All of these coverage requirements apply to ground ambulance transports:
The Transport Is Medically Reasonable and Necessary
A medically reasonable and necessary ground ambulance transport must meet these requirements:
- Medical necessity is established when the patient’s condition is such that the 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.
- The purpose of the transport is to obtain a Medicare-covered service or to return from obtaining such service
While you must obtain a signed Physician Certification Statement (PCS) for the ambulance transport from the beneficiary’s attending physician in some circumstances, this statement does not, in and of itself, demonstrate that ambulance transport is medically reasonable and necessary. 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 transport is not covered if some means of transportation other than an ambulance could be used without endangering the beneficiary’s health, regardless of whether the other means of transportation is actually available.
A Medicare Beneficiary Is Transported
The transport of a Medicare beneficiary must occur for ambulance transport to be payable under the Medicare Program. When multiple ambulance providers and suppliers respond, payment is made only if you actually transport the beneficiary.
The Destination Is Local
As a general rule, the ground ambulance transport destination must be local, which means that only mileage to the nearest appropriate facility equipped to treat the beneficiary is covered. If two or more facilities meet this requirement and can appropriately treat the beneficiary, the full mileage to any of these facilities is covered.
The Facility Is Appropriate
An appropriate facility is an institution that is generally equipped to provide the needed hospital or skilled nursing care for the beneficiary’s illness or injury. An appropriate hospital must have a physician or a physician specialist available to provide the necessary care required to treat the beneficiary’s condition.
Because all duly licensed hospitals and SNFs are presumed to be appropriate sources of health care, clear evidence must indicate that a ground ambulance transport to a more distant institution is the nearest appropriate facility. Some circumstances that may justify ground ambulance transport to a more distant institution include:
- The beneficiary’s condition requires a higher level of trauma care or other specialized services that is only available at the more distant hospital. Specialized service is a covered service that is not available at the facility where the beneficiary is a patient.
- No beds are available at the nearest institution.
A ground ambulance transport to a more distant hospital solely to avail the beneficiary of the services of a specific physician or physician specialist is not covered. Medicare will pay the base rate and mileage for medically necessary ambulance transport to the nearest appropriate facility. If the transport is to a facility that is not the nearest appropriate facility, the beneficiary is only responsible for additional mileage to his or her preferred facility.
If a beneficiary is initially transported to an institution that is not equipped to provide the needed hospital or skilled nursing care for the beneficiary’s illness or injury and is then transported to a second institution that is adequately equipped, both ground ambulance types of transport will be covered provided the second transport is to the nearest appropriate facility.
When a ground ambulance transports a beneficiary to and from the nearest appropriate facility to obtain necessary diagnostic and/or therapeutic services (such as a Computerized Axial Tomography scan or cobalt therapy), the transport is only covered to the extent of the payment that would have been made to bring the service to the beneficiary.
A ground ambulance transport from an institution to the beneficiary’s home is covered when the home is either:
- Within the locality of the institution; locality is the service area surrounding the institution to which individuals normally travel or are expected to travel to receive hospital or skilled nursing services. MACs have the discretion to define locality in their service areas.
- Outside the locality of the institution but in relation to the beneficiary’s home, it is the nearest appropriate facility
The beneficiary was suffering from an illness or injury which contraindicated transportation by other means. Examples include:
- Transported in an emergency situation (i.e., the result of the accident, injury, or acute illness)
- Needed to be restrained to prevent injury to the beneficiary or others
- Was unconscious or in shock
- Required oxygen or other emergency treatment during transport to the nearest facility
- Exhibits signs and symptoms of acute respiratory distress or cardiac distress such as shortness of breath or chest pain
- Exhibits signs and symptoms that indicated the possibility of acute stroke
- Had to remain immobile because of a fracture that had not been set or the possibility of a fracture
- Is experiencing severe hemorrhage
- Could be moved only by stretcher
- Was bed-confined before and after the ambulance trip
In the absence of any of the conditions listed above, additional documentation should be obtained to establish medical needs.
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