LCD/NCD Portal

L29916

 

NON- EMERGENCY GROUND AMBULANCE SERVICES

 

06/30/2009

 

INDICATIONS

• Medical necessity is established when the patient’s condition is such that use of any other method of transportation is contraindicated.

• In any case in which some means of transportation other than an ambulance could be used without endangering the individual’s health, whether or not such other transportation is actually available, no payment may be made for ambulance services.

• In all cases, the appropriate documentation must be kept on file and, upon request, presented to the carrier/intermediary.

• It is important to note that the presence or absence of a physician’s order for transport by ambulance does not necessarily prove (or disprove) whether the transport was medically necessary.

• The ambulance service must meet all program coverage criteria in order for payment to be made.

• Reasons to allow non-emergency ground ambulance services include:

o The beneficiary is bed confined* before and after the ambulance trip and meets the above criteria.

o There is risk of physical injury to the patients or others requiring observation during transport.

o The patient requires ongoing IV meds/fluids (and a heparin/saline lock is contraindicated) during transport.

o Medical treatment and/or observation during transport is required to prevent endangering of the beneficiary’s health.

o *“Bed confined” is defined as the inability to get up from bed without assistance, the inability to ambulate and the inability to sit in a chair, including a wheelchair.

 All three components must be met in order for the patient to meet the requirements of the definition of “bed confined”.

 Bed confined is not synonymous with bed rest or nonambulatory.

 Bed confinement, by itself is neither sufficient nor is it necessary to determine coverage for Medicare ambulance benefits.

 

LIMITATIONS

• In addition to meeting the criteria in the “Indications” section of this LCD, non-emergency ambulance services will not be covered for the following reasons:

o Transportation to a funeral home.

o Transfer from one residence to another.

o Transfer from a hospital which has appropriate facilities and staff for treatment to another hospital

o Transportation via:

 Ambi-buses.

 Ambulettes.

 Stretcher vans.

 Wheelchair vans.

 Mobility assistance vehicle (MAV).

 Medicabs.

 Vans.

 Privately owned vehicles.

 Taxicabs.

o Transportation to a dialysis facility for routine maintenance dialysis, unless the patient’s condition justifies the medical necessity of the transport.

o The patient refuses to be transported.

 

Coding Information

 

Bill Type Codes

• Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.

• Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type.

• Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

 

 

12x Hospital Inpatient (Medicare Part B only)

13x Hospital Outpatient

22x Skilled Nursing - Inpatient (Medicare Part B only)

23x Skilled Nursing - Outpatient

85x Critical Access Hospital

 

Revenue Codes

• Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service.

• In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination.

• Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

 

 

0540 Ambulance - General Classification

0541 Ambulance - Supplies

0542 Ambulance - Medical Transport

0543 Ambulance - Heart Mobile

0544 Ambulance - Oxygen

0545 Ambulance - Air Ambulance

0546 Ambulance - Neonatal Ambulance Services

0547 Ambulance - Pharmacy

0548 Ambulance - EKG Transmission

0549 Ambulance - Other Ambulance

 

 

CPT/HCPCS Codes

 

 

A0425 GROUND MILEAGE, PER STATUTE MILE

A0426 AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, NON-EMERGENCY TRANSPORT, LEVEL 1 (ALS 1)

A0428 AMBULANCE SERVICE, BASIC LIFE SUPPORT, NON-EMERGENCY TRANSPORT, (BLS)

A0999 UNLISTED AMBULANCE SERVICE

 

 

ICD-9 Codes that Support Medical Necessity

 

 

The presence of one of these two ICD-9-CM codes on the claim, for HCPCS codes A0426 and A0428, is intended to indicate that the patient’s condition was such that transportation by any other means is contraindicated. If one of these two covered diagnoses is not on the claim, the service will be denied.

V49.84* BED CONFINEMENT STATUS

V49.89* OTHER SPECIFIED CONDITIONS INFLUENCING HEALTH STATUS

• The use ICD-9-CM code V49.84 indicates that the patient is bed confined and transportation by any other means is contraindicated due to the medical condition of the patient.

• The use of ICD-9-CM code V49.89 indicates that transportation by any other means is contraindicated due to the medical condition of the patient.

o The use of one of these two ICD-9-CM codes does not prohibit the inclusion of additional ICD-9-CM codes on the claim to indicate the specific condition and/or signs/symptoms requiring ambulance transport.

o The ambulance fee schedule medical conditions list located in the Medicare Claims Processing Manual, Pub 100-04, Chapter 15, section 40 can also be used as an educational guideline for determining appropriate medical conditions and applicable ICD-9-CM codes related to ambulance transports.

o The intent of the medical conditions list is primarily as an educational guideline and although it will help ambulance suppliers to communicate the patient’s condition, use of the codes does not guarantee payment of the claim or payment for a certain level of service.

Documentation Requirements

• The medical record should include documentation of dispatch instructions, patient’s condition, other on-scene information, and details of the transport (e.g., medications administered, changes in the patient’s condition and mileage).

o Documentation should also include the physician certification statement when required. (See Coding Guidelines)

• Medical records must include a trip record which documents:

o A detailed description of the patient’s condition at the time of transport for Medicare to reasonably determine that other means of transportation are contraindicated.

o A description of specific monitoring and/or treatments ordered and performed/administered during transport.

 

Sources of Information and Basis for Decision

 

FCSO LCD 29953, Non- Emergency Ground Ambulance Services, 06/30/2009. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

Palmetto GBA LCD for Ambulance Services (L933)

 

Trailblazer Health Enterprises, LLC LCD for Ambulance services (Ground ambulance)

 

Wisconsin Physicians Service Insurance Corporation LCD for ambulance

Services (L26601)

 

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

CMS LCD L29916 Non- Emergency Ground Ambulance Services