Medical Necessity

Coverage Indications, Limitations, and/or Medical Necessity

The Medicare payment benefit for AMBULANCE services is very restricted. AMBULANCE suppliers must understand the benefit and refrain from seeking Medicare payment for services that do not conform to the limited benefit requirements as stated in regulation. Physicians and others who order and certify medical necessity of AMBULANCE services must also understand and abide by the limitations of Medicare coverage of AMBULANCE services.

Medical Necessity

AMBULANCE transportation is covered when the patient’s condition requires the vehicle itself or the specialized services of the trained AMBULANCE personnel. A requirement of coverage is that the needed services of the AMBULANCE personnel were provided and clear clinical documentation validates their medical need and their provision in the record of the service (usually the trip/run sheet).

Emergency AMBULANCE Services

Emergency AMBULANCE services are a covered benefit when the services meet the medical necessity requirements as outlined in the CMS manuals and Federal Register sections listed in the CMS National Coverage Policy section above. Please refer to the listed references for full coverage details.

The patient’s condition is an emergency that renders the patient unable to be safely transported to the hospital in a moving vehicle (other than an AMBULANCE) for the amount of time required to complete the transport. Emergency AMBULANCE services are services provided after the sudden onset of a medical condition. For the purposes of this LCD, acute signs or symptoms of sufficient severity must manifest the emergency medical condition such that the absence of immediate medical attention could reasonably be expected to result in one or more of the following:

  • Place the patient’s health in serious jeopardy.
  • Cause serious impairment to bodily functions.
  • Cause serious dysfunction of any body organ or part.

Non-Emergency AMBULANCE Service

The patient being transported has, at the time of ground transport, a condition such that all other methods of ground transportation are contraindicated.

The patient is before, during and after transportation, bed-confined. For the purposes of this LCD, “bed-confined” means the patient must meet all of the following three criteria:

Unable to get up from bed without assistance.

Unable to ambulate.

Unable to sit in a chair (including a wheelchair).

CMS recognizes that it is standard and accepted medical practice in both hospitals and nursing homes to take steps to ensure that beneficiaries are up and out of bed as often as their condition permits. Such beneficiaries are not bed-confined.

Non-emergency AMBULANCE services may be those that are scheduled in advance – scheduled services being either repetitive or non-repetitive.

Refer to CFR, Title 42, Chapter IV, Subchapter B, Part 410, Subpart B, Section 410.40 for full details regarding non-emergency AMBULANCE services.

One condition of coverage is that the beneficiary be bed-confined. Please refer to CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 10, Section 10.2.3 for additional information on bed-confinement.

Statements about the patient’s bed-confined status must be validated in the record with contemporaneous objective observations and findings as to the patient’s functional physical or mental limitations that have rendered him bed-bound.

AMBULANCE transportation for services excluded from SNF consolidated billing must meet the criteria as reasonable and necessary as indicated in CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 20.3.1.

Refer to CMS IOM Publications 100-04, Medicare Claims Processing Manual, Chapter 15, Section 10.4 and 100-02, Medicare Benefit Policy Manual, Chapter 10, Section 10.3.3 for information on AMBULANCE transport for a beneficiary who is a SNF resident in a stay not covered by Part A.

Special Note Regarding Patients Transported To and From Hemodialysis Centers:

Only a fraction (approximately 10 percent) of End Stage Renal Disease (ESRD) patients on chronic hemodialysis requires AMBULANCE transportation to and from hemodialysis sessions. The presence of ESRD and the requirement for hemodialysis do not alone qualify a patient for AMBULANCE transportation. Medicare payment requires patients transported to and from hemodialysis centers to have other conditions such as those described in the tables below and requires adequate documentation of those conditions in the AMBULANCE supplier’s trip/run sheet and in the medical records of other providers involved with the patient’s care.

Physician Certification Statement (PCS)

For scheduled and non-scheduled non-emergency AMBULANCE transports, providers of AMBULANCE transportation must obtain a written statement (PCS) from the patient’s attending physician certifying that medical necessity requirements for AMBULANCE transportation are met. Refer to CFR, Title 42, Chapter IV, Subchapter B, Part 410, Subpart B, Section 410.40 for full details regarding PCS requirements.

Limitations

Medicare does not cover the following services:

  • Transportation via Mobile Intensive Care Unit (MICU) (if billed under Medicare Part A).
  • Medicare does not provide payment for “AMBULANCE response and treatment, no transport.”

Non-emergency AMBULANCE transportation is not covered for patients who are restricted to bed rest by a physician’s instructions but who do not meet the criteria as outlined in the manuals.

Per regulation, AMBULANCE services are not based only on the diagnosis. In addition to the diagnosis meeting medical necessity the requirement that any other means of transportation is contraindicated must also be met. Therefore, in order to support medical necessity, all AMBULANCE transports require dual diagnosis codes. Billing and Coding: AMBULANCE Services (Ground AMBULANCE), A54574 provides a list of suggested primary diagnosis codes as well as the required dual diagnosis codes. Please refer to the billing and coding article for proper billing and coding instructions.

(A54574) In addition, a secondary diagnosis, from the list below, must be reported based on the patient’s need for the service. Do not report a secondary diagnosis code from the list below if it does not apply.

ICD-10 Code

Z74.01 Bed confinement status

Z74.3* Need for continuous supervision

Z78.1* Physical restraint status

Z99.89* Dependence on other enabling machines and devices

*Note: Use code Z74.3 to denote cardiac/hemodynamic monitoring required en route.
*Note: Use code Z78.1 to denote patient safety: danger to self and others – monitoring other and unspecified reactive psychosis.
*Note: Use code Z99.89 to denote the need for continuous IV fluid(s), “active airway management”, or the need for multiple machines/devices.

Non-emergency AMBULANCE transportation is not covered if transportation is provided for the patient who is transported to receive a service that could have been safely and effectively provided in the point of origin (residence, Skilled Nursing Facility [SNF], hospital, etc.). Such transportation is not covered even if the patient could only have gone for the service by AMBULANCE.

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