Print

Date Printed: August 23, 2017: 06:00 AM

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

09-A0000-01

Original Effective Date: 02/15/02

Reviewed: 04/19/16

Revised: 04/24/17

Subject: Ambulance Services

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates Decision Tree   Previous Information
           

DESCRIPTION:

Ambulance and medical transport services involve the use of specially designed and equipped vehicles used for transporting ill or injured patients and may involve ground, air, or sea transportation in both emergency and non-emergency situations. These services are identified by seven categories for ground ambulance services and two categories for air ambulance services (see DEFINITIONS section of this policy).

Ground ambulance services include the following categories:

  1. Basic Life Support (BLS)
  2. Basic Life Support (BLS) – Emergency
  3. Advanced Life Support, Level 1 (ALS1)
  4. Advanced Life Support, Level 1 (ALS1 – Emergency)
  5. Advanced Life Support, Level 2 (ALS2)
  6. Specialty Care Transport (SCT)
  7. Paramedic Intercept (PI)

NOTE: Ground ambulance services refer to both land and water transportation.

Air ambulance services include the following categories:

  1. Fixed Wing Air Ambulance (FW)
  2. Rotary Wing Air Ambulance (RW)

POSITION STATEMENT:

 

Certificate of Medical Necessity

Submit a completed Certificate of Medical Necessity (CMN) along with your request for ambulance services to expedite the medical review process.

1. Click the link Ambulance Services - Certificate of Medical Necessity (MS Word) to open the form.

2. Complete all fields on the form thoroughly.

3. Print and submit a copy of the form with your request.

Note: Florida Blue regularly updates CMNs. Ensure you are using the most current copy of a CMN before submitting to Florida Blue. For a complete list of available CMNs, visit the Certificates of Medical Necessity page.

Ambulance transportation includes the services of ambulance attendants and the provision of reusable equipment and devices (e.g., stretchers, restraints, backboards, inflatable leg and arm splints).

Examples of situations when ambulance transportation meets the definition of medical necessity include, but are not limited to, the following:

Ground emergency ambulance transport services may be eligible for coverage when ALL of the following criteria are met:

Round trip ambulance service rendered to a hospital inpatient being transported to another facility for the purpose of obtaining specialized diagnostic or therapeutic services (C.T. scan, radiotherapy), meets the definition of medical necessity when:

NOTE: Reimbursement for round trip ambulance service for a hospital inpatient is included in the facility fee paid to the admitting hospital and is not reimbursed separately.

Ambulance service to a physician's office or physician-directed clinic meets the definition of medical necessity when ALL of the following conditions exist:

Water or air ambulance transportation (fixed wing or rotary) meets the definition of medical necessity when ALL of the following are met:

(Refer to member contract first; most require transport to the nearest facility that can provide required, not desired, treatment.)

  1. The ambulance must have the necessary equipment and supplies to address the needs of the member;
  2. The member's condition must be such that any form of transportation other than by ambulance would be medically contraindicated;
  3. The member's condition is such that the time needed to transport by land poses a threat to the member's survival or seriously endangers the member's health; or the member's location is such that accessibility is only feasible by air or water transportation;
  4. The member is transported to the nearest hospital with appropriate facilities for treatment;
  5. There is a medical condition that is life threatening or first responders deem to be life threatening, including, but not limited to, ONE of the following:

Water or air ambulance transportation (fixed wing or rotary) to transport a member from one acute care hospital to another meets the definition of medical necessity when ALL of the following are met:

(Refer to member contract first; most require transport to the nearest facility that can provide required, not desired, treatment.)

Water or air ambulance transportation (fixed wing or rotary) for a deceased member meets the definition of medical necessity when ALL of the following criteria are met:

(Refer to member contract first; most require transport to the nearest facility that can provide required, not desired, treatment.)

NOTE: When air ambulance service does not meet the requirements for air ambulance, but does meet the requirements for ground ambulance service, reimbursement is based on the allowance for ground ambulance service, unless the fare for air ambulance is less.

Ambulance transportation of a newborn (birth thru 28 days) to or from the nearest available facility, appropriately staffed and equipped to treat the newborn's condition, meets the definition of medical necessity when prescribed by the attending physician and is certified as necessary for the health and safety of the newborn. Ambulance transportation of a newborn may be indicated by the use of a ground or air ambulance.

Ambulance transportation of a deceased member does not meet the definition of medical necessity if the member is legally pronounced dead before the ambulance was called. The services are considered eligible for coverage if the member is legally pronounced dead after the ambulance was called, but before pickup, or en route to the hospital.

Reimbursement is based on the allowance for:

Ground ambulance services for involuntary transport to a psychiatric facility may be eligible for coverage when the transport is:

Ambulance Services that do not meet the definition of medical necessity include the following:

NOTE: Ambulance response and treatment services provided by the ambulance personnel, but the member does not require transportation to a hospital, may be considered eligible for coverage in some situations. Examples include, but are not limited to the following:

The following ambulance services are not eligible for coverage:

BILLING/CODING INFORMATION:

The following codes may be used to describe ambulance services:

CPT Coding:

99466

Critical care services delivered by a physician, face-to-face, during an inter-facility transport of critically ill or critically injured pediatric patient, 24 months of age or younger; first 30 – 74 minutes of hands-on care during transport.

99467

Critical care services delivered by a physician, face-to-face, during an inter-facility transport of critically ill or critically injured pediatric patient, 24 months of age or younger; each additional 30 minutes (List separately in addition to code for primary service).

HCPCS Coding:

A0021

Ambulance service, outside state per mile, transport (Medicaid only) (non-covered)

A0080

Non-emergency transportation: per mile – vehicle provided by volunteer (individual or organization), with no vested interest (non-covered)

A0090

Non-emergency transportation: per mile – vehicle provided by individual (family member, self, neighbor) with vested interest (non-covered)

A0100

Non-emergency transportation: taxi (non-covered)

A0110

Non-emergency transportation and bus, intra- or interstate carrier (non-covered)

A0120

Non-emergency transportation mini-bus, mountain area transports, or other transportation systems (non-covered)

A0130

Non-emergency transportation: wheelchair van (non-covered)

A0140

Non-emergency transportation and air travel (private or commercial), intra- or interstate (non-covered)

A0160

Non-emergency transportation: per mile – case worker or social worker (non-covered)

A0170

Transportation: ancillary: parking fees, tolls, other (non-covered)

A0180

Non-emergency transportation: ancillary: lodging – recipient (non-covered)

A0190

Non-emergency transportation: ancillary: meals – recipient (non-covered)

A0200

Non-emergency transportation: ancillary: lodging – escort (non-covered)

A0210

Non-emergency transportation: ancillary: meals – escort (non-covered)

A0225

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

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 not 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

A0420

Ambulance waiting time (ALS or BLS), one-half (1/2) hour increments (see Waiting Time Table in the Reimbursement section of this policy)

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 wing); (requires medical review)

A0425

Ground mileage, per statute mile

A0426

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

A0427

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

A0428

Ambulance service, basic life support, non-emergency transport (BLS)

A0429

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

A0430

Ambulance service, conventional air services, transport, one way (fixed wing)

A0431

Ambulance service, conventional air services, transport, one way (rotary wing)

A0432

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

A0433

Advanced life support, level 2 (ALS 2)

A0434

Specialty care transport (SCT)

A0435

Fixed wing air mileage, per statute mile

A0436

Rotary wing air mileage, per statute mile

A0888

Non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) (non-covered)

A0998

Ambulance response and treatment, no transport (non-covered)

A0999

Unlisted ambulance service

S0207

Paramedic intercept, non-hospital-based ALS service (non-voluntary), non-transport (non-covered)

S0208

Paramedic intercept, hospital-based ALS service (non-voluntary), non-transport (non-covered)

S0209

Wheelchair van, mileage, per mile (non-covered)

S0215

Non-emergency transportation; mileage, per mile (non-covered)

S9960

Ambulance service, conventional air services, nonemergency transport, one way (fixed wing) (non-covered)

S9961

Ambulance service, conventional air services, nonemergency transport, one way (rotary wing) (non-covered)

LOINC Codes:

The following information may be required documentation to support medical necessity: Physician history and physical, initial assessment, procedure note, visit note.

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Ambulance transport, description of services performed to support level of service

52019-7

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Ambulance transport, distance traveled length

15510-1

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Ambulance transport, medical reason for transport

15515-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

REIMBURSEMENT INFORMATION:

Reimbursement for waiting time is considered incidental to other ambulance services provided on the same date of service and is not eligible for a separate allowance.

Mileage is reimbursed in addition to the ambulance transportation.

Reimbursement for ambulance mileage is based on loaded transport (i.e., total miles from the point where the patient was picked up to the patient’s destination).

Air ambulance mileage is reimbursed according to the actual miles flown with patient onboard and is expressed in statute miles rather than nautical miles.

Reimbursement for disposable and non-disposable supplies (including, but not limited to oxygen, inflatable leg and arm splints, backboards, and neck boards/collars) and other services (including, but not limited to EKGs, drugs, extra attendants) is included in the allowance for the ambulance transportation.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following were reviewed on the last guideline reviewed date and are located at cms.gov:

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Non-Emergency Ground Ambulance Services (L33383) located at fcso.com.

DEFINITIONS:

Ambulance transportation categories:

Basic Life Support (BLS): when medically necessary, the provision of BLS services as defined in the National EMS Education and Practice Blueprint for the EMT – Basic, including the establishment of a peripheral intravenous (IV) line. BLS provides techniques and skills included in an emergency medical technician (EMT) basic training course to individuals as they are transported to the nearest hospital.

Basic Life Support (BLS) – emergency: when medically necessary, the provision of BLS services, as specified above, in the context of an emergency response (defined below).

Advanced Life Support, level 1 (ALS1): when medically necessary, the provision of an assessment by an Advanced Life Support (ALS) provider or supplier or the provision of one or more ALS interventions. An ALS provider/supplier is defined as a provider trained to the level of the EMT-Intermediate or Paramedic as defined in the National EMS Education and Practice Blueprint. An ALS intervention is defined as a procedure beyond the scope of an AMT-Basic as defined in the National EMS Education and Practice Blueprint.

Advanced Life Support, level 1 (ALS1) – emergency: when medically necessary, the provision of ALS1 services, as specified above, in the context of an emergency response. An emergency response is one that, at the time the ambulance supplier is called, is provided after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the beneficiary’s health in serious jeopardy; in impairment to bodily functions; or in serious dysfunction to any bodily organ or part.

Advanced Life Support, level 2 (ALS2): when medically necessary, the administration of three or more different medications and the provision of at least one of the following ALS procedures:

Specialty Care Transport (SCT): when medically necessary, for a critically injured or ill beneficiary, a level of inter-facility service provided beyond the scope of the paramedic defined in the National EMS Education and Practice Blueprint. This is necessary when a beneficiary’s condition requires ongoing care that must be provided by one or more health professionals in an appropriate specialty area, e.g., nursing, medicine, respiratory care, cardiovascular care, or a paramedic with additional training.

Advanced Life Support (ALS): ALS provides sophisticated medical care, such as cardiac monitoring, defibrillation, management of pediatric and obstetrical emergencies, and stabilization of individuals in critical or life threatening conditions as they are transported to the nearest hospital. The ALS ambulatory emergency medical technicians receive medical directions via radio contact with a hospital-based physician.

Air Ambulance: a helicopter or a fixed wing aircraft used for transporting individuals with life-threatening injuries or conditions for rapid transport to the nearest medical/trauma center by critical care personnel.

Emergency Response: a response that, at the time the ambulance is called, is provided after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the patient’s health in serious jeopardy; in impairment to bodily functions; or in serious dysfunction to any bodily organ or part.

Emergency Water Transport: emergency water transportation provided by a specially designed marine ambulance for over water transport.

Paramedic Intercept (PI): Paramedic intercept services are ALS services provided by an entity that does not provide the ambulance transport.

Statute mile: a unit of distance equal to 1.609 km, 5280 ft. or 0.869 nmi (nautical miles).

RELATED GUIDELINES:

Oxygen, 09-E0400

OTHER:

None applicable.

REFERENCES:

  1. American College of Emergency Physicians. Air Ambulance Medical Transport Advertising and Marketing, (2008).
  2. American College of Emergency Physicians. Alternate Ambulance Transportation and Destination, (2001).
  3. American College of Emergency Physicians. Appropriate Utilization of Air Medical Transport in the Out-Of-Hospital Setting, 2008; accessed at acep.org 04/15/16.
  4. American College of Emergency Physicians. Emergency Ambulance Destination, (2006).
  5. American College of Emergency Physicians. Equipment for Ambulances. Equipment for Ambulances, (2006).
  6. American College of Emergency Physicians. Equipment for Ambulances, (2007).
  7. American College of Emergency Physicians. Guidelines for Ambulance Diversion (1999, reaffirmed 2012); accessed at acep.org 04/15/16.
  8. American College of Emergency Physicians. Medical Direction for Staffing of Ambulances, (2005).
  9. American College of Emergency Physicians. Patient Non-Transport, (2000).
  10. American College of Emergency Physicians/National Association of EMS Physicians. Alternate Ambulance Transportation and Destination (2001; reaffirmed 2008); accessed at acep.org 04/15/16.
  11. Blue Cross Blue Shield Association Medical Policy – Ambulance and Medical Transport Services, archived 02/10.
  12. Centers for Medicare and Medicaid Services (CMS), Medicare Claims Processing Manual, Chapter 15 – Ambulance, rev. 10/23/15; accessed at cms.gov 04/15/16.
  13. Centers for Medicare and Medicaid Services (CMS), Medicare Benefit Policy Manual, Chapter 10, Ambulance Services, rev. 07/11/14; accessed at cms.gov/manuals 04/15/16.
  14. First Coast Service Options, Inc (FCSO), Non- Emergency Ground Ambulance Services (L33383), 10/01/15.
  15. Floccare DJ,, Stuhlmiller Df, Braithwaite SA, et al. Appropriate and safe utilization of helicopter emergency medical services: a joint position statement with resource document. Prehosp Emerg Care. 2013; 17(4):521–525.
  16. Florida Medicare Part B Medical Policy # A0426 – Ground Ambulance Services, (retired 04/01/05).
  17. Florida Medicare Part B Medical Policy # A0430 – Air Ambulance Services, (retired 04/01/05).
  18. Medicare Carriers Manual (2120.1-2124.H, 2125, 3102, 5116, 5215).
  19. Medicare Program Memorandum, AB-00-118 (Change Request 1461), (11/30/00).
  20. Medicare Program Memorandum, AB-00-88 (Change Request 1281), (09/18/00).
  21. Medicare Program Memorandum, B-00-09 (Change Request 1065).

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 04/19/16.

GUIDELINE UPDATE INFORMATION:

02/15/02

Medical Coverage Guideline Reformatted.

04/01/02

2nd Quarter HCPCS coding (deletions).

07/01/02

3rd Quarter HCPCS coding additions.

10/01/02

4th Quarter HCPCS coding addition; add clarification statement for ambulance mileage.

01/01/03

HCPCS coding update.

01/01/04

Annual HCPCS coding update; addition of non-covered statement for non-transport paramedic intercept services; revision of coverage statement for supplies.

02/15/04

Reviewed; no changes.

01/01/06

Annual HCPCS coding update: added A0998.

02/15/06

Scheduled review (consensus review); no change in guideline.

04/01/06

2nd Quarter HCPCS coding update: removed Q3019 and Q3020.

09/15/06

Revision consisting of change in reimbursement guidelines for ambulance waiting time; add clarification for reimbursement of oxygen; revise Program Exception information for Medicare Advantage.

01/01/07

Annual HCPCS coding update (A0800 deleted).

09/15/07

Scheduled review; reformatted guideline; updated references.

01/01/09

Annual HCPCS coding update: added 99466, 99467; deleted 99289, 99290.

09/15/09

Scheduled review; no changes to position statement; updated references.

01/01/10

Annual HCPCS coding update: revised descriptors for 99466 and 99467.

02/15/11

Revision: formatting changes.

09/15/11

Revision; formatting changes.

03/15/12

Revisions to Position Statement and Reimbursement information.

01/01/14

Annual HCPCS coding update: added S9960 and S9961. Program Exceptions section updated

05/15/16

Revision; position statement, program exception, and references updated; formatting updates.

04/24/17

Revision; Billing/Coding section.

Date Printed: August 23, 2017: 06:00 AM