Medicare Claims Processing Manual Chapter 15 - Ambulance

63 Pages·2009·1.15 MB·English

CMS Manual System Department of Health &
Human Services (DHHS)
Pub 100-04 Medicare Claims Processing Centers for Medicare &
Medicaid Services (CMS)
Transmittal 1696 Date: MARCH 6, 2009
Change Request 6347

Subject: Updates to the Medicare Claims Processing Manual Publication 100-04, Chapter 15.

I. SUMMARY OF CHANGES: With the expiration of the transition period to the full implementation of
the ambulance fee schedule on January 1, 2008, it is necessary to update any and all information contained
in the Ambulance Claims Processing Chapter (15) of the Internet Only Manual (IOM) Publication 100-04.
Information has been reorganized or has become obsolete. Some of the information has been moved to
Pub.100-02, Medicare Benefit Policy Manual Chapter 10.

New / Revised Material
Effective Date: April 6, 2009
Implementation Date: April 6, 2009

Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized
material. Any other material was previously published and remains unchanged. However, if this revision
contains a table of contents, you will receive the new/revised information only, and not the entire table of
contents.

II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual is not updated)
R=REVISED, N=NEW, D=DELETED-Only One Per Row.

R/N/D Chapter / Section / Subsection / Title
R 15/10/Overview

R 15/10.1/Authorities
N 15/10.1.1/Statutes and Regulations

N 15/10.1.2/Other References to Ambulance Related Policies in the
CMS Internet Only Manuals
R 15/10.2/Summary of the Benefit
R 15/10.3/Definitions
R 15/10.4/Additional Introductory Guidelines
R 15/20/Payment Rules
R 15/20.1/Payment Under the Ambulance Fee Schedule
R 15/20.1.1/General
R 15/20.1.2/Jurisdiction
R 15/20.1.3/Services Provided
R 15/20.1.4/Components of the Ambulance fee Schedule
R 15/20.1.5/ZIP Code Determines Fee Schedule Amount
N 15/20.1.5.1/CMS Supplied National ZIP Code File and National
Ambulance Fee Schedule
R 15/20.1.6/Contractor Determination of Fee Schedule Amounts
R 15/20.2/Payment for Mileage Charges
R 15/20.3/Air Ambulance
R 15/20.4/Ambulance Inflation Factor (AIF)
R 15/20.5/Documentation Requirements
D 15/20.5.1/Air Ambulance for Deceased Beneficiary
D 15/20.6/Update Charges
D 15/20.6.1/Ambulance Inflation Factor (AIF)
D 15/20.7/Joint Responses
D 15/20.8/Other Unusual Circumstances
D 15/20.9/Single Ambulance Where Multiple Patients Are on Board
D 15/20.10/Waiting Time Charges Made by Ambulance Companies
D 15/20.10.1/Requirements for Approval of Waiting Time
D 15/20.11/Documentation Requirements
R 15/30/General Billing Guidelines
R 15/30.1/Multi-Carrier System(MCS) Guidelines
R 15/30.1.1/MCS Coding Requirements for Suppliers
R 15/30.1.2/Coding Instructions for Paper and Electronic Claim
Forms
R 15/30.1.3/Coding Instructions for Form CMS-1491
R 15/30.1.4/CWF Editing of Ambulance Claims for Inpatients
R 15/30.2/Fiscal Intermediary Shared System (FISS) Guidelines
R 15/30.2.1/A/MAC Bill Processing Guidelines Effective April 1,
2002, as a Result of Fee Schedule Implementation
R 15/30.2.2/SNF Billing
R 15/30.2.3/Indian Health Service / Tribal Billing
D 15/30.2.4/Indian Health Services / Tribal Billing
D 15/30.3/Ambulance Fee Schedule - Medical Conditions List and
Instructions
R 15/40/Medical Conditions List and Instructions
D 15/50/Carriers Disclosure to Suppliers

III. FUNDING:
SECTION A: For Fiscal Intermediaries and Carriers:
No additional funding will be provided by CMS; Contractor activities are to be carried out within their
operating budgets.

SECTION B: For Medicare Administrative Contractors (MACs):
The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined
in your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is
not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically
authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to
be outside the current scope of work, the contractor shall withhold performance on the part(s) in question
and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions
regarding continued performance requirements.

IV. ATTACHMENTS:

Business Requirements

Manual Instruction

*Unless otherwise specified, the effective date is the date of service.
Attachment - Business Requirements
Pub. 100-04 Transmittal: 1696 Date: March 6, 2009 Change Request: 6347

SUBJECT: Updates to the Medicare Claims Processing Manual, Publication 100-04, Chapter 15

Effective Date: April 6, 2009

Implementation Date: April 6, 2009

I. GENERAL INFORMATION

A. Background: The Ambulance Fee Schedule was implemented in April 2002 based on Section 1834(l) of
the Social Security Act. The specifics of the fee schedule implementation were detailed in a Final Rule. See 67
Fed. Reg. 7900 (February 27, 2002). The Final Rule allowed for payment for various ground ambulance
services and rotary and fixed wing air ambulance services under a fee schedule. The full implementation of the
Ambulance Fee Schedule was phased in over a five-year transition period. For the first four years of the
implementation, ambulance suppliers were paid for services rendered based on a blended payment rate of
former payment methodologies and the ambulance fee schedule amounts. As of the beginning of the fifth year
of the transition, payment for ambulance services was based on 100 percent of the fee schedule amounts. For
ambulance claims with dates of service January 1, 2006 and later, payment is based on 100 percent of the fee
schedule amount. The end of the transition period, as well as other recent changes to claims processing
instructions, warranted a revision to the Ambulance chapter of the Medicare Claims Processing Manual to
enhance the clarity of those instructions.

B. Policy: This transmittal communicates the revisions to the Ambulance chapter of the Medicare Claims
Processing Manual (Publication 100-04, Chapter 15).

II. BUSINESS REQUIREMENTS TABLE
Number Requirement Responsibility (place an “X” in each applicable
column)
A D F C R Shared-System OTHER
/ M I A H Maintainers
B E R H F M V C
R I I C M W
M M I S S S F
A A E S
C C R
6347.1 Contractors shall be in compliance with the instructions in X X X
Pub. 100-04, Medicare Claims Processing Manual, Chapter
15.

III. PROVIDER EDUCATION TABLE

Number Requirement Responsibility (place an “X” in each applicable
column)
A D F C R Shared-System OTHER
/ M I A H Maintainers
B E R H F M V C
R I I C M W
M M I S S S F
A A E S
C C R
6347.2 A provider education article related to this instruction will X X X
be available at
http://www.cms.hhs.gov/MLNMattersArticles/ shortly
Number Requirement Responsibility (place an “X” in each applicable
column)
A D F C R Shared-System OTHER
/ M I A H Maintainers
B E R H F M V C
R I I C M W
M M I S S S F
A A E S
C C R
after the CR is released. You will receive notification of
the article release via the established "MLN Matters"
listserv.
Contractors shall post this article, or a direct link to this
article, on their Web site and include information about it
in a listserv message within one week of the availability of
the provider education article. In addition, the provider
education article shall be included in your next regularly
scheduled bulletin. Contractors are free to supplement
MLN Matters articles with localized information that
would benefit their provider community in billing and
administering the Medicare program correctly.

IV. SUPPORTING INFORMATION

A. For any recommendations and supporting information associated with listed requirements, use the box below:
"Should" denotes a recommendation.

X-Ref Recommendations or other supporting information:
Requirement
Number

B. For all other recommendations and supporting information, use this space:

V. CONTACTS

Pre-Implementation Contact(s): Contact Eric Coulson at [phone] or [email protected]

Post-Implementation Contact(s): For ambulance Medicare payment policy questions, contact Roechel Kujawa at [phone] or
[email protected]. For questions pertaining to the processing of claims for institutionally-based ambulance services,
contact Valeri Ritter at [phone] or [email protected]. For questions pertaining to the processing of claims for
ambulance suppliers, contact Eric Coulson at [phone] or [email protected].

VI. FUNDING

A. For Fiscal Intermediaries and Carriers:
No additional funding will be provided by CMS; contractor activities are to be carried out within their operating budgets.

B. For Medicare Administrative Contractors (MACs):
The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS
does not construe this as a change to the MAC Statement of Work. The contractor is not obligated to incur costs in excess of the
amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers
anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the
part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding
continued performance requirements.
Medicare Claims Processing Manual
Chapter 15 - Ambulance

Table of Contents
(Rev. 1696, 03-06-09)
10 - Overview
10.1 - Authorities
10.1.1 - Statutes And Regulations
10.1.2 - Other References to Ambulance Related Policies in the CMS
Internet Only Manuals
10.2 - Summary of the Benefit
10.3 - Definitions
10.4 - Additional Introductory Guidelines
20 - Payment Rules
20.1 - Payment Under the Ambulance Fee Schedule
20.1.1 - General
20.1.2 - Jurisdiction
20.1.3 - Services Provided
20.1.4 - Components of the Ambulance Fee Schedule
20.1.5 - ZIP Code Determines Fee Schedule Amounts
20.1.5.1 - CMS Supplied National ZIP Code File and National
Ambulance Fee Schedule File
20.1.6 - Contractor Determination of Fee Schedule Amounts
20.2 - Payment for Mileage Charges
20.3 - Air Ambulance
20.4 – Ambulance Inflation Factor (AIF)
20.5 - Documentation Requirements
30 – General Billing Guidelines
30.1 – Multi-Carrier System (MCS) Guidelines
30.1.1 – MCS Coding Requirements for Suppliers
30.1.2 - Coding Instructions for Paper and Electronic Claim Forms
30.1.3 - Coding Instructions for Form CMS-1491
30.1.4 - CWF Editing of Ambulance Claims for Inpatients
30.2 – Fiscal Intermediary Shared System (FISS) Guidelines
30.2.1 - A/MAC Bill Processing Guidelines Effective April 1, 2002, as a
Result of Fee Schedule Implementation
30.2.2 – SNF Billing
30.2.3 – Indian Health Services/Tribal Billing
40 – Medical Conditions List and Instructions
10 - Overview
(Rev. 1696; Issued: 03-06-09; Effective/Implementation Date: 04-06-09)

10.1 – Authorities
(Rev. 1696; Issued: 03-06-09; Effective/Implementation Date: 04-06-09)

10.1.1 – Statutes and Regulations
(Rev. 1696; Issued: 03-06-09; Effective/Implementation Date: 04-06-09)

Section 1861(s) (7) of the Social Security Act (Act) establishes an ambulance service as a
Medicare Part B service. Payment for ambulance services is addressed at § 1834(l) of
the Act. Coverage rules are addressed at 42 Code of Federal Regulations (CFR) §
410.40. Additional rules, including rules regarding vehicular and staffing requirements,
are specified at 42 CFR § 410.41. Payment rules under the fee schedule established in
2002 are specified at 42 CFR Part 414, Subpart H (§ 414.601 et seq.). Payment rules for
ambulances services furnished by a critical access hospital (CAH) or by an entity owned
and operated by a CAH are specified at 42 CFR § 413.70(b)(5). Other general Medicare
provisions apply to ambulance services. See Title XVIII of the Act and 42 CFR Parts 400
to 429 to determine applicability.

10.1.2 – Other References to Ambulance Related Policies in the CMS
Internet Only Manuals (IOM)
(Rev. 1696; Issued: 03-06-09; Effective/Implementation Date: 04-06-09)

Coverage: Manual instructions regarding coverage of ambulance services, including
specifications for vehicular and staffing requirements, are specified in the Internet-Only
Manual (IOM), Pub. 100-02, Medicare Benefit Policy Manual, chapter 10.
Medical Review: Manual instructions regarding medical review for ambulance services
are specified in the IOM, Pub.100-08, Medicare Program Integrity Manual, chapter 6.
Payment and Claims Processing: This chapter restates previously issued instructions to
Medicare fee-for-service claim processing contractors for processing claims under the
Part B ambulance fee schedule (FS). For historical reference, refer to
www.cms.hhs.gov/center/ambulance on the CMS website to view the previous version of
this chapter.

10.2 – Summary of the Benefit
(Rev. 1696; Issued: 03-06-09; Effective/Implementation Date: 04-06-09)

Ambulance services are covered under Medicare Part B. However, a Part B payment for
an ambulance service furnished to a Medicare beneficiary is available only if the
following, fundamental conditions are met:
• Actual transportation of the beneficiary occurs.
• The beneficiary is transported to an appropriate destination.
• The transportation by ambulance must be medically necessary, i.e., the
beneficiary’s medical condition is such that other forms of transportation are
medically contraindicated.
• The ambulance provider/supplier meets all applicable vehicle, staffing, billing,
and reporting requirements.
• The transportation is not part of a Part A service.
Other requirements specified in this chapter or in the above-cited CMS Manuals may
also apply to the provider/supplier or to a particular transport or billing.

10.3 - Definitions
(Rev. 1696; Issued: 03-06-09; Effective/Implementation Date: 04-06-09)

Most of the definitions previously found in this chapter can now be found in IOM Pub.
100-02, Medicare Benefit Policy Manual, chapter 10 - Ambulance Services. Other
definitions pertaining to payment and claims processing follow.

A/MAC
Definition: For the purposes of this chapter only, the term refers to those contractors that
process claims for institutionally-based ambulance providers billed on CMS-1450 Form
(UB04) and/or a HIPAA compliant ANSI X12N 837I electronic transaction.
B/MAC
Definition: For the purposes of this chapter only, the term refers to those contractors that
process claims for ambulance suppliers billed on a CMS-1500 Form and/or a HIPAA
compliant ANSI X12N 837P electronic transaction.
Date of Service
Definition: The date of service (DOS) of an ambulance service is the date that the loaded
ambulance vehicle departs the point of pickup. In the case of a ground transport, if the
beneficiary is pronounced dead after the vehicle is dispatched but before the (now
deceased) beneficiary is loaded into the vehicle, the DOS is the date of the vehicle’s