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Medicare Billing for Ambulance Services during COVID-19 Pandemic


Article - Medicare Billing for Ambulance Services during COVID-19 Pandemic

To provide ground ambulance providers and suppliers the flexibility to furnish medically necessary emergency and non-emergency ambulance transports for beneficiaries during the PHE for the COVID-19 pandemic, CMS is temporarily expanding the list of allowable destinations for ground ambulance transports. During the COVID-19 PHE, a covered destination for a ground ambulance transport may include any destination that is equipped to treat the condition of the patient in a manner consistent with state and local Emergency Medical Services (EMS) protocols where the services will be furnished.

These destinations may include but are not limited to: any location that is an alternative site determined to be part of a hospital, CAH or SNF; community mental health centers; federally qualified health centers; rural health clinics; physician’s offices; urgent care facilities; ambulatory surgical centers; any location furnishing dialysis services outside of the ESRD facility when an ESRD facility is not available; and the beneficiary’s home. There must be a medically necessary ground ambulance transport of a patient in order for the ambulance service to be covered.

Medicare Billing for Ambulance Services

Advanced Life Support (ALS)

ALS assessment, intervention, and ambulance transport are defined as follows:

Advanced life support (ALS) assessment is an assessment performed by an ALS crew as part of an emergency response that was necessary because the patient's reported condition at the time of dispatch was such that only an ALS crew was qualified to perform the assessment. An ALS assessment does not necessarily result in a determination that the patient requires an ALS level of service. ALS intervention means a procedure that is, in accordance with State and local laws, required to be furnished by ALS personnel. Advanced life support, level 1 (ALS1) means transportation by ground ambulance vehicle, medically necessary supplies and services, and either an ALS assessment by ALS personnel or the provision of at least one ALS intervention.

Advanced life support, level 2 (ALS2) means either transportation by ground ambulance vehicle, medically necessary supplies and services, and the administration of at least three medications by intravenous push/bolus or by continuous infusion, excluding crystalloid, hypotonic, isotonic, and hypertonic solutions (Dextrose, Normal Saline, Ringer's Lactate); or transportation, medically necessary supplies, and services, and the provision of at least one of the following ALS procedures:

  1. Manual defibrillation/cardioversion,
  2. Endotracheal intubation,
  3. Central venous line,
  4. Cardiac pacing,
  5. Chest decompression,
  6. Surgical airway, and
  7. Intraosseous line.

Medicare ambulance coverage policy provides that an ALS assessment is an assessment performed by an ALS crew as part of an emergency response that was necessary because the patient's reported condition at the time of dispatch was such that only an ALS crew was qualified to perform the assessment. An ALS assessment does not necessarily result in a determination that the patient requires an ALS level of service. In the case of an appropriately dispatched ALS emergency service, if the ALS crew completes an ALS assessment, the services provided by the ambulance transportation service provider or supplier is covered at the ALS emergency level, regardless of whether the patient required ALS intervention services during the transport, provided that ambulance transportation itself was medically reasonable and necessary and all other coverage requirements are met (see Medicare Benefit Policy Manual, Chapter 10, Section 30.1.1.).

Ground Ambulance Transports

CMS recognizes that COVID-19 transports require following infectious disease protocols, such as decontamination procedures, professional protective equipment (PPE), and the required engagement of paramedics which may increase the cost of transports involving suspected or diagnosed COVID-19 patients. However, ground ambulance transports must be billed according to the level of service furnished. Only transports that meet the requirements for billing at the ALS level of service can be billed at the ALS rate. Section 1861(s)(7) of the Act describes the ambulance services benefit under Medicare as a transportation benefit, and thus an ambulance transport of a beneficiary is required in order for the ambulance to be paid under Medicare.

For both emergency and non-emergency ambulance transportation, Medicare pays for ground (land and water) and air ambulance transport services only if they are furnished to a Medicare beneficiary whose medical condition is such that other forms of transportation are contraindicated. The beneficiary’s condition must require both the ambulance transportation itself and the level of service provided for the billed services to be considered medically necessary.

Defining Approved Destination

CMS defines “approved destination” at 42 CFR 410.40(f), Origin, and destination requirements. Medicare can only pay for ambulance transportation when it meets the origin and destination requirements and all other coverage requirements. Medicare will pay for ambulance transportation according to the usual payment guidelines. Ambulance transportation charges for patients who were evacuated from and returned to originating hospitals should be included in the inpatient claims submitted by the originating hospitals. Payment will be included in the diagnostic related group (DRG) payment amounts made to hospitals paid under the prospective payment system.

42 CFR 410.40(f) allows Medicare to pay for an ambulance transport provided that transportation by any other means is contraindicated by the patient’s condition and all other Medicare requirements are met) to the following destinations:

  •  From any point of origin to the nearest hospital, Critical Access Hospital (CAH), or SNF that is capable of furnishing the required level and type of care for the beneficiary’s illness or injury and the return trip to the beneficiary’s home. The hospital or CAH must have available the type of physician or physician specialist needed to treat the beneficiary’s condition.
  • For beneficiaries residing in an SNF who are receiving Part B benefits only, ambulance transport from an SNF to the nearest supplier of medically necessary services not available at the SNF where the beneficiary is a resident, including the return trip. For SNF residents receiving Medicare Part A benefits, this type of ambulance service is subject to SNF consolidated billing.
  • For a beneficiary who is receiving renal dialysis for treatment of ESRD, from a beneficiary’s home to the nearest facility that furnishes renal dialysis, including the return trip.

A physician’s office normally is not a covered destination under Medicare Part B. However, under certain circumstances, an ambulance transport may temporarily stop at a physician’s office without affecting the coverage status of the transport. Note that there is an exception to this rule during the COVID-19 PHE, as explained further below. Should a facility that would normally be the nearest appropriate facility be unavailable during an emergency/disaster, Medicare may pay for transportation to another facility so long as that facility meets all Medicare requirements and is still the nearest facility that is available and equipped to provide the needed care for the illness or injury involved.

Medicare payment for ambulance transport to a temporary expansion site may be available if the site is determined to be part of a hospital, CAH, or SNF that is an approved destination for ambulance transport under 42 CFR 410.40(f). If the temporary expansion site is part of a hospital, CAH, or SNF that is an approved destination under 42 CFR 410.40(f) for ambulance transport, Medicare will pay for the transport on the same basis as it would to any other approved destination.

Billing Scenarios

1. Will all transports of COVID-19 patients or patients suspected to have COVID-19 be designated as Advanced Life Support (ALS) transports?

AnswerNo, payment for ambulance transport is based on the level of service provided.

2. Should HCPCS code A0998 (ambulance response and no transport) be reported for treatment in place?

Answer: No, HCPCS code A0998 (ambulance response and no transport) is not covered under the ambulance services benefit (defined in section 1861(s)(7) of the Act), and thus is not payable under Medicare’s Ambulance Fee Schedule.

3. Can ground ambulance providers and suppliers report other services they provide to PUI or COVID-19 patients?

Answer: Under § 414.610(d), payment under the ambulance fee schedule represents payment in full (subject to applicable Medicare Part B deductible and coinsurance requirements) for all services, supplies, and other costs for an ambulance transport service furnished to a Medicare beneficiary.

4. How can one consider any COVID-19 positive patient to meet the medical necessity requirements for ambulance transport?

Answer: The medical necessity requirements for coverage of ambulance services have not been changed. For both emergency and non-emergency ambulance transportation, Medicare pays for ground (land and water) and air ambulance transport services only if they are furnished to a Medicare beneficiary whose medical condition is such that other forms of transportation are contraindicated. The beneficiary’s condition must require both the ambulance transportation itself and the level of service provided for the billed services to be considered medically necessary.

5. If the ambulance crew provides treatment but does not transport anyone, can the company bill Medicare for the services provided?

AnswerMedicare law prohibits payment for an ambulance service unless a medically necessary transport of a Medicare beneficiary has taken place. However, when an enrolled physician or other qualified health professional furnishes services from an ambulance, he or she may bill for those services under the Medicare Physician Fee Schedule, assuming that the services furnished were in accordance with applicable state law and services are within his or her scope of practice requirements.

6. If a beneficiary who is living at home and using a stationary oxygen unit, has to be transported to another location by ambulance (because other means of transportation are contraindicated), can Medicare pay for any portable oxygen necessary to transport the beneficiary?

AnswerMedicare’s standard payment to ambulance providers and suppliers under the Ambulance Fee Schedule for ambulance transports already includes payment for all necessary supplies, including oxygen, provided during the transport. Thus, if the transport is a Medicare-covered service (e.g., the beneficiary must be transported by ambulance to a covered destination because other means of transportation are contraindicated), then no separate payment for furnishing oxygen would be made. However, if the transport does not qualify as a Medicare-covered service, then payment under Part B may be made to a Durable Medical Equipment supplier for furnishing portable oxygen when supplemental oxygen is needed for the beneficiary during the transport.

7. A known or suspected COVID-19 patient using a touch screen to sign or holding an electronic pen or stylus could contaminate these devices for future patients and for ambulance personnel. Is staff permitted to sign on behalf of a patient with known or suspected COVID-19?

Answer: Yes, but only under specific, limited circumstances. CMS will accept the signature of the ambulance provider’s or supplier’s transport staff if that beneficiary or an authorized representative gives verbal consent. CMS has determined that there is good cause to accept transport staff signatures under these circumstances. See 42 CFR 424.36(e). CMS recommends that ambulance providers and suppliers follow the Centers for Disease Control’s Interim Guidance for Emergency Medical Services (EMS) Systems and 911 Public Safety Answering Points (PSAPs) for COVID-19 in the United States. This guidance includes general guidelines for cleaning or maintaining EMS transport vehicles and equipment after transporting a patient with known or suspected COVID-19. However, in cases where it would not be possible or practical (such as a difficult to clean surface) to disinfect the electronic device after being touched by a beneficiary with known or suspected COVID-19, documentation should note the verbal consent.

Visit our blog section for more billing resources on COVID-19 and Ambulance Billing. These resources will help you to prepare your practice and address patient concerns during the COVID-19 pandemic. To get reimbursed for medical services rendered during the COVID-19 pandemic, contact Medical Billers and Coders (MBC) at 888-357-3226/info@medicalbillersandcoders.com

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