L29953-LCD

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Local Coverage Determination (LCD) for Non- Emergency Ground Ambulance Services (L29953)

Contractor Information

Contractor Name

First Coast Service Options, Inc. opens in new window

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29953

LCD Title

Non- Emergency Ground Ambulance Services

Contractor's Determination Number A0425

Primary Geographic Jurisdiction opens in new window Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 06/30/2009 Original Determination Ending Date

Revision Effective Date

For services performed on or after 06/30/2009 Revision Ending Date

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1861(s)(7) defines ambulance service where the use of other methods of transportation is contraindicated by the individual's condition, but only to the extent provided in regulations.

Title XVIII of the Social Security Act, §1862 (a)(1)(A). allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Medicare Benefit Policy Manual (Pub 100-02) Chapter 10 Medicare Claims Processing Manual (Pub 100-04) Chapter 15

Medicare Program Integrity Manual (Pub 100-08) Chapter 1, Section 1.1.2

Change request 5442, Pub 100-04, Medicare Claims Processing, transmittal 1185, dated February 7, 2007

Indications and Limitations of Coverage and/or Medical Necessity

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:

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

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

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

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

*“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:

• Transportation to a funeral home

• Transfer from one residence to another

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

• Transportation via ambi-buses, ambulettes, stretcher vans, wheelchair vans, mobility assistance vehicle (MAV), medicabs, vans, privately owned vehicles, and taxicabs

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

• 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.

999x Not Applicable

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.

99999 Not Applicable

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 condtion 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.

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. 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. 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.

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity XX000 Not Applicable

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

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

Medical records must include a trip record which documents:

• 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.

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

Appendices

Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they

may be subject to medical review.

Sources of Information and Basis for Decision 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)

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was

developed in cooperation with advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period 02/20/2009

End Date of Comment Period 04/06/2009

Start Date of Notice Period 05/01/2009

Revision History Number Original

Revision History Explanation Revision Number:Original Start Date of Comment Period:02/20/2009

Start Date of Notice Period:05/01/2009 Original Effective Date: 06/30/2009

LCR B2009-071

April 2009 Update

Reason for Change