Difference Between EMS and non-EMS Billing


One may well question the need to be aware of the difference between Emergency and Non-Emergency Ambulance Transportation. But the need to know this is necessary when it affects billing, especially since Medicare has tightened rules about the usage of ambulance services, to combat financial fraud, and more so for three states Pennsylvania, New Jersey, and South Carolina. Medical Billers and Coders are so familiar with applicable Medicare and insurance regulations of ambulance transport services

However, physicians in other states too need to be aware of the differences, especially when billing, so as not to affect their Revenue Cycle Management process which could have consequences on their financial status.

Emergency response is one when an ambulance responds immediately to sudden onset of a medical condition of great severity where a patient’s health is in serious jeopardy; impairment to bodily functions; or serious dysfunction to any bodily organ or part.

A non-emergency response is covered when it meets all “medical necessity” and can be scheduled or unscheduled. Also, some non-emergency transport is based on the status of the patient being “bed-confined.” For bed confinement, all of the following criteria must be met:

  • the patient is unable to get up from bed without assistance; and
  • the patient is unable to ambulate; and
  • the patient is unable to sit in a chair or wheelchair
Ground Ambulance Services

Ground emergency ambulance services are considered medically necessary when all of the following criteria are met:

  • The Ambulance must comply with all local, state, and federal laws and must have all the appropriate, valid licenses and permits; and
  • The ambulance services must have the necessary patient care equipment and supplies; and
  • The patient’s condition must be such that any other form of transportation would be medically contraindicated; and
  • The patient must be transported to the nearest hospital with the appropriate facilities for the treatment of the patient’s illness or injury or, in the case of organ transplantation, to the approved facility

Ground non-emergency ambulance services between health care facilities are medically necessary when all of the following criteria are met, besides what is essential in an emergency situation

  • Prior authorization has been received for transport; and
  • If, medically necessary diagnostic or therapeutic services (e.g., MRI, CT scan, etc.) are unavailable at the originating facility, only then can ambulance services to or from one hospital to another hospital be permitted
  • Ground non-emergency medical transport of individuals confined to the bed may be considered medically necessary after meeting certain criteria
Air Ambulance Services

All air ambulance services require authorization.

Only in very exceptional circumstances, air ambulance services will be deemed be medically necessary. In these circumstances, all of the criteria pertaining to ground transportation must be met as well as the following:

  • All necessary patient care equipment and supplies to address the needs of the patient should be present;
  • Only when land ambulance services are not available and the patient’s medical condition requires an immediate and rapid response;
  • The terrain is inaccessible by land vehicle;
  • Factors like distance and time frames in cases like organ transplant in times of medical urgency
  • The patient’s condition is such that the time needed to transport a patient by land poses a threat to the patient’s health.
All air ambulance services do not fall under the Non-Emergency criteria and will always fall under the Emergency service
Generally, Medicare Part B in an emergency, and does not cover transportation to or from a doctor’s office. Routine ambulance service for a patient to or from home in non-emergency situations is not covered by Medicare Part A or Medicare Part B. But, Medicare Part B occasionally covers non-emergency ambulance transportation between home and a hospital or other place of treatment or diagnosis if the patient’s doctor certifies that patient life could be endangered if transported in something other than an ambulance and can pay pays 80 percent of the Medicare-approved.
The submission of medical necessity forms and trip sheets are not required for non-ems ambulance transportation claims billed with the origin and destination modifiers. However, do note that Medicare guidelines need to be adhered to before claims payment especially for other origin and destination modifier combinations billed for a non-ems ambulance and/or scheduled ground transportation services, and are subject to retrospective review

Once these differences have been noted, and the criteria of “Medical necessity” are taken into account, then billing makes it much easier and avoidance of decrease in revenue can be easily averted.