCARDIAL INFARCTION EPISODE OF CARE UNSPECIFIED - SUBENDOCARDIAL INFARCTION SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE SUBSEQUENT EPISODE OF CARE 413.1 PRINZMETAL ANGINA 415.11 IATROGENIC PULMONARY EMBOLISM AND INFARCTION 415.13 SADDLE EMBOLUS OF PULMONARY ARTERY 415.19 OTHER PULMONARY EMBOLISM AND INFARCTION 423.3 CARDIAC TAMPONADE 426.0 ATRIOVENTRICULAR BLOCK COMPLETE 426.3 OTHER LEFT BUNDLE BRANCH BLOCK 426.4 RIGHT BUNDLE BRANCH BLOCK 426.51-426.54 427.0-427.1 RIGHT BUNDLE BRANCH BLOCK AND LEFT POSTERIOR FASCICULAR BLOCK - TRIFASCICULAR BLOCK PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA - PAROXYSMAL VENTRICULAR TACHYCARDIA

427.31 - ATRIAL FIBRILLATION - ATRIAL FLUTTER 427.32 427.41 - VENTRICULAR FIBRILLATION - VENTRICULAR FLUTTER 427.42 427.5 CARDIAC ARREST 427.69 OTHER PREMATURE BEATS 427.81 SINOATRIAL NODE DYSFUNCTION 428.0-428.1 CONGESTIVE HEART FAILURE UNSPECIFIED - LEFT HEART FAILURE 428.20 - UNSPECIFIED SYSTOLIC HEART FAILURE - ACUTE ON CHRONIC 428.23 SYSTOLIC HEART FAILURE 428.30 - UNSPECIFIED DIASTOLIC HEART FAILURE - ACUTE ON CHRONIC 428.33 DIASTOLIC HEART FAILURE UNSPECIFIED COMBINED SYSTOLIC AND DIASTOLIC HEART 428.40 - FAILURE - ACUTE ON CHRONIC COMBINED SYSTOLIC AND 428.43 DIASTOLIC HEART FAILURE 428.9* HEART FAILURE UNSPECIFIED 431 INTRACEREBRAL HEMORRHAGE 434.00 - CEREBRAL THROMBOSIS WITHOUT CEREBRAL INFARCTION - 434.01 CEREBRAL THROMBOSIS WITH CEREBRAL INFARCTION 434.10 - CEREBRAL EMBOLISM WITHOUT CEREBRAL INFARCTION - 434.11 CEREBRAL EMBOLISM WITH CEREBRAL INFARCTION CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITHOUT 434.90 - CEREBRAL INFARCTION - CEREBRAL ARTERY OCCLUSION 434.91 UNSPECIFIED WITH CEREBRAL INFARCTION 435.9 UNSPECIFIED TRANSIENT CEREBRAL ISCHEMIA 436 ACUTE BUT ILL-DEFINED CEREBROVASCULAR DISEASE 438.0 COGNITIVE DEFICITS 438.20 - HEMIPLEGIA AFFECTING UNSPECIFIED SIDE - HEMIPLEGIA 438.22 AFFECTING NONDOMINANT SIDE 438.40 - MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - 438.42 MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 451.11 PHLEBITIS AND THROMBOPHLEBITIS OF FEMORAL VEIN (DEEP) (SUPERFICIAL) 451.19 PHLEBITIS AND THROMBOPHLEBITIS OF OTHER 458.9 HYPOTENSION UNSPECIFIED 459.0 HEMORRHAGE UNSPECIFIED 493.91 - ASTHMA UNSPECIFIED TYPE WITH STATUS ASTHMATICUS - 493.92 ASTHMA UNSPECIFIED WITH (ACUTE) EXACERBATION 496* CHRONIC AIRWAY OBSTRUCTION NOT ELSEWHERE CLASSIFIED 514 PULMONARY CONGESTION AND HYPOSTASIS 518.4 ACUTE EDEMA OF LUNG UNSPECIFIED 518.7 TRANSFUSION RELATED ACUTE LUNG INJURY (TRALI)

530.3 STRICTURE AND STENOSIS OF ESOPHAGUS 560.81 INTESTINAL OR PERITONEAL ADHESIONS WITH OBSTRUCTION (POSTOPERATIVE) (POSTINFECTION) 560.89 OTHER SPECIFIED INTESTINAL OBSTRUCTION 578.9 HEMORRHAGE OF GASTROINTESTINAL TRACT UNSPECIFIED 646.80 OTHER SPECIFIED COMPLICATIONS OF PREGNANCY UNSPECIFIED AS TO EPISODE OF CARE 707.03 - PRESSURE ULCER, LOWER BACK - PRESSURE ULCER, BUTTOCK 707.05 707.23 - PRESSURE ULCER, STAGE III - PRESSURE ULCER, STAGE IV 707.24 718.40 - CONTRACTURE OF JOINT SITE UNSPECIFIED - CONTRACTURE OF 718.49 JOINT OF MULTIPLE SITES 719.49* PAIN IN JOINT INVOLVING MULTIPLE SITES 724.1 PAIN IN THORACIC SPINE 724.2 LUMBAGO 724.5 BACKACHE UNSPECIFIED 729.81 SWELLING OF LIMB 780.01 - COMA - PERSISTENT VEGETATIVE STATE 780.03 780.09 ALTERATION OF CONSCIOUSNESS OTHER 780.1-780.2 HALLUCINATIONS - SYNCOPE AND COLLAPSE 780.32 COMPLEX FEBRILE CONVULSIONS 780.33 POST TRAUMATIC SEIZURES 780.39 OTHER CONVULSIONS 780.60 - FEVER, UNSPECIFIED - POSTPROCEDURAL FEVER 780.62* 780.65* HYPOTHERMIA NOT ASSOCIATED WITH LOW ENVIRONMENTAL TEMPERATURE 780.72 FUNCTIONAL QUADRIPLEGIA 780.97 ALTERED MENTAL STATUS 781.2-781.4* ABNORMALITY OF GAIT - TRANSIENT PARALYSIS OF LIMB 781.6 MENINGISMUS 782.5 CYANOSIS 784.0 HEADACHE 784.3 APHASIA 785.0-785.1 TACHYCARDIA UNSPECIFIED - PALPITATIONS 785.4 GANGRENE 785.50 - SHOCK UNSPECIFIED - SEPTIC SHOCK 785.52

785.59 OTHER SHOCK WITHOUT TRAUMA 786.09* RESPIRATORY ABNORMALITY OTHER 786.50 - UNSPECIFIED CHEST PAIN - PAINFUL RESPIRATION 786.52 787.01 NAUSEA WITH VOMITING 787.03 VOMITING ALONE 789.01 - ABDOMINAL PAIN RIGHT UPPER QUADRANT - ABDOMINAL PAIN 789.07 GENERALIZED 789.09 ABDOMINAL PAIN OTHER SPECIFIED SITE ABDOMINAL OR PELVIC SWELLING MASS OR LUMP UNSPECIFIED 789.30 - SITE - ABDOMINAL OR PELVIC SWELLING MASS OR LUMP 789.37 GENERALIZED ABDOMINAL OR PELVIC SWELLING MASS OR LUMP OTHER 789.39 SPECIFIED SITE 789.40 - ABDOMINAL RIGIDITY UNSPECIFIED SITE - ABDOMINAL RIGIDITY 789.47 GENERALIZED 789.49 ABDOMINAL RIGIDITY OTHER SPECIFIED SITE 789.60 - ABDOMINAL TENDERNESS UNSPECIFIED SITE - ABDOMINAL 789.67 TENDERNESS GENERALIZED 789.69 ABDOMINAL TENDERNESS OTHER SPECIFIED SITE ELEVATED BLOOD PRESSURE READING WITHOUT DIAGNOSIS OF 796.2 HYPERTENSION 799.01 - ASPHYXIA - HYPOXEMIA 799.02 799.1 RESPIRATORY ARREST 799.82 APPARENT LIFE THREATENING EVENT IN INFANT OTHER CLOSED SKULL FRACTURE WITHOUT INTRACRANIAL 803.00 - INJURY WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER 803.06 CLOSED SKULL FRACTURE WITHOUT INTRACRANIAL INJURY WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION OTHER CLOSED SKULL FRACTURE WITHOUT INTRACRANIAL 803.09 803.10-803.16 803.19 803.20-803.26 INJURY WITH CONCUSSION UNSPECIFIED OTHER CLOSED SKULL FRACTURE WITH CEREBRAL LACERATION AND CONTUSION WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER CLOSED SKULL FRACTURE WITH CEREBRAL LACERATION AND CONTUSION WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION OTHER CLOSED SKULL FRACTURE WITH CEREBRAL LACERATION AND CONTUSION WITH CONCUSSION UNSPECIFIED OTHER CLOSED SKULL FRACTURE WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER CLOSED SKULL FRACTURE WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED

803.29 803.30-803.36 803.39 803.40-803.46 803.49 803.50-803.56 803.59 803.60-803.66 803.69 803.70-803.76 803.79 803.80-803.86 DURATION OTHER CLOSED SKULL FRACTURE WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED OTHER CLOSED SKULL FRACTURE WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH STATE OF UNCONSCIOUSNESS UNSPECIFIED - OTHER CLOSED SKULL FRACTURE WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION OTHER CLOSED SKULL FRACTURE WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED OTHER CLOSED SKULL FRACTURE WITH INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER SITE OF CLOSED SKULL FRACTURE WITH INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION OTHER SITE OF CLOSED SKULL FRACTURE WITH INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH CONCUSSION UNSPECIFIED OTHER OPEN SKULL FRACTURE WITHOUT INJURY WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER OPEN SKULL FRACTURE WITHOUT INTRACRANIAL INJURY WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION OTHER OPEN SKULL FRACTURE WITHOUT INTRACRANIAL INJURY WITH CONCUSSION UNSPECIFIED OTHER OPEN SKULL FRACTURE WITH CEREBRAL LACERATION AND CONTUSION WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER OPEN SKULL FRACTURE WITH CEREBRAL LACERATION AND CONTUSION WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION OTHER OPEN SKULL FRACTURE WITH CEREBRAL LACERATION AND CONTUSION WITH CONCUSSION UNSPECIFIED OTHER OPEN SKULL FRACTURE WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER OPEN SKULL FRACTURE WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION OTHER OPEN SKULL FRACTURE WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED OTHER OPEN SKULL FRACTURE WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS

803.89 803.90-803.96 803.99 805.00-805.08 805.10-805.18 805.2-805.9 806.00-806.09 806.10-806.19 806.20-806.29 806.30-806.39 806.4-806.5 806.60-806.62 806.69 806.70-806.72 806.79 UNSPECIFIED - OTHER OPEN SKULL FRACTURE WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION OTHER OPEN SKULL FRACTURE WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED OTHER OPEN SKULL FRACTURE WITH INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER OPEN SKULL FRACTURE WITH INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION OTHER OPEN SKULL FRACTURE WITH INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH CONCUSSION UNSPECIFIED CLOSED FRACTURE OF CERVICAL VERTEBRA UNSPECIFIED LEVEL - CLOSED FRACTURE OF MULTIPLE CERVICAL VERTEBRAE OPEN FRACTURE OF CERVICAL VERTEBRA UNSPECIFIED LEVEL - OPEN FRACTURE OF MULTIPLE CERVICAL VERTEBRAE CLOSED FRACTURE OF DORSAL (THORACIC) VERTEBRA WITHOUT SPINAL CORD INJURY - OPEN FRACTURE OF UNSPECIFIED PART OF VERTEBRAL COLUMN WITHOUT SPINAL CORD INJURY CLOSED FRACTURE OF C1-C4 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - CLOSED FRACTURE OF C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY OPEN FRACTURE OF C1-C4 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - OPEN FRACTURE OF C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY CLOSED FRACTURE OF T1-T6 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - CLOSED FRACTURE OF T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY OPEN FRACTURE OF T1-T6 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - OPEN FRACTURE OF T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY CLOSED FRACTURE OF LUMBAR SPINE WITH SPINAL CORD INJURY - OPEN FRACTURE OF LUMBAR SPINE WITH SPINAL CORD INJURY CLOSED FRACTURE OF SACRUM AND COCCYX WITH UNSPECIFIED SPINAL CORD INJURY - CLOSED FRACTURE OF SACRUM AND COCCYX WITH OTHER CAUDA EQUINA INJURY CLOSED FRACTURE OF SACRUM AND COCCYX WITH OTHER SPINAL CORD INJURY OPEN FRACTURE OF SACRUM AND COCCYX WITH UNSPECIFIED SPINAL CORD INJURY - OPEN FRACTURE OF SACRUM AND COCCYX WITH OTHER CAUDA EQUINA INJURY OPEN FRACTURE OF SACRUM AND COCCYX WITH OTHER SPINAL CORD INJURY

806.8-806.9 CLOSED FRACTURE OF UNSPECIFIED VERTEBRA WITH SPINAL CORD INJURY - OPEN FRACTURE OF UNSPECIFIED VERTEBRA WITH SPINAL CORD INJURY 808.0 - CLOSED FRACTURE OF ACETABULUM - OPEN FRACTURE OF PUBIS 808.3 808.41 - CLOSED FRACTURE OF ILIUM - MULTIPLE CLOSED PELVIC 808.44 FRACTURES WITHOUT DISRUPTION OF PELVIC CIRCLE 808.49 CLOSED FRACTURE OF OTHER SPECIFIED PART OF PELVIS 808.51 - OPEN FRACTURE OF ILIUM - MULTIPLE OPEN PELVIC FRACTURES 808.54 WITHOUT DISRUPTION OF PELVIC CIRCLE 808.59 OPEN FRACTURE OF OTHER SPECIFIED PART OF PELVIS 808.8 - UNSPECIFIED CLOSED FRACTURE OF PELVIS - UNSPECIFIED OPEN 808.9 FRACTURE OF PELVIS 810.10 - OPEN FRACTURE OF CLAVICLE UNSPECIFIED PART - OPEN 810.13 FRACTURE OF ACROMIAL END OF CLAVICLE 812.10 - FRACTURE OF UNSPECIFIED PART OF UPPER END OF HUMERUS 812.13 OPEN - FRACTURE OF GREATER TUBEROSITY OF HUMERUS OPEN 812.19 OTHER OPEN FRACTURE OF UPPER END OF HUMERUS 812.20 - FRACTURE OF UNSPECIFIED PART OF HUMERUS CLOSED - 812.21 FRACTURE OF SHAFT OF HUMERUS CLOSED 812.30 - FRACTURE OF UNSPECIFIED PART OF HUMERUS OPEN - FRACTURE 812.31 OF SHAFT OF HUMERUS OPEN FRACTURE OF UNSPECIFIED PART OF LOWER END OF HUMERUS 812.50 - OPEN - FRACTURE OF UNSPECIFIED CONDYLE(S) OF HUMERUS 812.54 OPEN 812.59 OTHER FRACTURE OF LOWER END OF HUMERUS OPEN 818.1 ILL-DEFINED OPEN FRACTURES OF UPPER LIMB MULTIPLE CLOSED FRACTURES INVOLVING BOTH UPPER LIMBS 819.0 - AND UPPER LIMB WITH RIB(S) AND STERNUM - MULTIPLE OPEN 819.1 FRACTURES INVOLVING BOTH UPPER LIMBS AND UPPER LIMB WITH RIB(S) AND STERNUM FRACTURE OF UNSPECIFIED INTRACAPSULAR SECTION OF NECK 820.00 - OF FEMUR CLOSED - FRACTURE OF BASE OF NECK OF FEMUR 820.03 CLOSED 820.09 OTHER TRANSCERVICAL FRACTURE OF FEMUR CLOSED 820.10 - FRACTURE OF UNSPECIFIED INTRACAPSULAR SECTION OF NECK 820.13 OF FEMUR OPEN - FRACTURE OF BASE OF NECK OF FEMUR OPEN 820.19 OTHER TRANSCERVICAL FRACTURE OF FEMUR OPEN 820.20-820.22 820.30-820.32 FRACTURE OF UNSPECIFIED TROCHANTERIC SECTION OF FEMUR CLOSED - FRACTURE OF SUBTROCHANTERIC SECTION OF FEMUR CLOSED FRACTURE OF UNSPECIFIED TROCHANTERIC SECTION OF FEMUR OPEN - FRACTURE OF SUBTROCHANTERIC SECTION OF FEMUR OPEN

820.8 - FRACTURE OF UNSPECIFIED PART OF NECK OF FEMUR CLOSED - 820.9 FRACTURE OF UNSPECIFIED PART OF NECK OF FEMUR OPEN 821.00 - FRACTURE OF UNSPECIFIED PART OF FEMUR CLOSED - FRACTURE 821.01 OF SHAFT OF FEMUR CLOSED 821.10 - FRACTURE OF UNSPECIFIED PART OF FEMUR OPEN - FRACTURE OF 821.11 SHAFT OF FEMUR OPEN 821.20 - FRACTURE OF LOWER END OF FEMUR UNSPECIFIED PART CLOSED 821.23 - SUPRACONDYLAR FRACTURE OF FEMUR CLOSED 821.29 OTHER FRACTURE OF LOWER END OF FEMUR CLOSED 821.30 - FRACTURE OF LOWER END OF FEMUR UNSPECIFIED PART OPEN - 821.33 SUPRACONDYLAR FRACTURE OF FEMUR OPEN 821.39 OTHER FRACTURE OF LOWER END OF FEMUR OPEN 822.1 OPEN FRACTURE OF PATELLA 823.00 - CLOSED FRACTURE OF UPPER END OF TIBIA - CLOSED FRACTURE 823.02 OF UPPER END OF FIBULA WITH TIBIA 823.10 - OPEN FRACTURE OF UPPER END OF TIBIA - OPEN FRACTURE OF 823.12 UPPER END OF FIBULA WITH TIBIA 823.30 - OPEN FRACTURE OF SHAFT OF TIBIA - OPEN FRACTURE OF SHAFT 823.32 OF FIBULA WITH TIBIA 823.90 - OPEN FRACTURE OF UNSPECIFIED PART OF TIBIA - OPEN 823.92 FRACTURE OF UNSPECIFIED PART OF FIBULA WITH TIBIA 835.00 - CLOSED DISLOCATION OF HIP UNSPECIFIED SITE - OTHER CLOSED 835.03 ANTERIOR DISLOCATION OF HIP 835.10 - OPEN DISLOCATION OF HIP UNSPECIFIED SITE - OTHER OPEN 835.13 ANTERIOR DISLOCATION OF HIP 836.50 - CLOSED DISLOCATION OF KNEE UNSPECIFIED PART - LATERAL 836.54 DISLOCATION OF TIBIA PROXIMAL END CLOSED 836.59 OTHER DISLOCATION OF KNEE CLOSED 836.60 - DISLOCATION OF KNEE UNSPECIFIED PART OPEN - LATERAL 836.64 DISLOCATION OF TIBIA PROXIMAL END OPEN 836.69 OTHER DISLOCATION OF KNEE OPEN 839.00 - CLOSED DISLOCATION CERVICAL VERTEBRA UNSPECIFIED - 839.08 CLOSED DISLOCATION MULTIPLE CERVICAL VERTEBRAE 839.10 - OPEN DISLOCATION CERVICAL VERTEBRA UNSPECIFIED - OPEN 839.18 DISLOCATION MULTIPLE CERVICAL VERTEBRAE 839.20 - CLOSED DISLOCATION LUMBAR VERTEBRA - CLOSED 839.21 DISLOCATION THORACIC VERTEBRA 839.30 - OPEN DISLOCATION LUMBAR VERTEBRA - OPEN DISLOCATION 839.31 THORACIC VERTEBRA 839.40 CLOSED DISLOCATION VERTEBRA UNSPECIFIED SITE 839.42 CLOSED DISLOCATION SACRUM 839.50 - OPEN DISLOCATION VERTEBRA UNSPECIFIED SITE - OPEN 839.52 DISLOCATION SACRUM 839.69 CLOSED DISLOCATION OTHER LOCATION

839.71 OPEN DISLOCATION STERNUM 839.79 OPEN DISLOCATION OTHER LOCATION 839.8 - CLOSED DISLOCATION MULTIPLE AND ILL-DEFINED SITES - OPEN 839.9 DISLOCATION MULTIPLE AND ILL-DEFINED SITES INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITHOUT OPEN INTRACRANIAL WOUND WITH STATE OF 854.00 - CONSCIOUSNESS UNSPECIFIED - INTRACRANIAL INJURY OF 854.06 OTHER AND UNSPECIFIED NATURE WITHOUT OPEN INTRACRANIAL WOUND WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE 854.09 WITHOUT OPEN INTRACRANIAL WOUND WITH CONCUSSION 854.10-854.16 854.19 870.1-870.4 UNSPECIFIED INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH OPEN INTRACRANIAL WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED - INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH OPEN INTRACRANIAL WOUND WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED LACERATION OF EYELID FULL-THICKNESS NOT INVOLVING LACRIMAL PASSAGES - PENETRATING WOUND OF ORBIT WITH FOREIGN BODY 871.0-871.7 OCULAR LACERATION WITHOUT PROLAPSE OF INTRAOCULAR TISSUE - UNSPECIFIED OCULAR PENETRATION 871.9 UNSPECIFIED OPEN WOUND OF EYEBALL 907.2* LATE EFFECT OF SPINAL CORD INJURY 933.1 FOREIGN BODY IN LARYNX 934.9 FOREIGN BODY IN RESPIRATORY TREE UNSPECIFIED 949.0-949.5 BURN OF UNSPECIFIED SITE UNSPECIFIED DEGREE - DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE UNSPECIFIED SITE WITH LOSS OF A BODY PART 959.01 OTHER AND UNSPECIFIED INJURY TO HEAD 959.09 OTHER AND UNSPECIFIED INJURY TO FACE AND NECK 959.11 - OTHER INJURY OF CHEST WALL - OTHER INJURY OF ABDOMEN 959.12 959.19 OTHER AND UNSPECIFIED INJURY OF OTHER SITES OF TRUNK 959.6-959.9* OTHER AND UNSPECIFIED INJURY TO HIP AND THIGH - OTHER AND UNSPECIFIED INJURY TO UNSPECIFIED SITE 977.9 POISONING BY UNSPECIFIED DRUG OR MEDICINAL SUBSTANCE 991.6 HYPOTHERMIA 994.0 - EFFECTS OF LIGHTNING - DROWNING AND NONFATAL

994.1 SUBMERSION 994.7-994.8 ASPHYXIATION AND STRANGULATION - ELECTROCUTION AND NONFATAL EFFECTS OF ELECTRIC CURRENT 995.0 OTHER ANAPHYLACTIC REACTION 995.27 OTHER DRUG ALLERGY 995.29 UNSPECIFIED ADVERSE EFFECT OF OTHER DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE 995.3 ALLERGY UNSPECIFIED NOT ELSEWHERE CLASSIFIED 995.80 UNSPECIFIED ADULT MALTREATMENT 998.30 DISRUPTION OF WOUND, UNSPECIFIED 998.32 DISRUPTION OF EXTERNAL OPERATION (SURGICAL) WOUND 998.33 DISRUPTION OF TRAUMATIC INJURY WOUND REPAIR V07.0 NEED FOR ISOLATION V15.6 PERSONAL HISTORY OF POISONING PRESENTING HAZARDS TO HEALTH V15.89 OTHER SPECIFIED PERSONAL HISTORY PRESENTING HAZARDS TO HEALTH STATUS POST ADMINISTRATION OF TPA (RTPA) IN A DIFFERENT V45.88 FACILITY WITHIN THE LAST 24 HOURS PRIOR TO ADMISSION TO CURRENT FACILITY V46.11 - DEPENDENCE ON RESPIRATOR, STATUS - ENCOUNTER FOR V46.12 RESPIRATOR DEPENDENCE DURING POWER FAILURE V46.14 MECHANICAL COMPLICATION OF RESPIRATOR [VENTILATOR] V46.2* DEPENDENCE ON SUPPLEMENTAL OXYGEN V49.75 - BELOW KNEE AMPUTATION STATUS - ABOVE KNEE AMPUTATION V49.76 STATUS V49.84 BED CONFINEMENT STATUS V49.87 PHYSICAL RESTRAINTS STATUS Ntes: Use cde 041.9 t dente special handling in rute islatin. Use cde 293.0 t dente chemical restraint. Use cde 293.1 t dente patient safety: danger t self and thers mnitring ther and unspecified reactive psychsis. Use cde 298.8 t dente patient safety: danger t self and thers seclusin (flight risk). Use cde 312.39 if behavir is such that restraints were required t ensure patient safety. Use cde 428.9 t dente cardiac/hemdynamic mnitring required en rute. Use cde 496 t dente suctining required en rute, need fr titrated xygen therapy r IV fluid(s).

Use cde 719.49 t dente specialized handling en rute psitin requires specialized handling. Use f diagnsis cdes 780.60 780.62 and 780.65 alne will nt be sufficient t allw ambulance transprtatin. Use an additinal diagnsis t indicate the assciated cnditin f the patient that necessitates ambulance transprtatin f a febrile persn. Use cde 781.3 t dente patient safety risk f falling ff wheelchair r stretcher while in mtin. Use cde 786.09 t dente airway cntrl/psitining required en rute. Use cde 907.2 t dente special handling en rute t reduce pain. Use cde 959.9 t reprt a fall with injuries and ther multiple injury cnditins such as injuries sustained in mtr vehicle accidents. Use cde V46.2 t indicate that transprtatin was necessary due t administratin f medically necessary xygen r required IV medicatins when the patient is incapable f self-administratin. Table 2 Cvered fr Ambulance Services fr Return Transprtatin Fllwing Receipt f Medical Care: 191.9 MALIGNANT NEOPLASM OF BRAIN UNSPECIFIED SITE 199.1-199.2 OTHER MALIGNANT NEOPLASM OF UNSPECIFIED SITE - MALIGNANT NEOPLASM ASSOCIATED WITH TRANSPLANT ORGAN 312.39* OTHER DISORDERS OF IMPULSE CONTROL 436 ACUTE BUT ILL-DEFINED CEREBROVASCULAR DISEASE 438.0 COGNITIVE DEFICITS 438.20-438.22 HEMIPLEGIA AFFECTING UNSPECIFIED SIDE - HEMIPLEGIA AFFECTING NONDOMINANT SIDE 438.40-438.42 MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE 707.03-707.05 PRESSURE ULCER, LOWER BACK - PRESSURE ULCER, BUTTOCK 707.23-707.24 PRESSURE ULCER, STAGE III - PRESSURE ULCER, STAGE IV 718.40-718.49 CONTRACTURE OF JOINT SITE UNSPECIFIED - CONTRACTURE OF JOINT OF MULTIPLE SITES 780.01-780.03 COMA - PERSISTENT VEGETATIVE STATE 780.09 ALTERATION OF CONSCIOUSNESS OTHER 781.2-781.4* ABNORMALITY OF GAIT - TRANSIENT PARALYSIS OF LIMB

806.00-806.09 806.10-806.19 806.20-806.29 806.30-806.39 806.4-806.5 806.60-806.62 806.69 806.70-806.72 806.79 806.8-806.9 CLOSED FRACTURE OF C1-C4 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - CLOSED FRACTURE OF C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY OPEN FRACTURE OF C1-C4 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - OPEN FRACTURE OF C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY CLOSED FRACTURE OF T1-T6 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - CLOSED FRACTURE OF T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY OPEN FRACTURE OF T1-T6 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - OPEN FRACTURE OF T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY CLOSED FRACTURE OF LUMBAR SPINE WITH SPINAL CORD INJURY - OPEN FRACTURE OF LUMBAR SPINE WITH SPINAL CORD INJURY CLOSED FRACTURE OF SACRUM AND COCCYX WITH UNSPECIFIED SPINAL CORD INJURY - CLOSED FRACTURE OF SACRUM AND COCCYX WITH OTHER CAUDA EQUINA INJURY CLOSED FRACTURE OF SACRUM AND COCCYX WITH OTHER SPINAL CORD INJURY OPEN FRACTURE OF SACRUM AND COCCYX WITH UNSPECIFIED SPINAL CORD INJURY - OPEN FRACTURE OF SACRUM AND COCCYX WITH OTHER CAUDA EQUINA INJURY OPEN FRACTURE OF SACRUM AND COCCYX WITH OTHER SPINAL CORD INJURY CLOSED FRACTURE OF UNSPECIFIED VERTEBRA WITH SPINAL CORD INJURY - OPEN FRACTURE OF UNSPECIFIED VERTEBRA WITH SPINAL CORD INJURY 808.0 - CLOSED FRACTURE OF ACETABULUM - OPEN FRACTURE OF 808.3 PUBIS 808.41 - CLOSED FRACTURE OF ILIUM - MULTIPLE CLOSED PELVIC 808.44 FRACTURES WITHOUT DISRUPTION OF PELVIC CIRCLE 808.49 CLOSED FRACTURE OF OTHER SPECIFIED PART OF PELVIS 808.51 - OPEN FRACTURE OF ILIUM - MULTIPLE OPEN PELVIC FRACTURES 808.54 WITHOUT DISRUPTION OF PELVIC CIRCLE 808.59 OPEN FRACTURE OF OTHER SPECIFIED PART OF PELVIS 808.8 - UNSPECIFIED CLOSED FRACTURE OF PELVIS - UNSPECIFIED OPEN 808.9 FRACTURE OF PELVIS FRACTURE OF UNSPECIFIED INTRACAPSULAR SECTION OF NECK 820.00 - OF FEMUR CLOSED - FRACTURE OF BASE OF NECK OF FEMUR 820.03 CLOSED 820.09 OTHER TRANSCERVICAL FRACTURE OF FEMUR CLOSED 820.10-820.13 FRACTURE OF UNSPECIFIED INTRACAPSULAR SECTION OF NECK OF FEMUR OPEN - FRACTURE OF BASE OF NECK OF FEMUR OPEN

820.19 OTHER TRANSCERVICAL FRACTURE OF FEMUR OPEN FRACTURE OF UNSPECIFIED TROCHANTERIC SECTION OF FEMUR 820.20 - CLOSED - FRACTURE OF SUBTROCHANTERIC SECTION OF FEMUR 820.22 CLOSED 820.30-820.32 FRACTURE OF UNSPECIFIED TROCHANTERIC SECTION OF FEMUR OPEN - FRACTURE OF SUBTROCHANTERIC SECTION OF FEMUR OPEN FRACTURE OF UNSPECIFIED PART OF NECK OF FEMUR CLOSED - FRACTURE OF UNSPECIFIED PART OF NECK OF FEMUR OPEN FRACTURE OF UNSPECIFIED PART OF FEMUR CLOSED - FRACTURE OF SHAFT OF FEMUR CLOSED FRACTURE OF UNSPECIFIED PART OF FEMUR OPEN - FRACTURE OF SHAFT OF FEMUR OPEN FRACTURE OF LOWER END OF FEMUR UNSPECIFIED PART CLOSED - SUPRACONDYLAR FRACTURE OF FEMUR CLOSED 820.8-820.9 821.00-821.01 821.10-821.11 821.20-821.23 821.29 OTHER FRACTURE OF LOWER END OF FEMUR CLOSED 821.30 - FRACTURE OF LOWER END OF FEMUR UNSPECIFIED PART OPEN - 821.33 SUPRACONDYLAR FRACTURE OF FEMUR OPEN 821.39 OTHER FRACTURE OF LOWER END OF FEMUR OPEN 959.01 OTHER AND UNSPECIFIED INJURY TO HEAD 959.11-959.12 OTHER INJURY OF CHEST WALL - OTHER INJURY OF ABDOMEN 959.19 OTHER AND UNSPECIFIED INJURY OF OTHER SITES OF TRUNK V46.11 - V46.12 DEPENDENCE ON RESPIRATOR, STATUS - ENCOUNTER FOR RESPIRATOR DEPENDENCE DURING POWER FAILURE V46.14 MECHANICAL COMPLICATION OF RESPIRATOR [VENTILATOR] V46.2* DEPENDENCE ON SUPPLEMENTAL OXYGEN V49.75 - V49.76 BELOW KNEE AMPUTATION STATUS - ABOVE KNEE AMPUTATION STATUS V49.84 BED CONFINEMENT STATUS V49.87 PHYSICAL RESTRAINTS STATUS Ntes: Use cde 312.39 if behavir is such that restraints were required t ensure patient safety. Use cde 781.3 t dente patient safety risk f falling ff wheelchair r stretcher while in mtin. Use cde V46.2 t indicate that transprtatin was necessary due t administratin f medically necessary xygen when the patient is incapable f self-administratin. Diagnses that Supprt Medical Necessity N/A ICD-9 Cdes that DO NOT Supprt Medical Necessity

N/A ICD-9 Cdes that DO NOT Supprt Medical Necessity Asterisk Explanatin Diagnses that DO NOT Supprt Medical Necessity All diagnses nt listed in the ICD-9-CM Cdes That Supprt Medical Necessity sectin f this LCD fr thse HCPCS cdes where limited cverage was established. Back t Tp General Infrmatin Dcumentatins Requirements It is the respnsibility f the ambulance supplier t maintain (and furnish t Medicare upn demand) cmplete and accurate dcumentatin f the beneficiary s cnditin t demnstrate the ambulance service being furnished meets the medical necessity criteria. Dcumentatin must be legible. The dcuments required fr this Medicare purpse include the fllwing: A PCS (fr thse services fr which the physician certificatin is required - see Physician s Certificatin Statement sectin). The certificatin itself is nt the sle factr used in determining whether payment fr ambulance services will be allwed: The PCS may be cmpleted and signed by the fllwing medical prfessinals: the patient s attending physician (MD r DO), r fr instances in which the physician signature is nt available, a PA, NP, CNS, Registered Nurse (RN), r discharge planner emplyed by the hspital r facility where the beneficiary is treated with knwledge f the beneficiary s cnditin at the time the transprt was rdered r the service was rendered. This is applicable t nn-emergency, nn-scheduled transprts. Repetitive nn-emergency scheduled transprts must be signed by the attending physician. A particular frm r frmat is nt required fr the certificatin. Suppliers and physicians may develp their wn certificatin frm. Ambulance cmpany emplyees shuld nt cmplete frms n behalf f these individuals. Fr repetitive services, the PCS may include the expected length f time ambulance transprt wuld be required but may nt exceed 60 days.

Signature f the medical prfessinal cmpleting the PCS must als be legible (r accmpanied by a typed r printed name) and include credentials. Signatures n the PCS must be dated at the time they are cmpleted. Trip recrd must include: A detailed descriptin f the patient s cnditin at the time f transprt. Cverage will nt be allwed if the trip recrd cntains an insufficient descriptin f the patient s cnditin at the time f transfer fr Medicare t reasnably determine that ther means f transprtatin are cntraindicated. Cverage will nt be allwed if the descriptin f the patient s cnditin is limited t cnclusry statements and/r pinins, such as the fllwing: Patient is nn-ambulatry. Patient mved by drawsheet. Patient culd nly be mved by stretcher. Patient is bed-cnfined. Patient is unable t sit, stand r walk. The trip recrd must paint a picture f the patient s cnditin and must be cnsistent with dcumentatin fund in ther supprting medical recrd dcumentatin (including the physician s certificatin). The trip recrd must include the fllwing: A cncise explanatin f symptms reprted by the patient and/r ther bservers and details f the patient s physical assessments that clearly demnstrate that the patient requires ambulance transprtatin and cannt be safely transprted by an alternate mde. An bjective descriptin f the patient s physical cnditin in sufficient detail t demnstrate that the patient s cnditin r

functinal status at the time f transprt meets Medicare limitatin f cverage fr ambulance services. Descriptin f the traumatic event when trauma is the basis fr suspected injuries. A detailed descriptin f existing safety issues. A detailed descriptin f special precautins taken (if any) and explanatin f the need fr such precautins. A descriptin f specific mnitring and treatments required, rdered and perfrmed/administered. That a treatment (such as xygen) and/r mnitring (such as cardiac rhythm mnitring) were perfrmed absent sufficient descriptin f the patient s cnditin (t demnstrate that the treatment and/r mnitring was medically necessary) is inadequate n its wn merit t justify payment fr the ambulance service. Fr example, when xygen is supplied as a basis fr ambulance transprtatin, the patient s pretreatment capillary bld xygen saturatin and clinical respiratry descriptin must be recrded. The tw must be cnsistent with xygen need. Statements such as the fllwing, absent supprting infrmatin in relevant bullets abve, are insufficient t justify Medicare payment fr ambulance services: Patient cmplained f shrtness f breath. Histry f strke. Past histry f knee replacement. Hypertensin. Chest pain. Generalized weakness. Is bed-cnfined. Signatures, including credentials, frm the prvider(s) wh renders the services dcumented:

Services prvided/rdered must be authenticated by the authr. The methd used must be a handwritten r electrnic signature: If the signature is fund t be illegible r missing frm the medical dcumentatin, a signature lg r attestatin statement t determine the identity f the authr may be requested: A signature lg includes the typed r printed name and usual signature f the authr assciated with initials r an illegible signature. An attestatin statement is required when a signature is missing frm the dcumentatin; it must be signed and dated by the authr f the medical recrd entry and must cntain sufficient infrmatin t identify the beneficiary, date f service and be specific t the service dcumented. Prviders shuld nt add late signatures t the dcumentatin. Pint f pick-up/destinatin (identify place and cmplete address). Fr hspital-t-hspital transprts, the trip recrd must clearly indicate the precise treatment r prcedure (r medical specialist) that is available nly at the receiving hspital. Nn-specific r vague statements such as needs cardiac care r needs higher level f care are insufficient. Any additinal available dcumentatin that supprts medical necessity f ambulance transprt (fr example, emergency rm reprt, SNF recrd, End Stage Renal Disease (ESRD) facility recrd, hspital recrd). Dispatch recrd. Dcumentatin supprting the number f laded miles billed.

Appendices N/A Utilizatin Guidelines Mst patients wh require ambulance transprtatin have a shrt-term need due t an acute illness r injury. Lnger term repetitive r frequent ambulance transprtatin is medically necessary fr relatively few patients. Medicare expects that mre than eight cvered ambulance trips per year will rarely be medically necessary fr an individual beneficiary and will cver n mre than 12 ambulance trips per beneficiary per year withut review f the patient s medical recrd. Ntice: This LCD impses utilizatin guideline limitatins that supprt autmated frequency denials. Despite Medicare's allwing up t these maximums, each patient s cnditin and respnse t treatment must medically warrant the number f services reprted fr payment. Medicare requires the medical necessity fr each service reprted t be clearly demnstrated in the patient s medical recrd. Medicare expects that patients will nt rutinely require the maximum allwable number f services Surces f Infrmatin and Basis fr Decisin Other Cntractr Lcal Cverage Determinatins Ambulance Services (Grund Ambulance), TrailBlazer LCD (04001 and 04002) L26738. Ambulance Services (Grund Ambulance), TrailBlazer LCD (00400) L14259, (00900) L14294. Advisry Cmmittee Meeting Ntes This LCD des nt reflect the sle pinin f the cntractr r cntractr medical directr. Althugh the final decisin rests with the cntractr, this LCD was develped in cperatin with advisry grups, which include representatives frm varius specialties. Advisry Cmmittee meeting dates: TX Octber 8, 2008. CO Octber 30, 2008. NM Octber 23, 2008. OK Octber 15, 2008. Start Date f Cmment Perid 10/31/2008 End Date f Cmment Perid 12/15/2008 Start Date f Ntice Perid 02/27/2009 Revisin Histry Number R7 Revisin Histry Explanatin

R7 10/01/2011 Per CR 7454 (annual ICD-9-CM diagnsis cde update) added diagnsis cdes 415.13, 808.43, 808.44, 808.53, 808.54 and 995.0 t CPT/HCPCS cdes A0425, A0426, A0427, A0428, A0429, A0433 and A0434 in Table 1, and added diagnsis cdes 808.43, 808.44, 808.53 and 808.54 t CPT/HCPCS cdes A0425, A0426, A0427, A0428, A0429, A0433 and A0434 in Table 2 f the ICD-9-CM Cdes that Supprt Medical Necessity sectin f the LCD. Effective date: 10/01/2011. R6 07/01/2011 Per CR 7228, ntice f autmatic denial fr claim line items with a GZ mdifier added t definitin f GZ mdifier in Cding Guidelines sectin f related article. Effective date: 07/01/2011. R5 04/14/2009 Per prvider request, updated text under Dcumentatin Requirements sectin f LCD t further clarify bullet regarding dcumentatin fr number f laded miles. Effective date: 04/14/2009. R4 01/01/2011 Updated the text under ICD-9-CM Cdes that Supprt Medical Necessity t include infrmatin fr the new 5010 electrnic frmat requirements. Effective date: 01/01/2011 Per CR 6698, updated text under Physician Certificatin Statement and Dcumentatin Requirements sectin t clarify signature requirements. Effective date: 03/01/2010 Per prvider request, updated text under Dcumentatin Requirements regarding trip recrd fr number f laded miles. Effective date: 04/14/2009. Text mdified in numerus sectins in LCD t clarify clinical requirements fr benefit cverage. Effective date: 04/14/2009. R3 01/01/2011 Per CR 7121 (annual HCPCS update), descriptin changed fr the GA mdifier. Effective date: 01/01/2011. R2 10/18/2010 Use f LCD and related article made applicable t prviders transitining frm WPS t TrailBlazer with additin f cntractr number 04901. Effective date: dates f service n r after 10/18/2010. Per CR 7006 (Annual ICD-9-CM Diagnsis Cding Update), diagnsis cde 780.33 was added t limited cverage table 1 and cde V49.87 was added t tables 1 and 2. Effective

date: 10/01/2010. R1 10/01/2009 Per CR 6520 (Annual ICD-9-CM Diagnsis Cding Update), added new diagnsis cde 799.82 t (Table 1) HCPCS cdes A0425, A0426, A0427, A0428, A0429, A0433, A0434 and A0999. Effective date: 10/01/2009. 08/27/2011 - This plicy was updated by the ICD-9 2011-2012 Annual Update. Reasn fr Change Related Dcuments This LCD has n Related Dcuments. LCD Attachments Cmment and Ntice Summary 4T-3AB pens in new windw Medical Cnditins 4T-3AB pens in new windw Article 4T-3AB-R7 Ambulance pens in new windw Back t Tp All Versins Updated n 10/13/2011 with effective dates 10/01/2011 - N/A Updated n 08/27/2011 with effective dates 07/01/2011-09/30/2011 Updated n 07/26/2011 with effective dates 07/01/2011 - N/A Updated n 05/09/2011 with effective dates 01/01/2011-06/30/2011 Updated n 04/08/2011 with effective dates 01/01/2011 - N/A Updated n 01/27/2011 with effective dates 01/01/2011 - N/A Updated n 12/07/2010 with effective dates 10/18/2010-12/31/2010 Updated n 11/02/2010 with effective dates 10/18/2010 - N/A Updated n 09/13/2010 with effective dates 09/07/2010-10/17/2010 Updated n 08/01/2010 with effective dates 10/01/2009-09/06/2010 Updated n 08/01/2010 with effective dates 10/01/2009 - N/A Updated n 03/31/2010 with effective dates 10/01/2009 - N/A Updated n 09/28/2009 with effective dates 10/01/2009 - N/A Sme lder versins have been archived. Please visit the MCD Archive Site pens in new windw t retrieve them. Read the LCD Disclaimer pens in new windw Back t Tp Fter Links

Get Help with File Frmats and Plug-Ins pens in new windw Submit Feedback pens in new windw Department f Health & Human Services Medicare.gv USA.gv Web Plicies & Imprtant Links Privacy Plicy Freedm f Infrmatin Act N Fear Act Centers fr Medicare & Medicaid Services, 7500 Security Bulevard Baltimre, MD 21244 Ambulance Services (Grund Ambulance) 4T-3AB (L28627) I. Medical Cnditins Cmplaint r Symptm Cnditin Requirement Examples f Symptms and Findings Necessary (and Dcumented) fr Cverage Abdminal pain Abnrmal cardiac rhythm/cardiac dysrhythmia Accmpanied by ther signs r symptms Symptmatic r ptentially lifethreatening arrhythmia Assciated symptms include nausea, vmiting, fainting. Assciated signs include tender r pulsatile mass, distentin, rigidity, rebund tenderness n exam, guarding. Necessary symptms include syncpe r near syncpe, chest pain and dyspnea. Signs required include severe bradycardia r tachycardia (rate < 60 r > 120), signs f cngestive heart failure. Examples include junctinal and ventricular rhythms, nn-sinus tachycardias, PVCs > 6/min, bi- and trigeminy, ventricular tachyarrhythmias, PEA, asystle. Patients are expected t have cnditins that require mnitring during and after transprtatin.

Abnrmal skin signs Alchl r drug intxicatin Allergic reactin Animal bites/sting/ envenmatin Sexual assault Severe intxicatin Ptentially lifethreatening manifestatins Ptentially life- r limbthreatening With significant external and/r internal injuries Includes diaphrhesis, cyansis, delayed capillary refill, diminished skin turgr, mttled skin. Presence f ther emergency cnditins Unable t care fr self. Unable t ambulate. Altered level f cnsciusness. Airway may r may nt be at risk. Includes rapidly prgressive symptms, prir histry f anaphylaxis, wheezing, ral/facial/laryngeal edema Symptms f specific envenmatin, significant face, neck, trunk and extremity invlvement. Special handling and/r mnitring required. Presence f ther emergency cnditins. Bld glucse Abnrmal <80 r >250 with symptms Signs include altered mental status (altered beynd baseline functin), vmiting, significant vlume cntractin, significant cardiac dysfunctin. Back pain (see general pain listing belw) Sudden nset, severe nn-traumatic pain suggestive f cardiac r vascular rigin r requiring special psitining nly available by ambulance 7 10 n 10-pint severity scale. Neurlgic symptms and/r signs, absent leg pulses, pulsatile abdminal mass, cncurrent chest r abdminal pain Respiratry arrest Includes apnea r hypventilatin requiring ventilatry assistance and airway management Respiratry distress, shrtness f breath, need fr supplemental xygen Objective evidence f abnrmal respiratry functin Includes tachypnea, labred respiratin, hypxemia requiring xygen administratin. Includes patients wh require advanced airway management such as ventilatr management, apnea

mnitring fr pssible intubatin and deep airway suctining. Includes patients wh require psitining nt pssible in ther cnveyance vehicles. Nte that xygen administratin absent signs r symptms f respiratry distress is, by itself, inadequate reasn t justify ambulance transprtatin in a patient capable f self-administratin f xygen. Patient must require xygen therapy and be s frail as t require assistance f medically trained persnnel. Cardiac arrest with resuscitatin in prgress Chest pain (nntraumatic) Chking episde Cardiac rigin suspected. Obvius nn-emergent cause nt identified Respiratry r neurlgic impairment Pain characterized as severe, tight, dull r crushing, substernal, epigastric, left-sided chest pain. Especially with assciated pain f the jaw, left arm, neck, back, GI symptms (such as nausea, vmiting), arrhythmias, palpitatins, difficulty breathing, pallr, diaphresis, alteratin f cnsciusness. Atypical pain accmpanied by nausea and vmiting, severe weakness, feeling f impending dm r abnrmal vital signs. Cld expsure Altered level f cnsciusness (nntraumatic) Ptentially life- r limbthreatening Neurlgic dysfunctin in additin t any baseline abnrmality Findings include temperature < 95º F, signs f deep frst bite r presence f ther emergency cnditins. Acute cnditin with Glasgw Cma Scale <15 r transient symptms f dizziness assciated with neurlgic r cardivascular symptms and/r signs r abnrmal vital signs

Cnvulsins/seizures Active seizing r immediate pst-seizure at risk f repeated seizure and requires medical mnitring/bservatin Cnditins include new nset r untreated seizures r histry f significant change in baseline cntrl f seizure activity. Findings include nging seizure activity, pst-ictal neurlgic dysfunctin. Nn-traumatic headache Heat expsure Hemrrhage Infectius diseases requiring islatin prcedures/public health risk Hazardus substance expsure Medical device failure Neurlgic dysfunctin Assciated neurlgic signs and/r symptms r abnrmal vital signs Ptentially lifethreatening Ptentially lifethreatening The nature f the infectin r the behavir f the patient must be such that failure t islate pses significant risk f spread f a cntagius disease. The nature f the expsure shuld be such that ptential injury is likely. Life- r limb-threatening malfunctin, failure r cmplicatin Acute r unexplained neurlgic dysfunctin in additin t any baseline abnrmality Findings include ht and dry skin, cre temperature >105º, neurlgic dysfunctin, muscle cramps, prfuse sweating, severe fatigue. Includes uncntrlled bleeding with signs f shck and active severe bleeding (quantity identified) nging r recent with ptential fr immediate rebleeding. Infectins in this categry are limited t thse infectins fr which islatin is prvided bth befre and after transprtatin. Txic fume r liquid expsure via inhalatin, absrptin, ral, radiatin, smke inhalatin Malfunctin f ventilatr, internal pacemaker, internal defibrillatr, implanted drug delivery device, O 2 supply malfunctin, rthpedic device failure Signs include facial drping, lss f visin withut phthalmlgic explanatin, aphasia, dysphasia, difficulty swallwing, numbness, tingling extremity, stupr, delirium, cnfusin, hallucinatins, paralysis, paresis (fcal weakness), abnrmal mvements, vertig, unsteady gait/balance.

Pain nt therwise specified in this table Pisns ingested, injected, inhaled r absrbed, alchl r drug intxicatin Cmplicatin f pregnancy/childbirth and pstperative prcedure cmplicatins Psychiatric/behaviral Pain is the reasn fr the transprt. Acute nset r bed-cnfining. Ptentially lifethreatening Requires special handling fr transprt Is expressing active signs and/r symptms f uncntrlled psychiatric cnditin r acute substance withdrawal. Is a threat t self r thers requiring restraint (chemical r physical) r mnitring and/r interventin f trained medical persnnel during transprt fr patient and crew safety. Transprt is required by state Pain is severity f 7 10 n 10-pint severity scale despite pharmaclgic interventin. Patient needs specialized handling t be mved. Other emergency cnditins are present r reasnably suspected. Signs f ther life- r limbthreatening cnditins are present. Assciated cardipulmnary, neurlgic, r peripheral vascular signs and symptms are present. Requires cardipulmnary and/r neurlgic mnitring and supprt and/r urgent pharmaclgic interventin. Includes circumstances in which quantity and identity f agent knwn t be lifethreatening; instances in which quantity and identity f agent are nt knwn but there are signs and symptms f neurlgic dysfunctin, abnrmal vital signs, r abnrmal cardipulmnary functin. Als, includes circumstances in which quantity and identity f agent are nt knwn but life-threatening pisning reasnably suspected. Includes majr wund dehiscence, evisceratin, rgan prlapse, hemrrhage r rthpedic appliance failure Includes disrientatin, suicidal ideatins, attempts and gestures, hmicidal behavir, hallucinatins, vilent r disruptive behavir, sign/symptms r DTs, drug withdrawal signs/symptms, severe anxiety, acute episde r exacerbatin f parania. Refer t definitin f restraints in the CFR, Sectin 482.13(e). Fr behaviral r cgnitive risk such that patient requires attendant t assure patient des nt try t exit the ambulance prematurely, see CFR, Sectin 482.13(f)(2) fr definitin.

Fever Gastrintestinal distress General mbility issues and bed-cnfinement law/curt rder. Significantly high fever unrespnsive t pharmaclgic interventin r fever with assciated symptms Accmpanied by ther signs r symptms Patient s physical cnditin is such that patient risks injury during vehicle mvement despite restraints r psitining and/r recrd demnstrates specialized handling required and prvided Temperature after pharmaclgic interventin >102º (adult) Temperature after pharmaclgic interventin >104º (child) Assciated neurlgic r cardivascular symptms/signs, ther abnrmal vital signs Severe nausea and vmiting r severe, incapacitating diarrhea with evidence f vlume depletin, abnrmal vital signs r neurlgic dysfunctin This may be due t any r multiple f the cnditins listed abve. All cnditins that cntribute t general mbility issues must be adequately described. Includes cnditins such as: Decubitus ulcers n sacrum r buttcks that are grade 3 r greater fr transfers requiring mre than 60 minutes f sitting. Lwer extremity cntractures that are f sufficient degree as t prhibit sitting in a wheelchair (severe fixed cntractures at r prximal t the knee). Unstable jints. Includes flail weightbearing jints fllwing jint surgery. Includes ther patients wh, in the expressed pinin f the perating surgen, must abslutely bear n weight n a pstperative jint r patients wh are incapable f prtecting the jint withut the assistance f the trained medical ambulance persnnel. Patients wh have undergne successful weight bearing jint repair/replacement and thse wh have successfully undergne lng-bne fracture repair

II. Cnditins Trauma On-Scene Cnditin (General) On-Scene Cnditin (Specific) (and wh are nt therwise immbilized in casts that prhibit sitting) will generally nt be included. Severely debilitating chrnic neurlgical cnditins such as degenerative cnditins r strkes with severe sequelae. Neurlgical deficits must be described. Mrbid besity (as a sle qualifying cnditin) causing the patient t meet the regulatry definitin f bedcnfined. Medicare des nt expect this t ccur with persns whse BMI is <80. Cmments and Examples (Nt All- Inclusive) Majr trauma Other trauma Hemrrhage As defined by ACS Field Triage Decisin Scheme Need t mnitr r maintain airway r immbilize head/neck Ptentially life-threatening hemrrhage Trauma with ne f the fllwing: Glasgw < 14; systlic BP < 90; RR < 10 r > 29; all penetrating injuries t head, neck, trs, extremities prximal t elbw r knee; flail chest; cmbinatin f trauma and burns; pelvic fracture; tw r mre lng-bne fractures; pen r depressed skull fracture; paralysis; severe mechanism f injury including: ejectin, death f anther passenger in same patient cmpartment, falls > 20 feet, 20-inch defrmity in vehicle r 12-inch defrmity f patient cmpartment, aut pedestrian/bike, pedestrian thrwn/run ver, mtrcycle accident at speeds > 20 miles per hur and rider separated frm vehicle Decreased level f cnsciusness, bleeding int airway, significant trauma t head, face r neck Includes uncntrlled bleeding with signs f shck and active severe bleeding (quantity identified), nging r recent, with ptential fr immediate rebleeding Suspected Suspected fracture r Includes suspected fractures r dislcatins

fractures/dislcatins Penetrating extremity injuries Traumatic amputatins Suspected internal, head, chest r abdminal injuries Burns Lightning Electrcutin Near-drwning Eye injuries dislcatin requires splinting/immbilizatin and renders patient unable t be transprted by anther vehicle Life-r limb-threatening injury Life-threatening injury r reattachment pprtunity exists Majr: per American Burn Assciatin (ABA) Acute visin lss r blurring, severe pain r chemical expsure, penetrating, severe lid laceratins f spine and lng bnes and jints prximal t knee and elbw. The recrd will demnstrate histry f significant trauma and r findings t supprt such suspicins. Uncntrlled hemrrhage, cmprmised neurvascular supply, uncntrllable pain requiring pharmaclgic interventin Signs f clsed head injury, pen head injury, pneumthrax, hemthrax, abdminal bruising, psitive abdminal signs n exam, internal bleeding criteria, evisceratin Partial thickness burns > 10 percent Ttal Bdy Surface Area (TBSA); invlvement f face, hands, feet, genitalia, perineum r majr jints; third-degree burns; electrical, chemical, inhalatin burns with preexisting medical disrders; burns and trauma Article Title Ambulance Services (Grund Ambulance) 4T-3AB-R7 Cntractr s Determinatin Number 4T-3AB

Cntractr Name TrailBlazer Health Enterprises Cntractr Number 04001 (04101, 04201, 04301, 04401, 04901). 04002 (04102, 04202, 04302, 04402). Cntractr Type MAC Part A. MAC Part B. AMA CPT/ADA CDT Cpyright Statement CPT cdes, descriptins and ther data nly are cpyright 2010 American Medical Assciatin (r such ther date f publicatin f CPT). All rights reserved. Applicable FARS/DFARS clauses apply. Current Dental Terminlgy (CDT) (including prcedure cdes, nmenclature, descriptrs and ther data cntained therein) is cpyright by the American Dental Assciatin. 2002, 2004 American Dental Assciatin. All rights reserved. Applicable FARS/DFARS apply. Primary Gegraphic Jurisdictin CO. NM. OK. TX: Indian Health Service. End Stage Renal Disease (ESRD) facilities. Skilled Nursing Facilities (SNFs). Rural Health Clinics (RHCs). Transitined WPS legacy prviders. Oversight Regin Regin IV. Regin VI. Original Article Effective Date 04/14/2009 Article Revisin Effective Date

10/01/2011 Article Ending Effective Date N/A Article Text Abstract The Medicare payment benefit fr ambulance services is very restricted. Ambulance suppliers must understand the benefit and refrain frm seeking Medicare payment fr services that d nt cnfrm t the limited benefit requirements as stated in regulatin. Physicians and thers wh rder and certify medical necessity f ambulance services must als understand and abide by the limitatins f Medicare cverage f ambulance services. Ambulance services invlve the assessment and administratin f emergency care by medically trained persnnel (see definitin belw) and transprtatin f patients within an apprpriate, safe and mnitred envirnment. Ambulance transprtatin is a cvered service under Medicare when the patient s cnditin is such that the use f any ther methd f transprtatin wuld endanger the patient s health. Medicare cverage fr ambulance transprtatin is limited by CMS natinal plicy in accrdance with federal law. Fr the purpses f the related LCD, the fllwing definitins apply: Medically trained persnnel refers t individuals wh have fulfilled state training and educatinal requirements and are certified r licensed by their respective state t prvide Basic Life Supprt (BLS) and/r Advanced Life Supprt (ALS) Emergency Medical Technician (EMT)-level services. The vehicle used as an ambulance must be specially designed r equipped fr transprtatin f the sick r injured and have custmary patient care equipment. At a minimum, the ambulance must cntain a stretcher, linens, emergency medical supplies, xygen equipment and ther lifesaving emergency medical equipment, and be equipped with emergency warning lights, sirens and telecmmunicatins equipment as required by state r lcal law. This shuld include, at a minimum, ne tw-way vice radi r wireless telephne. Definitins f Levels f Service BLS Basic Life Supprt: Medically necessary transprtatin by grund ambulance vehicle and medically necessary supplies and services, plus the prvisin f BLS ambulance services. The ambulance must be staffed by an

individual wh is qualified in accrdance with state and lcal laws as an Emergency Medical Technician-Basic (EMT-Basic). These laws may vary frm state t state. Fr example, nly in sme states is an EMT-Basic permitted t perate limited equipment n bard the vehicle, assist mre qualified persnnel in perfrming assessments and interventins, and establish a peripheral intravenus (IV) line. ALS Assessment Advanced Life Supprt Assessment: An assessment perfrmed by an ALS crew as part f an emergency respnse that was necessary because the patient s reprted cnditin at the time f dispatch was such that nly an ALS crew was qualified t perfrm the assessment. An ALS assessment des nt necessarily result in a determinatin that the patient requires an ALS level f service. ALS Interventin Advanced Life Supprt Interventin: A prcedure that is, in accrdance with state and lcal laws, beynd the scpe f practice f an EMT- Basic. ALS1 Advanced Life Supprt, Level 1: Where medically necessary, transprtatin by grund ambulance vehicle prviding medically necessary supplies and services, and either an ALS assessment by ALS persnnel r the prvisin f at least ne ALS interventin. EMT-Intermediate scpe includes but is nt limited t: Administratin f IV fluids (except bld r bld prducts). Peripheral venus puncture. Bld drawing. Mnitring IV slutins during transprt, which cntain ptassium. Administratin f apprved medicatins, IV, Sub Q, sublingual, nebulizer inhalatin, IM (limited t deltid and thigh sites nly). ALS2 Advanced Life Supprt, Level 2: Medically necessary grund ambulance vehicle transprtatin prviding medically necessary supplies and services alng with at least ne f the fllwing: Three separate administratins f ne r mre medicatins by intravenus push/blus r by cntinuus infusin excluding crystallids (hyptnic, istnic and hypertnic slutins) such as dextrse, nrmal saline r ringer s lactate. Manual defibrillatin/cardiversin. Endtracheal intubatin. Central venus line Cardiac pacing. Chest cmpressin. Surgical airway. Intrasseus line. SCT Specialty Care Transprt: Specialty care transprt is the interfacility transprtatin f a critically injured r ill beneficiary by a grund ambulance vehicle, including the prvisin f medically necessary supplies and services beynd the scpe f the EMT-Paramedic. SCT is necessary when a beneficiary s cnditin requires nging care that must be furnished by ne r mre health prfessinals in an apprpriate

specialty area, fr example, emergency r critical care nursing, emergency medicine, respiratry care, cardivascular care, r a paramedic with additinal training. Part A Prgram Instructins Reasns fr Denial All ther indicatins nt listed in the Indicatins and Limitatins f Cverage and/r Medical Necessity sectin f this LCD. The medical recrd des nt verify that the service described by the HCPCS cde was prvided. The claim includes ICD-9-CM diagnsis cdes but des nt include a cvered diagnsis cde frm the cvered list abve. Dcumentatin cntains an insufficient descriptin f the patient s cnditin at the time f transfer fr Medicare t reasnably determine that ther means f transprtatin are cntraindicated. Descriptin f the patient s cnditin is limited t cnclusry pinins, such as the fllwing: Patient is nn-ambulatry. Patient mved by drawsheet. Patient culd nly be mved by stretcher. Patient is bed-cnfined. Patient is unable t sit, stand, r walk. Dcumentatin in the trip recrd cnflicts with ther supprting medical recrds (including physician s certificatin). Failure t btain apprpriate physician rder and/r certificatin (as defined and required in this LCD). Transfer frm a hspital r Skilled Nursing Facility (SNF), which has apprpriate facilities, t a secnd hspital r SNF. The patient is nt transprted (see exceptin regarding patient death). The patient is ambulatry, there is n emergency, and there is n ther cnditin that cntraindicates transprt by ther means. Transprtatin is t a nn-cvered destinatin. Transprtatin is fr purpses f btaining a nn-cvered service. If the transprt was medically apprpriate but the beneficiary culd have been treated at a clser hspital than the ne t which he was transprted, the transprt payment is limited t the rate fr the distance frm the pint f pick up t that clser hspital. Transprt was t a funeral hme. The ambulance was used slely because ther means f transprtatin were unavailable. The individual merely needed assistance in getting frm his rm r hme t a vehicle. The service des nt fllw the guidelines f this LCD. Cding Guidelines

Refer t the Crrect Cding Initiative (CCI) fr crrect cding guidelines and specific applicable cde cmbinatins prir t billing Medicare. Prvisins f this LCD d nt take precedence ver CCI edits. Ambulance prviders may submit claims using a cvered ICD-9-CM cde as listed in the LCD t reprt services fr patients whse cnditins warrant Medicare payment fr ambulance transprtatin. Reprt a diagnsis cde that best describes the patient s cnditin at the time f transprt. As a reminder t prviders f ambulance services, rule ut r suspected diagnses shuld nt be reprted using specific ICD-9-CM cdes. In such instances where a diagnsis is nt cnfirmed, it is mre crrect t use a symptm, finding r injury cde. Mdifiers: GM: Multiple patients n ne ambulance trip. QM: Ambulance service prvided under arrangement by a prvider f services (Part A nly). QN: Ambulance services furnished directly by a prvider f services (Part A nly). QL: Patient prnunced dead after ambulance called. GA: Waiver f liability statement issued as required by payer plicy, individual case. (Use fr patients wh d nt meet the cvered indicatins and limitatins f this LCD and fr whm an ABN is n file.) (ABN des nt have t be submitted but must be made available upn request.) GW: Service nt related t hspice patient s terminal cnditin. GY: Item r service is statutrily excluded r des nt meet the definitin f any Medicare benefit. Use mdifier GY t reprt ambulance services fr patients whse cnditin des nt meet the requirements f this LCD r fr whm ambulance transprtatin is nn-cvered. GZ: Item r service expected t be denied as nt reasnable and necessary. (Use fr patients wh d nt meet the cvered indicatins and limitatins f this LCD and wh did nt sign an ABN and the prvider expects the item/service t be denied. All claim line items submitted with the GZ mdifier will be denied autmatically and will nt be subject t cmplex medical review.) See als Bill Type and Revenue Cde sectins belw. Origin/destinatin: Prviders must reprt an rigin and destinatin mdifier fr each ambulance trip prvided. Origin and destinatin mdifiers used fr ambulance services are created by cmbining tw alpha characters. Each alpha character, with the exceptin f X, represents an rigin cde r a destinatin cde. The pair f alpha cdes creates ne mdifier. The first psitin alpha cde equals rigin; the secnd alpha cde equals destinatin: D Diagnstic r therapeutic site ther than P r H when these are used as rigin cdes E Residential, dmiciliary, custdial facility (ther than an 1819 facility) G Hspital-based dialysis facility (hspital r hspital-related)

H Hspital I Site f transfer (e.g., airprt r helicpter pad) between mdes f ambulance transprt J Nn-hspital-based dialysis facility N Skilled Nursing Facility (SNF)(1819 facility) P Physician s ffice R Residence S Scene f accident r acute event X (Destinatin cde nly) Intermediate stp at physician s ffice n the way t the hspital Fr additinal infrmatin n mdifiers, see the mdifier sectin f the Ambulance Manual: http://www.trailblazerhealth.cm/publicatins/training%20manual/ambulance. pdf Part B Prgram Instructins Reasns fr Denial All ther indicatins nt listed in the Indicatins and Limitatins f Cverage and/r Medical Necessity sectin f this LCD. The medical recrd des nt verify that the service described by the HCPCS cde was prvided. The claim includes ICD-9-CM diagnsis cdes but des nt include a cvered diagnsis cde frm the cvered list abve. Dcumentatin cntains an insufficient descriptin f the patient s cnditin at the time f transfer fr Medicare t reasnably determine that ther means f transprtatin are cntraindicated. Descriptin f the patient s cnditin is limited t cnclusry pinins, such as the fllwing: Patient is nn-ambulatry. Patient mved by drawsheet. Patient culd nly be mved by stretcher. Patient is bed-cnfined. Patient is unable t sit, stand, r walk. Dcumentatin in the trip recrd cnflicts with ther supprting medical recrds (including physician s certificatin). Failure t btain apprpriate physician rder and/r certificatin (as defined and required in this LCD). Transfer frm a hspital r Skilled Nursing Facility (SNF), which has apprpriate facilities, t a secnd hspital r SNF. The patient is nt transprted (see exceptin regarding patient death). The patient is ambulatry, there is n emergency, and there is n ther cnditin that cntraindicates transprt by ther means.

Transprtatin t a nn-cvered destinatin. Transprtatin is fr purpses f btaining a nn-cvered service. If the transprt was medically apprpriate but the beneficiary culd have been treated at a nearer hspital than the ne t which he was transprted, the transprt payment is limited t the rate fr the distance frm the pint f pick up t that nearer hspital. Transprt was t a funeral hme. The ambulance was used slely because ther means f transprtatin were unavailable. The individual merely needed assistance in getting frm his rm r hme t a vehicle. The service des nt fllw the guidelines f this LCD. Cding Guidelines Refer t the Crrect Cding Initiative (CCI) fr crrect cding guidelines and specific applicable cde cmbinatins prir t billing Medicare. Prvisins f this LCD d nt take precedence ver CCI edits. Ambulance prviders may submit claims using a cvered ICD-9-CM cde as listed in the LCD t reprt services fr patients whse cnditins warrant Medicare payment fr ambulance transprtatin. Reprt a diagnsis cde that best describes the patient s cnditin at the time f transprt. As a reminder t prviders f ambulance services, rule ut r suspected diagnses shuld nt be reprted using specific ICD-9-CM cdes. In such instances where a diagnsis is nt cnfirmed, it is mre crrect t use a symptm, finding r injury cde. Mdifiers: GM: Multiple patients n ne ambulance trip. QL: Patient prnunced dead after ambulance called. CR Catastrphe/Disaster related. GA: Waiver f liability statement issued as required by payer plicy, individual case. (Use fr patients wh d nt meet the cvered indicatins and limitatins f this LCD and fr whm an ABN is n file.) (ABN des nt have t be submitted but must be made available upn request.) GW: Service nt related t hspice patient s terminal cnditin. GY: Item r service is statutrily excluded r des nt meet the definitin f any Medicare benefit. Use mdifier GY t reprt ambulance services fr patients whse cnditin des nt meet the requirements f this LCD r fr whm ambulance transprtatin is nn-cvered. GZ: Item r service expected t be denied as nt reasnable and necessary. (Use fr patients wh d nt meet the cvered indicatins and limitatins f this LCD and wh did nt sign an ABN and the prvider expects the item/service t be denied. All claim line items submitted with the GZ mdifier will be denied autmatically and will nt be subject t cmplex medical review.) Bill Type and Revenue Cdes belw DO NOT apply t Part B. Origin/destinatin:

Prviders must reprt an rigin and destinatin mdifier fr each ambulance trip prvided. Origin and destinatin mdifiers used fr ambulance services are created by cmbining tw alpha characters. Each alpha character, with the exceptin f X, represents an rigin cde r a destinatin cde. The pair f alpha cdes creates ne mdifier. The first psitin alpha cde equals rigin; the secnd alpha cde equals destinatin: D Diagnstic r therapeutic site ther than P r H when these are used as rigin cdes E Residential, dmiciliary, custdial facility (ther than an 1819 facility) G Hspital-based dialysis facility (hspital r hspital-related) H Hspital I Site f transfer (e.g., airprt r helicpter pad) between mdes f ambulance transprt J Nn-hspital-based dialysis facility N Skilled Nursing Facility (SNF)(1819 facility) P Physician s ffice R Residence S Scene f accident r acute event X (Destinatin cde nly) Intermediate stp at physician s ffice n the way t the hspital Fr additinal infrmatin n mdifiers, see the mdifier sectin f the Ambulance Manual: http://www.trailblazerhealth.cm/publicatins/training%20manual/ambulance. pdf Bill Type Cdes Cntractrs may specify Bill Types t help prviders identify thse Bill Types typically used t reprt this service. Absence f a Bill Type des nt guarantee that the plicy des nt apply t that Bill Type. Cmplete absence f all Bill Types indicates that cverage is nt influenced by Bill Type and the plicy shuld be assumed t apply equally t all claims. 12X, 13X, 22X, 23X, 83X, 85X Revenue Cdes Cntractrs may specify Revenue Cdes t help prviders identify thse Revenue Cdes typically used t reprt this service. In mst instances Revenue Cdes are purely advisry; unless specified in the plicy services reprted under ther Revenue Cdes are equally subject t this cverage determinatin. Cmplete absence f all Revenue Cdes

indicates that cverage is nt influenced by Revenue Cde and the plicy shuld be assumed t apply equally t all Revenue Cdes. Nte: TrailBlazer has identified the Bill Type and Revenue Cdes applicable fr use with the CPT/HCPCS cdes included in this LCD. Prviders are reminded that nt all CPT/HCPCS cdes listed can be billed with all Bill Type and/r Revenue Cdes listed. CPT/HCPCS cdes are required t be billed with specific Bill Type and Revenue Cdes. Prviders are encuraged t refer t the CMS Internet-Only Manual Publicatin 100-04, Claims Prcessing Manual, fr further guidance. 054X CPT/HCPCS Cdes Nte: Prviders are reminded t refer t the lng descriptrs f the CPT cdes in their CPT bk. The American Medical Assciatin (AMA) and the Centers fr Medicare & Medicaid Services (CMS) require the use f shrt CPT descriptrs in plicies published n the Web. A0425 Grund mileage, per statute mile A0426 Ambulance service, ALS, nn-emergency transprt, level 1 A0427 Ambulance service, ALS, emergency transprt, level 1 A0428 Ambulance service, BLS, nn-emergency transprt A0429 Ambulance service, BLS, emergency transprt A0433 Advanced life supprt, level 2 (ALS2) A0434 Specialty Care Transprt (SCT) A0888 Nn-cvered ambulance mileage, per mile (e.g., fr miles traveled beynd clsest apprpriate facilit A0999 Unlisted ambulance service Other Cmments Multiple-patient transprts A single payment allwance fr mileage will be prrated by the number f patients n bard. Dwncding frm air t grund ambulance is a denial under Sectin 1862 (a)(1)(a) (Prgram Integrity Manual (PIM) Chapter 6, 12B). ABN is required. Aspirin alne des nt qualify as an indicatin that an ALS-2-level service has been supplied. Oxygen alne, even at high-flw rates, des nt qualify as an indicatin that an ALS-2-level has been supplied. IV fluids even with a fluid challenge d nt qualify as an indicatin that an ALS- 2-level service has been supplied. Nitrglycerin administered as an assist t the patient s wn nitrglycerin des nt qualify as an indicatin that an ALS-2-level service has been supplied. Nitrglycerin administered frm the ambulance stck under a physician s telephnic rder r standing rders des qualify as an indicatin (as ne f three medicatins) that an ALS-2-level service has been supplied. Ambulance fee schedule payment cvers bth the transprt f the beneficiary t the nearest apprpriate facility and all items and services assciated with such

transprt. Such items and services include but are nt limited t xygen, drugs and extra attendants, but nly when such items and services are bth medically necessary and cvered by Medicare under the ambulance benefit. Multiple arrivals When multiple units respnd t a call fr services, the entity that prvides the transprt fr the beneficiary shuld be the nly prvider billing the service. LCD Title: Ambulance Services (Grund Ambulance) 4T-3AB LCD Lead: DLP LCD Cmment and Ntice Summary Reprt Cmment Tpic #1 Cmmentatr Suggestin(s): Add ICD-9-CM cdes 781.2 781.4 with ntatin t use 781.3 t dente patient safety t Table 2 as is present in Virginia plicy (Texas plicy prir t transitin). Pre-Finalizatin Recmmendatin Add cdes. Finalizatin Recmmendatin Add cdes. Cmment Tpic #2 Cmmentatr Suggestin(s): Exert care if implementing utilizatin guidelines s as nt t limit access t deserving patients and nt have financial impact n ambulance prviders. Pre-Finalizatin Recmmendatin We acknwledge that access f qualified patients t receive necessary ambulance transprtatin is essential. Finalizatin Recmmendatin Implementatin will be dne with due care.

Cmment Tpic #3 Cmmentatr Suggestin(s): Add explanatin fr limited cverage in light f the nnmandatry nature f ICD-9-CM diagnsis reprting by ambulance suppliers. Pre-Finalizatin Recmmendatin Will add. Finalizatin Recmmendatin Add. Finalizatin Cmmittee Recmmendatin Prceed with finalizatin f Ambulance Services (Grund Ambulance) 4T-3AB fr CO/NM/OK/TX Part B and Part A, with changes as suggested abve.