Avoiding Denials of Ambulance Services

Recently CMS published Medicare Fee-for-Service (FFS) improper payment date for ambulance services for the 2020 reporting period. For this reporting period, the improper payment rate for ambulance services was 7.2 percent, with a projected improper payment amount of $349 million. As per the findings, insufficient documentation accounted for 62.5 percent of improper payments for ambulance services. Additional types of errors for ambulance services were medical necessity (23.5 percent) and incorrect coding (10.8 percent). In this article, we shared guidelines that will help you in avoiding denials of emergency and non-emergent ambulance services.

Avoiding Denials of Emergency Ambulance Services

Medicare requires the following conditions for the patient to be eligible for ambulance services:

  • Approved supplier of ambulance services transported patients to or from a proper location.
  • The patient suffered from an illness or injury, which contraindicated transportation by other means, and medically required ambulance services.
  • We note bed confinement isn’t the sole criterion in determining the medical necessity of ambulance transportation. We consider it 1 factor in medical necessity determinations.

Following scenarios highlight what Medicare Administrative Contractors (MACs) would presume medical necessity for both emergent and non-emergent ambulance services:

  • You transported a patient in an emergency, for example, because of an accident, injury, or acute illness
  • You needed to restrain the patient to prevent injury to the patient or others
  • The patient required oxygen or other emergency treatment during transport to a nearest proper facility
  • The patient was unconscious or in shock
  • The patient showed signs and symptoms of acute respiratory distress or cardiac distress, such as shortness of breath or chest pain
  • The patient showed signs and symptoms that show the possibility of acute stroke
  • The patient needed to stay immobile because of a fracture that hadn’t been set or the possibility of a fracture
  • The patient experienced a severe hemorrhage
  • A patient could be moved only by stretcher
  • The patient was bed-confined before and after the ambulance trip

Avoiding Denials of Non-Emergent Ambulance Services

Non-emergency transportation by ambulance is proper if either:

  • The patient is bed-confined, and it’s documented that the patient’s condition contraindicates other methods of transportation
  • Their medical condition, regardless of bed confinement, is such that transportation by ambulance is medically required

As a result, bed confinement isn’t the sole criterion in determining the ambulance transportation medical necessity. We consider bed confinement as 1 factor in medical necessity determinations. For us to consider the patient bed-confined, the patient must meet these criteria:

  • Can’t get up from bed without help
  • Can’t ambulate
  • Can’t sit in a chair or wheelchair

Special rules discuss non-emergency ambulance services that are either unscheduled or scheduled on a nonrepetitive basis. We cover medically necessary non-emergency ambulance services that are either unscheduled or scheduled on a nonrepetitive basis under 1 of these circumstances:

  • For residents of a facility who are under the care of a physician, if the ambulance provider or supplier gets a physician certification statement within 48 hours after transport.
  • For patient residing at home or in a facility who isn’t under the direct care of a physician, we don’t require physician certification.
  • If you can’t get a signed physician certification statement from the patient’s attending physician, they must get a non-physician certification statement.
  • If you can’t get the required physician or non-physician certification statement within 21 calendar days following the date of service, you must document attempts to get the requested certification and may then send the claim.
  • In all cases, the provider or supplier must keep documentation on file and, when asked, present it to the contractor. The physician’s, or non-physician’s, certification statement or signed return receipt doesn’t alone show ambulance transport was medically necessary. We require you to meet all other program criteria for us to make a payment.

Signature Requirements

Medicare would require a patient’s signature, or that of an authorized person to sign the claim form on behalf of the patient for you to send a claim. If the patient can’t sign because of a mental or physical condition, these individuals may sign the claim form on behalf of the patient:

  • Patient’s legal guardian
  • Relative or other people who get Social Security or other governmental benefits on behalf of a patient
  • Relative or other people who arrange for patient’s treatment or exercise other responsibility for their affairs
  • Representative of an agency or institution that didn’t provide the service of the claims payment, but provided other care, services, or help to the patient
  • Representative of provider or non-participating hospital claiming payment for services it provided, if the provider or non-participating hospital can’t get a patient or representative to sign the claim under 42 CFR Section 424.36(b)(1–4)
  • Your representative who’s present during an emergency and or non-emergency transport if you keep certain documentation in your records for at least 4 years from the date of service. You (or your employee) can’t ask for payment for services provided except under circumstances fully documented to show the patient can’t sign and there’s no other person who could sign.

Medicare covers ambulance services via ground transportation, as well as air ambulance services. This includes fixed wing and rotary wing ambulance services for patients when one shouldn’t use other means of transportation. For billed services to be medically necessary, the patient’s condition requires both ambulance transportation and the level of service.

MedicalBillersandCoders (MBC) is a leading revenue cycle company providing complete medical billing services. For any assistance required for ambulance services, contact us at info@medicalbillersandcoders.com888-357-3226

Reference: Medicare Benefit Policy Manual, Chapter 10

2020 Medicare Fee-for-Service Supplemental Improper Payment Data