Commercial

Medical Policy

Notification

Ground Ambulance Services (Emergency and Nonemergency) (AmeriHealth)

Notification Issued Date:

Title:

Ground Ambulance Services (Emergency and Nonemergency) (AmeriHealth)

Policy #:

12.04.02j

Policy

State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

EMERGENCY GROUND AMBULANCE SERVICES

MEDICALLY NECESSARY
Emergency Ground Ambulance AND Transportation

Emergency ground ambulance AND transportation are considered medically necessary and, therefore, covered when ALL of the following criteria are met:

The services provided are medically necessary to stabilize the individual’s medical condition.
The responding emergency medical services (EMS) ambulance, in accordance with state regulations, is a specially designed and equipped vehicle used to transport the sick or injured.
The responding EMS ambulance, in accordance with state regulations, is staffed by state-certified or qualified staff who are able to provide basic life support or advanced life support services, as appropriate, at the treating location during the time of the emergency.
The EMS staff is able to provide assessment, monitoring, assistance, treatment, and observation during transportation.
Transportation of the individual will be from the individual’s home, or the scene of the accident or medical emergency, to the nearest acute care hospital or other emergency care facility, where emergency health services can be provided to the individual.

Paramedic Intercept

When the above criteria for emergency ground ambulance AND transportation is met, paramedic intercept services are covered when an individual requires an Advanced Life Support (ALS) ambulance to provide a service that meets the definition of an ALS intervention (e.g., electrocardiogram monitoring, chest decompression, or intravenous therapy) and a Basic Life Support (BLS) ambulance provides the transport.

Emergency Ground Ambulance Services Without Transportation

Emergency ground ambulance services without transportation of an individual to an emergency facility is considered a benefit contract exclusion and, therefore, not eligible for reimbursement consideration.

For members enrolled in Pennsylvania products who are subject to the Commonwealth of Pennsylvania's mandate (Act 103 of 2018), emergency ground ambulance services without transportation is a covered service when ALL of the following medical necessity criteria are met:

The services provided are medically necessary to stabilize the individual’s medical condition.
The responding EMS ambulance is Pennsylvania licensed and rendering EMS services in the Commonwealth of Pennsylvania.
The responding EMS ambulance, in accordance with state regulations, is a specially designed and equipped vehicle used to transport the sick or injured.
The responding EMS ambulance, in accordance with state regulations, is staffed by state-certified or qualified staff who are able to provide BLS or ALS services, as appropriate, at the treating location during the time of the emergency.
The responding EMS staff provides on-scene emergency evaluation and, if necessary, treatment to stabilize the individual's medical condition, and it is subsequently determined that transportation to an acute care hospital or other emergency care facility for additional care is not required, or the individual declines transportation.

Acute Care Facility to Acute Care Facility Transport of a Registered Inpatient (Emergency)

Emergency ground ambulance transport from one acute care facility of a registered inpatient to another acute care facility to obtain necessary specialized diagnostic and/or therapeutic services, is considered medically necessary and, therefore, covered when ALL of the following criteria are met:

There is a medical condition that is life- or limb-threatening, or treating personnel deem to be life- or limb-threatening, and the individual's condition is such that a delay in treatment poses a threat to the individual's survival or seriously endangers the individual's health, or could result in serious impairment to the individual's bodily functions and/or serious dysfunction of any of the individual's bodily organs or parts.
The necessary diagnostic and/or therapeutic services must be provided in the inpatient setting.
The necessary diagnostic and/or therapeutic services are not available at the facility in which the member is admitted.
The necessary diagnostic and/or therapeutic services are available at the facility to which the member is being transported.

Other Facility to Facility Transport (Emergency)

Emergency ground ambulance transport from one facility to another facility to obtain necessary specialized diagnostic and/or therapeutic services is considered medically necessary and, therefore, covered when ALL of the following criteria are met:

There is a medical condition that is life- or limb-threatening, or treating personnel deem to be life- or limb-threatening, and the individual's condition is such that a delay in treatment poses a threat to the individual's survival or seriously endangers the individual's health, or could result in serious impairment to the individual's bodily functions and/or serious dysfunction of any of the individual's bodily organs or parts;
The necessary diagnostic and/or therapeutic services are not available at the facility in which the member is located.
The necessary diagnostic and/or therapeutic services are available at the facility to which the member is being transported.

Miscellaneous Items and Services

Supplies that are needed to stabilize an individual’s medical condition are considered medically necessary and, therefore, covered when the emergency ambulance service with transport is medically necessary.

NONEMERGENCY GROUND TRANSPORTATION

MEDICALLY NECESSARY
Nonemergency ground ambulance services with transportation is considered medically necessary and, therefore, covered when ALL of the following criteria (1) through (5) are met:

(1)	BENEFIT Nonemergency ambulance transport benefit requirements are met when nonemergency ambulance transport is outlined as a benefit according to the member contract. Member contracts may variously limit or exclude the eligibility of the transport origin, transport destination, type of provider or transport (e.g., nonemergency ambulance transport), and/or the participation status of the transport provider. Individual member benefits must be verified.
(2)	TRANSPORT TO OBTAIN COVERED TREATMENTS OR SERVICES This requirement is met when the nonemergency ambulance transport is requested to obtain a covered treatment or service for an individual or to return an individual from having obtained a covered treatment or service. A treatment or service is considered covered when it is identified in the member contract as a benefit and the individual meets the medical necessity criteria required to obtain the treatment or service. When a treatment or service for which an individual has a benefit does not meet medical necessity requirements, nonemergency ambulance transport for that treatment or service is considered not medically necessary and, therefore, not covered.
(3)	ORIGIN The origin (point of ambulance pick-up) is covered when all of the following criteria are met: The origin is not precluded from eligibility in the member contract. The origin must be one of the following: An individual's home (refer to the Description section of this policy for the definition of home) An acute care facility (e.g., hospital, rehabilitation hospital) An inpatient hospice A skilled nursing facility A dialysis facility
(4)	DESTINATION The destination for nonemergency ambulance transport is covered when all of the following criteria are met: The destination is not precluded from eligibility in the member contract. The destination has the facilities to treat the individual’s condition. The destination must be one of the following: The individual's home (when a destination, an individual’s home is exempt from the appropriate facilities requirements) An acute care facility (e.g., hospital, rehabilitation hospital) An inpatient hospice A skilled nursing facility A dialysis facility In addition to the above, the following destinations are covered only when the transport origin is either a skilled nursing, sub-acute, or acute rehabilitation facility where the individual is being treated at a skilled level of care: A physician's office A free-standing facility
(5)	MEDICAL NECESSITY Medical necessity requirements for nonemergency ambulance transport are met when the individual's health condition is such that the use of any other method of transportation (e.g., taxicab, private car, wheelchair coach) would be medically contraindicated (e.g., would endanger the member's medical condition). In addition: If covered, medically necessary services can be otherwise provided quickly, equally as safely, and more cost efficiently to the individual than by nonemergency ambulance transport, the transport is considered to be not medically necessary. For example, the transport of an individual to receive wound care is not considered reasonable if the wound care could be provided at the individual's bedside at less cost than transporting the individual to a facility to obtain the services. In products requiring precertification, a medical necessity determination is based on the medical information received at the time of the request for the service. The individual's condition at the time of transport must require the presence of medical personnel who are certified and/or licensed to provide monitoring and/or interventional medical services. The following list includes, but is not limited to, examples of medical conditions that may satisfy the medical necessity requirement: The individual is unconscious. The individual has to remain immobile because of a fracture that has not been set or because of the possibility of a fracture (e.g., hip fracture). The individual is in a body cast or spica cast. The individual is bed-confined before and after transport (refer to the Description section of this policy for a definition of bed-confined). The individual is unable to sit in a chair or wheelchair for the duration of the transport. The individual has lower extremity contractures that are of sufficient degree as to prohibit sitting in a wheelchair (severe fixed contractures at or proximal to the knee). Morbid obesity (as a sole qualifying condition) caused the individual to meet the definition of bed-confined. The individual has a health condition(s) that would be exacerbated by transport in a vehicle other than an ambulance. The individual must remain in a supine/prone position. The individual must be moved by a stretcher because of a specific physical condition or limitation. According to the American Academy of Orthopaedic Surgeons (AAOS): Post–hip replacement individuals may sit in a chair slightly higher than the average seat (e.g., wheelchair). Therefore, in most cases, this condition alone does not satisfy the medical necessity requirement. Post–knee replacement individuals should be able to bend their knee approximately 90 degrees at the time of discharge. Therefore, in most cases, this condition alone does not satisfy the medical necessity requirement. The individual requires maintenance of medical isolation precautions for active infectious processes. The individual requires restraints. The individual requires a skilled service during transport (e.g., ventilator care, nursing). The individual requires continued oxygen therapy and the assistance of medically trained personnel to monitor and/or adjust the oxygen during transport because the individual is not able to self-administer oxygen. In addition, clinical documentation must be consistent with a need for continued oxygen therapy.

Acute Care Facility to Acute Care Facility Transport of a Registered Inpatient (Nonemergency)

Nonemergency ground ambulance transport of a registered inpatient from one acute care facility to another acute care facility to obtain necessary specialized therapeutic services is considered medically necessary and, therefore, covered when ALL of the following criteria are met:

The above policy requirements (1) through (5) are met;
The necessary therapeutic services must be provided in the inpatient setting.
The necessary therapeutic services are not available at the facility in which the member is admitted.
The necessary therapeutic services are available at the facility to which the member is being transported.

Roundtrip Nonemergency Transport

A roundtrip nonemergency ground ambulance transport between an eligible point of origin (as defined above) and an eligible destination (as defined above) for an individual to receive eligible medical services not otherwise available at the point of origin is considered medically necessary and, therefore, covered when requirements (1) through (5) in this policy are met. Roundtrip nonemergency ground ambulance transport must be reported with the appropriate origin and destination modifier for each segment corresponding to the origin and destination of the roundtrip transport.

Repetitive Nonemergency Transport

Repetitive nonemergency ground ambulance transports that is three or more round trips (or six one-way trips) within a 10-day period OR at least one trip per week for at least 3 weeks is considered medically necessary and, therefore, covered when ALL of the following criteria are met:

The above policy requirements (1) through (5) are met.
A letter of medical necessity stating that transport is medically necessary must be signed by the patient’s attending provider.
The letter of medical necessity must be dated no later than 60 days in advance of the transport for those individuals who require repetitive ambulance services and whose transportation is scheduled in advance.

Miscellaneous Items and Services

When the nonemergency ground ambulance transport is medically necessary, miscellaneous items and services associated with the transport may also be covered. However, reimbursement eligibility varies as follows:

The transport of multiple individuals in the same ambulance vehicle is eligible for separate reimbursement consideration only when the nonemergency ambulance transport would have otherwise been covered and eligible for reimbursement consideration if provided to each individual separately.
The use of extra attendants is eligible for reimbursement consideration when both of the following conditions are met:
- The use of extra attendants has been prearranged with the Company.
- The attendants are state certified or qualified staff who are able to provide basic life support or advanced life support services, as appropriate.
- The nonemergency ambulance transport record indicates that unusual circumstances existed to necessitate the presence of extra attendants.
Disposable supplies (e.g., gauze, dressings, cervical collars) that are utilized in excess of the amount that would be considered appropriate in the treatment of the individual's medical condition are eligible for separate reimbursement consideration only when the nonemergency ambulance transport record indicates that unusual circumstances existed and when the applicable provider contract has a provision for such services.

Scheduled Ambulance Transport

All scheduled ground ambulance transports will be considered nonemergency. Transports to nursing homes, places of residence, and end-stage renal disease (ESRD) facilities will be considered nonemergency.

BENEFIT EXCLUSION
Nonemergency ground ambulance services without transportation of an individual, even if medical services are provided to the individual, is considered a benefit contract exclusion for all products of the Company and, therefore, not eligible for reimbursement consideration.

Transportation services other than ambulance (e.g., wheelchair vans, taxicabs) and/or ancillary transportation fees (e.g., parking fees, tolls) are considered a benefit contract exclusion for all products of the Company and, therefore, not eligible for reimbursement consideration.

SEA AMBULANCE TRANSPORT

Sea ambulance transportation is considered medically necessary and, therefore, covered in either of the following circumstances:

A land ambulance cannot reach the scene easily or quickly enough; or
The individual needs to be transported over a distance or terrain that makes water transportation the most practical transport mode.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

BILLING REQUIREMENTS

Only HCPCS code A0998 represents ambulance response and treatment without transportation. For members enrolled in Pennsylvania products who are subject to the Commonwealth of Pennsylvania's mandate (Act 103 of 2018), HCPCS code A0998 will be considered eligible for reimbursement in a situation where EMS staff respond to an emergency call and provide on-scene emergency evaluation and, if necessary, treatment to stabilize an individual's condition but does not provide transportation, either because the medical issue has resolved or the individual declined transportation. In situations where no emergency evaluation and/or treatment was rendered, HCPCS code A0998 is not eligible for reimbursement consideration. In addition, it is not appropriate to report mileage with A0998.

HCPCS code A0998 reported with an ambulance transport code on the same day by the same provider is not eligible for reimbursement consideration.

Ambulance transport codes should be reported with origin and destination modifiers indicating that an actual transport occurred. Ambulance transport codes reported with EE, NN, PP, SS or RR modifier combinations will be considered invalid and not eligible for reimbursement consideration.

Reusable devices and equipment (e.g., backboards, neck boards, inflatable splints) are not eligible for separate reimbursement, regardless of the provider's participation status with the Company, because they are always integral to the primary ambulance service codes with which they are reported.

Waiting time is not eligible for separate reimbursement because it is always integral to the primary nonemergency ambulance service code with which it is reported.

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

Guidelines

The vehicle and crew utilized for emergency and nonemergency ambulance transport should meet all applicable local, state, and federal regulatory, certification, and licensing requirements.

If an emergency occurs during a nonemergency ambulance transport, the Company considers it an emergency ambulance transport only if the individual's condition meets the Company's definition of an emergency condition (refer to the Description section of this policy for the definition of emergency).

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, ground ambulance services are covered under the medical benefits of the Company’s products when the criteria listed in this policy are met.

Subject to the terms and conditions of the applicable benefit contract, ground ambulance services that do not satisfy the criteria listed in this policy are considered not medically necessary.

The application of benefits may vary by product and/or group; therefore, individual member benefits must be verified.

In products without an Out-of-Network benefit (HMO), nonemergency ground transport may be covered to transport the member back to an In-Network Facility Provider in the member's service area as determined by the [(Fully-Insured) Health Benefit Plan or (Self-Insured) Claims Administrator], when the transfer is medically necessary (as determined by the company’s definition of medical necessity); AND the member's medical condition requires uninterrupted care and attendance by qualified medical staff during ground transport. Transportation back to the member's service area is not covered for family members or companions as it is a benefit contract exclusion.

In products with an Out-of-Network benefit (PPO and the POS product), nonemergency ground transport may be covered to transport the Member back to an In-Network Facility Provider as determined by the [(Fully-Insured) Health Benefit Plan or (Self-Insured) Claims Administrator] when the transfer is medically necessary (as determined by the company’s definition of medical necessity); AND the member's medical condition requires uninterrupted care and attendance by qualified medical staff during ground transport. Transportation back to the member's service area is not covered for family members or companions as it is a benefit contract exclusion.

MANDATES

This policy is in compliance with federal and/or state mandates.

Description

Ground ambulance services may involve ground or water transport in both emergency and nonemergency situations.

A ground ambulance vehicle is designed and equipped to respond to medical emergencies and to transport individuals who are sick or injured. The vehicle must comply with state and local laws governing the licensing and certification of an emergency medical transportation vehicle and must be staffed by state certified or qualified staff who are able to provide basic life support or advanced life support services, as appropriate.

A sea ambulance is a watercraft used for emergency medical assistance in situations where either a ground ambulance cannot reach the scene easily or quickly enough or the individual needs to be transported over a distance or terrain that makes water transportation the most practical transport mode. Sea ambulance crews are supplied with equipment that enables them to monitor and provide medical treatment to an individual during transportation.

DEFINITIONS

Appropriate facilities are generally equipped and staffed to provide the necessary care for the individual's health condition. In the case of an acute care hospital, it also means that a physician or a physician specialist is available to provide the necessary care required to treat the individual's condition.

Bed-confined, which is not synonymous with bed rest or nonambulatory, means that an individual is unable to do all of the following:

Get up from bed without assistance
Ambulate
Sit in a chair or wheelchair

Home is defined as the individual's place of residence (e.g., private residence/domicile, assisted living facility, long-term care facility, skilled nursing facility [SNF] at a custodial level of care).

Emergent/emergency refers to the sudden onset of a medical condition that manifests itself by acute symptoms of sufficient severity or pain such that a prudent layperson possessing an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in any of the following:

The health of the individual being placed in serious jeopardy
The health of a pregnant woman or her unborn child being placed in serious jeopardy
Serious impairment to the individual's bodily functions
Serious dysfunction of any of the individual's bodily organs or parts

Emergency response means responding immediately at the basic life support (BLS) or advanced life support (ALS) level of services to a 911 call or the equivalent due to a sudden onset of a medical condition, requiring medical assessment, monitoring, treatment, or observation of the individual. An immediate response is one in which the ambulance supplier begins as quickly as possible to take the steps necessary to respond to the call.

Nonemergency ambulance transport is an ambulance transport provided for an individual who has nonemergent conditions but still requires ambulance transportation because other methods of transportation are contraindicated (e.g., bed confinement status, need for continuous supervision, physical restraint status, and/or dependence on other enabling machines and devices). Nonemergency ambulance transport may be provided at either a BLS or an ALS level of care.

Nonemergent/nonemergency conditions are conditions that require medical attention, which may be provided or directed by a physician shortly after occurrence, but are not severe enough to meet this policy's definition of emergency.

Paramedic intercept services are ALS services provided by an entity that does not provide the ambulance transport. This type of service is most often provided for emergency ambulance transport in which a local volunteer ambulance that can provide only a BLS level of service is dispatched to transport an individual. If an individual requires ALS services such as electrocardiogram monitoring, chest decompression, or intravenous therapy, another entity dispatches a paramedic to meet the BLS ambulance at the scene or once the ambulance is on the way to the hospital. The ALS paramedics then provide services to the individual.

References

American College of Emergency Physicians (ACEP). Policy Statements. Appropriate interfacility patient transfer. [ACEP Web site]. Original: 09/1989. (Revised 01/2022). Available at: https://www.acep.org/patient-care/policy-statements/appropriate-interfacility-patient-transfer/#sm.00006vg9fr1bakdtbz9sgovgpzj01. Accessed May 22, 2023.

Centers for Medicare & Medicaid Services (CMS). MLN Fact Sheet: National expansion of the repetitive, scheduled non-emergent ambulance transport (RSNAT) prior authorization model. [CMS Web site]. September 2022. Available at: MLN68005343 - National Expansion of the Repetitive,Scheduled Non-Emergent Ambulance Transport (RSNAT) Prior Authorization Model (cms.gov). Accessed May 22, 2023.

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 10 - Ambulance Services. §30.1. Definition of ambulance services. [CMS Web site].(Revision #243: 04/13/18). Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c10.pdf. Accessed May 22, 2023.

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 10 - Ambulance services. [CMS Web site]. (Revision #243: 04/13/18). Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp10 2c10.pdf. Accessed May 22, 2023.

Centers for Medicare & Medicaid Services (CMS). Medicare Managed Care Manual. Chapter 4 - Benefits and beneficiary protections. §20.2. Definitions of emergency and urgently needed services. [CMS Web site]. (Revision #121: 04/22/16). Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c04.pdf. Accessed May 22, 2023.

Commonwealth of Pennsylvania. PA Code 28, Ch 9, §9.602. Definitions. [The Pennsylvania Code Web site]. Available at: https://www.pacode.com/secure/data/028/chapter9/s9.602.html. Accessed May 22, 2023.

Company Benefit Contracts.

General Assembly of Pennsylvania. House Bill #1013. [State of Pennsylvania Web site]. 09/25/2018. Available at:
https://www.legis.state.pa.us/cfdocs/legis/PN/Public/btCheck.cfm?txtType=PDF&sessYr=2017&sessInd=0&billBody=H&billTyp=B&billNbr=1013&pn=4069. Accessed May 22, 2023.

New Jersey (NJ) Administrative Code. Office of Emergency Medical Services. Title 8, Ch 40, Subchapter 1, §8:40-1.3. Mobility assistance vehicle and basic life support ambulance services. [State of NJ Department of Health and Senior Services Web site]. Available at: http://www.state.nj.us/health/ems/documents/reg-enforcement/njac840ar.pdf. Accessed May 22, 2023.

New Jersey (NJ) Administrative Code. Office of Emergency Medical Services. Title 8, Ch 41, Subchapter 1, §8:41-1.3. Advanced life support services; mobile intensive care programs, specialty care transport services and air medical services. [State of NJ Department of Health and Senior Services Web site]. Available at: http://www.state.nj.us/health/ems/documents/reg-enforcement/njac841r.pdf. Accessed May 22, 2023.

New Jersey (NJ) Administrative Code. Office of Emergency Medical Services. Title 8, Ch 41a, Subchapter 1, §8:41a-1.3. Emergency Medical Technicians - Paramedic: training and certification. [NJ Department of Health and Senior Services Web site]. Available at: http://www.state.nj.us/health/ems/documents/reg-enforcement/njac841r.pdf. Accessed May 22, 2023.

Novitas Solutions Inc. LCD L35162 Ambulance Services (Ground Ambulance). Original effective 10/01/2015. (Retired: 02/09/2023). Available at: LCD - Ambulance Services (Ground Ambulance) (L35162) (cms.gov). Accessed May 22, 2023.

Novitas Solutions Inc. Local Coverage Article. A54574. Billing and Coding: Ambulance Services (Ground Ambulance). Original 01/01/2015. (Retired: 02/09/2023). Available at: Article - Billing and Coding: Ambulance Services (Ground Ambulance) (A54574) (cms.gov). Accessed May 22, 2023.

Pennsylvania Department of Health. Bureau of Emergency Medical Services. EMS Informational Bulletins. Available at: Bulletins (pa.gov). Accessed October May 22, 2023.

Coding

CPT Procedure Code Number(s)

N/A

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

Report the most appropriate diagnosis code in support of medically necessary criteria as listed in the policy

HCPCS Level II Code Number(s)

AMBULANCE SERVICE CODES

A0140 Nonemergency transportation and air travel (private or commercial), intra- or interstate

A0225 Ambulance service, neonatal transport, base rate, emergency transport, one way

A0426 Ambulance service, advanced life support, nonemergency transport, level 1 (ALS 1)

A0427 Ambulance service, advanced life support, emergency transport, level 1 (ALS 1 - emergency)

A0428 Ambulance service, basic life support, nonemergency transport (BLS)

A0429 Ambulance service, basic life support, emergency transport (BLS, emergency)

A0433 Advanced life support, level 2 (ALS 2)

A0432 Paramedic intercept (PI), rural area, transport furnished by a volunteer ambulance company which is prohibited by state law from billing third-party payers

A0434 Specialty care transport (SCT)

A0998 Ambulance response and treatment, no transport

S0207 Paramedic intercept, nonhospital-based ALS service (nonvoluntary), nontransport

S0208 Paramedic intercept, hospital-based ALS service (nonvoluntary), nontransport

MISCELLANEOUS AMBULANCE CODES

A0380 BLS mileage (per mile)

A0382 BLS routine disposable supplies

A0384 BLS specialized service disposable supplies; defibrillation (used by ALS ambulances and BLS ambulances in jurisdictions where defibrillation is permitted in BLS ambulances)

A0390 ALS mileage (per mile)

A0392 ALS specialized service disposable supplies; defibrillation (to be used only in jurisdictions where defibrillation cannot be performed by BLS ambulances)

A0394 ALS specialized service disposable supplies; IV drug therapy

A0396 ALS specialized service disposable supplies; esophageal intubation

A0398 ALS routine disposable supplies

A0422 Ambulance (ALS or BLS) oxygen and oxygen supplies, life sustaining situation

A0424 Extra ambulance attendant, ground (ALS or BLS) or air (fixed or rotary winged); (requires medical review)

A0425 Ground mileage, per statute mile

A0999 Unlisted ambulance service

S0215 Nonemergency transportation; mileage, per mile

THE FOLLOWING SERVICE IS ALWAYS INTEGRAL TO THE PRIMARY TRANSPORT CODE AND, THEREFORE, IS NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT CONSIDERATION:

A0420 Ambulance waiting time (ALS or BLS), one-half (1/2) hour increments

BENEFIT EXCLUSION

A0080 Nonemergency transportation, per mile - vehicle provided by volunteer (individual or organization), with no vested interest

A0090 Nonemergency transportation, per mile - vehicle provided by individual (family member, self, neighbor) with vested interest

A0100 Nonemergency transportation; taxi

A0110 Nonemergency transportation and bus, intra- or interstate carrier

A0120 Nonemergency transportation: mini-bus, mountain area transports, or other transportation systems

A0130 Nonemergency transportation: wheelchair van

A0160 Nonemergency transportation: per mile - caseworker or social worker

A0170 Transportation ancillary: parking fees, tolls, other

A0180 Nonemergency transportation: ancillary: lodging - recipient

A0190 Nonemergency transportation: ancillary meals – recipient

A0200 Nonemergency transportation: ancillary: lodging – escort

A0210 Nonemergency transportation: ancillary: meals – escort

A0888 Noncovered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility)

S0209 Wheelchair van, mileage, per mile

For members enrolled in AmeriHealth New Jersey products or Pennsylvania groups who are not subject to the Commonwealth of Pennsylvania's mandate (Act 103 of 2018)

A0998 Ambulance response and treatment, no transport

Revenue Code Number(s)

0540 Ambulance - General Classification

0541 Ambulance - Supplies

0542 Ambulance - Medical Transport

0543 Ambulance - Heart Mobile

0544 Ambulance - Oxygen

0546 Ambulance - Neonatal Ambulance Services

0547 Ambulance - Pharmacy

0548 Ambulance - EKG Transmission

0549 Ambulance - Other Ambulance

MPMiscCodesNarrativesPub
Modifiers

D Diagnostic or therapeutic site other than P or H when these are used as origin codes
E Residential, domiciliary, custodial facility (other than 1819 facility)
G Hospital based ESRD facility
H Hospital
I Site of transfer (e.g. airport or helicopter pad) between modes of ambulance transport
J Freestanding ESRD facility
N Skilled nursing facility
P Physician’s office
R Residence
S Scene of accident or acute event
X Intermediate stop at physician’s office on way to hospital (This is a destination code only)

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From 12.04.02j:

07/31/2023

This version of the policy will become effective 07/31/2023.

The intent of this policy has not changed, although it has been modified to incorporate coverage criteria for Paramedic Intercept Services.

The following HCPCS codes were added to the policy as Medically Necessary:

A0432 Paramedic intercept (PI), rural area, transport furnished by a volunteer ambulance company which is prohibited by state law from billing third-party payers

S0207 Paramedic intercept, nonhospital-based ALS service (nonvoluntary), nontransport

S0208 Paramedic intercept, hospital-based ALS service (nonvoluntary), nontransport

Revisions From 12.04.02i:

11/02/2022

This policy has been reviewed and reissued to communicate the Company’s continuing position on Ground Ambulance Services (Emergency and Nonemergency).

07/01/2020

This policy has been reissued in accordance with the Company's annual review process.

01/01/2020

This version of the policy will become effective 01/01/2020.

This policy was updated to reflect a change in coverage position for members enrolled in Pennsylvania products, who are subject to Commonwealth of Pennsylvania's mandate (Act 103 of 2018), regarding emergency ambulance response and treatment, no transport. These services have been changed from being designated as a benefit exclusion to being medically necessary with criteria.

The following criteria has been added to this policy for members enrolled in Pennsylvania products, in accordance with the state of Pennsylvania's mandate regarding Emergency Ground Ambulance Services Without Transportation:

For members enrolled in Pennsylvania products, in accordance with the state of Pennsylvania's mandate (Act 103 of 2018), emergency ground ambulance services without transportation is a covered service when ALL of the following medical necessity criteria are met:

Emergency ground ambulance services without transportation is considered medically necessary and, therefore, covered when ALL of the following criteria are met:

The services provided are medically necessary to stabilize the individual’s medical condition.
The responding emergency medical services (EMS) ambulance is Pennsylvania licensed and rendering EMS services in the Commonwealth of Pennsylvania.
The responding EMS ambulance, in accordance with state regulations, is a specially designed and equipped vehicle used to transport the sick or injured.
The responding EMS ambulance, in accordance with state regulations, is staffed by state certified or qualified staff who are able to provide basic life support or advanced life support services, as appropriate, at the treating location during the time of the emergency.
The responding EMS staff provides on-scene emergency evaluation and, if necessary, treatment to stabilize the individual's medical condition, and it is subsequently determined that transportation to an acute care hospital or other emergency care facility for additional care is not required, or the individual declines transportation.

The list for examples of medical conditions that may satisfy the medical necessity requirement for nonemergency ground ambulance transport in individuals requiring oxygen therapy was revised: The following example was added to the policy:

The individual requires continued oxygen therapy and the assistance of medically trained personnel to monitor and/or adjust the oxygen during transport because the individual is not able to self-administer oxygen. In addition, clinical documentation must be consistent with a need for continued oxygen therapy.

The following examples of medical conditions for nonemergency ground ambulance transport in individuals requiring oxygen therapy were deleted from the policy:

The individual is not able to self-administer oxygen or requires active assistance with its administration by medical personnel during transport.
The individual requires the continuation of oxygen therapy that was initiated during the immediate hospitalization from which the transport is being requested and the individual does not have portable oxygen equipment at the time of the transport request.

Billing requirements to clarify reimbursement for emergency ambulance response and treatment, no transport have been incorporated into this policy:

Only HCPCS code A0998 represents ambulance response and treatment without transportation. For members enrolled in Pennsylvania products who are subject to the Commonwealth of Pennsylvania's mandate (Act 103 of 2018), HCPCS code A0998 will be considered eligible for reimbursement in a situation where EMS staff respond to an emergency call and provide on scene emergency evaluation and, if necessary, treatment to stabilize an individual's condition but does not provide transportation, either because the medical issue has resolved or the individual declined transportation. In situations where no emergency evaluation and/or treatment was rendered, HCPCS code A0998 is not eligible for reimbursement consideration. In addition, it is not appropriate to report mileage with A0998.
HCPCS code A0998 reported with an ambulance transport code on the same day by the same provider is not eligible for reimbursement consideration.

A billing requirement to submit the origin and destination modifier with the billed HCPCS code for ambulance transport when submitting an ambulance claim has been incorporated into this policy.

Ambulance transport codes should be reported with origin and destination modifiers indicating that an actual transport occurred. Ambulance transport codes reported with EE, NN, PP, SS or RR modifier combinations will be considered invalid and not eligible for reimbursement consideration.

Revisions From 12.04.02h:

01/01/2019

This version of the policy will become effective 01/01/2019.

This policy was updated to revise policy coverage criteria regarding Ground Ambulance Services.

Revisions From 12.04.02g:

08/13/2018

Effective 08/13/2018, this policy has been reviewed and reissued to communicate the Company’s continuing position on Nonemergency Ambulance Transport Services.

Revisions From 12.04.02f:

11/22/2017