Description
This policy provides direction on correct billing for ambulance services.
Definition
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Ambulance
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Specially designed or equipped vehicle used only for transporting the critically ill or injured to a health care facility. The ambulance service must meet state and local requirements for providing transportation for the critically ill or injured and must be operated by qualified personnel who are trained in the application of basic life support.
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Hospital Based Ambulance
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Ambulance owned/operated by a hospital for purposes of providing ambulance transport.
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Independent Ambulance
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Ambulance company not owned/operated by a hospital which provides ambulance transport.
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Loaded Miles
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Miles incurred after member is loaded onto ambulance for transport.
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Point of Pickup
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Location of the member at the time member is placed on board the ambulance.
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Policy
Blue Cross Blue Shield of North Dakota (BCBSND) may contract with ground ambulance providers if the provider’s headquarters or fully functioning business operations are located within BCBSND’s service area. Requests for or offers to contract with out-of-state air ambulance providers are reviewed on a case-by-case basis. BCBSND may contract with an air ambulance provider, if the air ambulance’s patients will be picked up in a location that is within BCBSND’s service area based upon the zip code of the point of pickup.
Ambulance services provided by an independent ambulance provider must be billed on the CMS-1500 Claim Form. Ambulance services provided by a hospital-based ambulance must be billed on the UB-04 Claim Form using the specific National Provider Identifier (NPI) assigned for ambulance. These services should not be billed under the acute hospital NPI. Hospital-based ambulance services are not allowed on inpatient claims, as ambulance transport is not included in inpatient reimbursement methods. Claims for ambulance services must be submitted separately as an outpatient claim. An exception for billing ambulance services through the acute hospital NPI is discussed below in the Intra-facility Ambulance Transport section.
Level of Service
If an Advanced Life Support (ALS) vehicle is used but no ALS service is performed, the appropriate Basic Life Support (BLS) codes should be used. For criteria on higher intensity services refer to the NDBCBS Ambulance Medical Policy.
Intra-facility Ambulance Transport
Medically necessary transports between provider sites will be reimbursed for the following conditions:
- The two locations have different NPIs
- The campuses are in two different locations (a campus is defined as areas located within 250 yards of main buildings) AND the member is not in an inpatient status at the time of transport.
Examples of transports eligible for payment:
- A member who demonstrates severe behavioral health issues is seen in a provider’s emergency room (ER) and is transported by ambulance for admission to the same provider’s psychiatric unit located outside of the campus containing the ER or to the psychiatric unit that has a different NPI.
- A member treated in the clinic for physical therapy services has a stroke and requires transport to a hospital ER for medical treatment.
- A member having a surgical procedure done in the Ambulatory Surgery Center (ASC) has a severe hemorrhage and requires transport to the hospital for additional care.
Examples of transports not eligible for separate payment:
- A member is hospitalized at Hospital A as an inpatient. The member requires diagnostic tests and is transported by ambulance to Hospital B for the test and then returns to Hospital A for continued inpatient care. Both the test plus the ambulance transport charges would be included on the inpatient claim submitted by Hospital A. Hospital A would be responsible for reimbursing the Ambulance Company and Hospital B services they provided.
- A member has a procedure performed in a facility’s ASC and is transported to the same facility’s outpatient hospital for additional non-emergent care/routine post-operative recovery.
- Transport by an ambulance to a clinic or mortuary is not eligible for reimbursement.
Ambulance Transport with Multiple Patients
When multiple patients are transported simultaneously either by ground or air, regardless of whether it is billed by UB-04 or a CMS-1500 Claim Form, the following rules apply:
- Two Patients: For two patients in the same ambulance, BCBSND will reimburse at 75 percent of the allowed amount for the level of service (base rate) furnished to each patient. The total mileage will be divided in two so each patient’s claim will be reimbursed for 50 percent of the allowed amount for the entire transport.
- Three or more patients: For three or more patients in the same ambulance, BCBSND will reimburse at 60 percent of the allowed amount for the level of service (base rate) furnished to each patient. The total mileage will be divided by the number of patients transported. For example, if three patients are transported in the same ambulance, the provider will be reimbursed for 60 percent of the allowed amount for each level of service (base rate) and 33 percent of the allowed amount for the total mileage for each patient.
- Submit separate claims for each patient with the modifier ‘GM’; appended to both base rate and mileage codes. Submit the separate claims to BCBSND at the same time for each patient in the ambulance.
Ground Ambulance Billing Guidelines
Claims from providers of emergency and non-emergency ground ambulance services provided within the United States, U.S. Virgin Islands and Puerto Rico are to be filed to the local Plan. Pick-up locations outside the United States, U.S. Virgin Islands and Puerto Rico, regardless of where the provider’s headquarters is located, must file claims to the Blue Cross Blue Shield Global Core (BCBSGC) medical assistance vendor for processing through the BCBSGC Program.
Federal Employee Program (FEP) ambulance claims should be filed to the BCBS Plan for the state where the member was picked up. If the provider is not contracted with that BCBS Plan and is contracted with the BCBS Plan in the state to which the member was transported, the claim may be filed to state BCBS Plan where the member was transported. For example, if an FEP member is picked up in Minnesota and brought to North Dakota, the FEP claim should be filed to Minnesota. In the event the ambulance provider is not contracted with Minnesota and is contracted with North Dakota, then the FEP claim can be filed to North Dakota.
The appropriate Healthcare Common Procedure Coding System (HCPCS) code should be used to identify whether the transport is emergent or non-emergent.
Code
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Description
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A0426
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Ambulance Service, advanced life support, non-emergency transports, level 1 (ALS 1)
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A0427
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Ambulance Service, advanced life support, emergency transport, level 1 (ALS 1- emergency)
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A0428
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Ambulance service, basic life support, non-emergency transport (BLS)
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A0429
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Ambulance service, basic life support, emergency transport (BLS-emergency)
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A0433
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Advanced life support, level 2 (ALS 2)
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A0434
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Specialty care transport (SCT)
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A0998
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Ambulance response and treatment, no transport
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Reimbursement will be based on the Base Rate and Mileage HCPCS codes that define the type of service provided. When billing for mileage, report the number of loaded miles in the “units” field. For any ambulance mileage less than 100 miles report the mileage as a numeric value that includes tenths of a mile for claims billed on the CMS-1500 Claim Form. Claims billed on the UB-04 Claim Form should be submitted to the nearest whole mile.
Note: Medicaid requires modifier 76 be appended to any subsequent ambulance services when a Medicaid patient is transported multiple times on a single date of service. Claims will be denied upon post pay review.
Supplies & Equipment
The base rate covers routine supplies and equipment such as IV solutions, oxygen, tubing, masks, gloves, dressings, catheters, EKG supplies, backboards, glucose checks and basic medications. Other services or supplies billed in addition to the base rate will be denied as an integral part of the actual transportation. An example of these would include:
Supplies
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Codes
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Supply codes
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A0382, A0384, A0392, A0394, A0396, A0398
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Waiting Time
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A0420
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Oxygen
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A0422
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Extra Attendant
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A0424
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Protective garments
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A4927, A4928, A4930
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Cardiac monitoring (including EKG)
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93000-93010, 93040-93042
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Pulse Oximetry
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94760 & 94761
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