Indications and Limitations of Coverage and/or Medical Necessity:

Ambulance services are covered services under Medicare when the patient’s condition is such that the use of any other method of transportation would endanger the patient’s health.  Ambulance services are frequently the initial step in the chain of delivery of quality medical care.  They involve the assessment and administration of emergency care by trained personnel and transportation of patients within an appropriate, safe and monitored environment.

Ambulance services must be medically necessary and reasonable. Medical necessity is established when the patient’s clinical condition is such that the use of any other method of transportation such as taxi, private care, Medicare, wheelchair van, or other type of vehicle would be contraindicated (i.e., would endanger the patient’s medical condition.) “In any case, in which some means of transportation other than an ambulance could be utilized without endangering the individual’s health, whether or not such other transportation is actually available, no payment may be made for ambulance service.

The patient’s condition at the time of the transport is the determining factor in whether a trip will covered.  The fact that the patient is elderly, has a positive medical history, or cannot care for him/herself does not establish medical necessity, Claims may be denied if the use of ambulance services unreasonable for the illness or injury involved.

Medicare will not pay for ambulance services when an ambulance was used simply for convenience or because other means of transportation were not available. 

• Ambulance services are not covered when other means of transportation could be utilized without endangering the individual’s health, whether or not such other transportation is actually available.

• The ambulance service is not covered if it fails to meet the reasonableness requirement even if it meets medical necessity requirements.

• Transport from a residence to a radiation oncology office and return.

• Transport to funeral home.

• Transport to a physician’s office or physician directed clinic for emergency treatment without continuing on to the hospital immediately thereafter.

• Transport for patient for family convenience.

• Transportation is not covered for those patients receiving diagnostic and/or therapeutic services which could have been reasonably brought to the beneficiary’s bedside at less cost than transporting the beneficiary fore the services.

Ambulance services will be denied as not medically necessary when the following are reported as the sole basis for establishing medical necessity: 

• Fainting/syncope

• A simple statement that patient is non-ambulatory or is bedridden is not sufficient, Non-ambulatory patients can often be transported without the use of an ambulance.

• Emphysema

• Invalid/homebound; shut-in

• Weakness

• Mileage for covered transports beyond the nearest facility

• General sickness/generalized pain

• Headache

More than One Patient

The use of an ambulance to transport more that one patient at the same time is not an accepted standard of practice, except in catastrophic circumstances (e.g., major trauma to multiple individuals).

If the services are reasonable and medically necessary, based on a review of all the documentation, appropriate reimbursement will be determined based on the number of patients transported, their condition, and the circumstances involved. It is inappropriate to bill for each beneficiary as if a single patient were being transported because this would result in an incorrect payment for the services, even if the services is medically necessary.

Waiting Time

Medicare covers waiting time for emergency ambulance services when the destination is a hospital.  To qualify for reimbursement, the waiting time must be both extraordinarily long and must involve usual circumstances.  It is reasonable to assume that the ambulance personnel would spend up to one-half hour in the processing paperwork in the delivery of a patient to the hospital. Therefore, the waiting time code should be used only if the patient’s condition dictated a delay beyond that one-half hour.  The ambulance company is responsible for obtaining the documentation to support this service from the physician or hospital personnel responsible for admitting or discharging patients.

Mileage

Medicare will cover mileage in addition to the base rate for ambulance transport.  Coverage is extended only to loaded mileage (from the pickup of a patient to his/her arrival at destination) Separate charges for unloaded mileage will be denied.  Mileage under only should be reported as one mile. (If unit is taking patient to an air transport  unit, patient must be in unit and wheels must role).

If multiple units respond to a call for services, only the ambulance that provides the transport will be reimbursed.

Effect of Beneficiary’s Death

• If the beneficiary is pronounced dead prior to the time the ambulance is called, there is no coverage for the ambulance service.

• If the beneficiary is pronounced dead after the ambulance is called but before the ambulance arrives at the scene, the supplier may be reimbursed for a BLS services, but not for mileage.

• If the beneficiary is pronounced dead after the ambulance arrives but before the patient is loaded, the supplier may be reimbursed only for BLS services not for ALS services or mileage.

• If the beneficiary is pronounced dead after being loaded into the ambulance, the supplier may be reimbursed for transport and mileage as if the beneficiary had not died.  This includes a scenario where the beneficiary is subsequently declared DOA at the facility.

Patient not transported (beneficiary refuses transport)

Generally, there is no reimbursement for ambulance services if the patient refuses transport.  The beneficiary may be held liable for any services provided.  This non covered service so an ABN is not required.

Advance Beneficiary Notice (ABN) 

The purpose of this form is to help the patient make an informed choice about whether or not they want to receive your services, because Medicare will not cover the service being provided. See Attached. 

Physician Certification Statement (PCS)

Medicare covers non-emergency, scheduled ambulance services if the ambulance supplier, before furnishing the services to the beneficiary, obtains a written order (certification) from the beneficiary’s attending physician, Physician assistant (PA), nurse practitioner (NP) registered nurse (RN) certifying that the medical necessity requirements are met. The physician’s order must be dated not earlier than 60 days before that date the services is furnished.

Origin/Destination

Medicare requires the physical address of where the patient is picked up and transported to.  Therefore we must have and address in order for us to submit the claim to Medicare and Medicaid to get it paid.  In the event that you do not know that exact address of the location where you are, give us as much detail as possible (Highway name and number, landmarks city and zip).

Zip Codes:

Medicare requires the zip code of the origin of transport and the destination of transport.

These zip codes should be put on your trip report in order for us to submit them to the insurance carriers.

Signatures:

The signatures on the trip report are what makes that document a legal document.  The signatures verify that the information on the trip report and narrative is true to the best of your knowledge and the signatures of the person receiving the patient is our back-up that we did indeed transport that patient to that destination and that this person received them.  Without these signatures, if an insurance company denies the claim or disputes it, we have no grounds to try and collect the money owed to the county.

Waiver of Liability:

One of the most important things that you can do in your regimen of paperwork is to have the patient or guarantor of the bill sign the Waiver of Liability. This allows us to bill the patient for the money owed if the insurance company denies payment for the transport.

We realize that there are times when these signatures can not be obtained by the patient.  If there is a family member on the scene or at the hospital upon your arrival, you will need to have them sign as a guarantor for the patient.  If the patient is in such condition that he/she is not able to sign and there are no family members present, then of course, you can’t obtain the signatures.

We must have this information on those patients who are probably able to use another means of transportation to the hospital, and yet they choose to use the ambulance services even though there condition doesn’t seem to make the transport medically necessary.   This Waiver of Liability gives us the authorization by the patient and the insurance company to bill the patient when the insurance company denies the claim.

We must have this form signed by those patients who are self pay and have no insurance.  This waiver says the patient will be financially responsible for paying the bill for the transport.

Ambulance Condition Indicators

We would like to remind our ambulance providers that Medicare does not process ambulance claims based on ICD 9 codes. (Attached you will find a copy of condition codes).