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Use of Medical Condition Codes on Ambulance Claims

Ambulance suppliers may voluntarily submit medical condition codes on claims; therefore, submission of medical condition code (s) alone on a claim will not determine reimbursement for the ambulance service. The detailed transport information submitted on the claim, as well as any documentation on the ambulance transport report, will determine whether the ambulance transport meets Medicare coverage guidelines.

Emergency Medical Technicians (EMT) cannot diagnose, but they can code what they observed based on the Medical Condition Code List. The medical condition codes included on the Medical Condition Code listing may be used. Suppliers must use these codes accurately. Place them in Box 19 of the CMS 1500 claim form or the electronic equivalent. In addition to using these codes, the supplier is still required to completely document all services provided for each trip on every claim. There are also transportation indicators that may be used to indicate the reason for the transport. These must be placed in Item 19 of the CMS 1500 claim form or in the narrative field of the electronic equivalent. Please see the Ambulance Medical Fee Schedule-Medical Conditions List and Instructions found in the CMS Internet Only Manual (IOM), Publication 100-04, Chapter 15, Section 40.

Incorrect use of the Medical Condition Codes can result in claim denials.

If you choose to use Medical Condition codes, be sure to:

  • Submit medical conditions codes exactly as they are on the list, i.e. do not submit an invalid or truncated code.
  • Always include the details of the trip including patient's medical condition and all services provided. Submit them in Item 19 of the claim form.
  • The transportation indicators must also be submitted in item 19.

More information about the Ambulance Fee Schedule Medical Condition List is found in the CMS Internet Only Manual (IOM),Publication 100-4, Medicare Claims Processing Manual, Chapter 15, section 30.3.

Note: Diagnosis (ICD-9) codes are updated every year in October.

There is currently no Local Coverage Determination (LCD) on ambulance. WPS processes claims based on the Medicare coverage guidelines published in the CMS Internet Only Manuals (IOM). See website references below to locate the ambulance regulations in the CMS IOM manuals.

CMS Internet Only Manual (IOM),Publication 100-2, Medicare Benefit Policy Manual, Chapter 30, 30.1.1 and 30.1.2.

CMS Internet Only Manual (IOM),Publication 100-4, Medicare Claims Processing Manual, Chapter 15, 10.3 for additional definitions.

Use of Diagnosis (ICD-9) codes on ambulance claims

Diagnosis ICD-9 codes are not required on ambulance claims until you begin to submit in the 5010 format. The 5010 format is required after January 1, 2012. Medical necessity for ambulance transports is based on the information placed in item 19 of the CMS-1500 claim form or the electronic equivalent. All ambulance claims must include this information.

If providers choose to submit ICD-9 or a condition code on ambulance claims, they must bill valid ICD-9 or condition codes, or their services will be denied. Examples would include diagnosis codes that were mistyped or truncated. Providers must also correctly link one diagnosis submitted in item 21 using an indicator to that diagnosis in item 24e.

ICD-9 codes will be used until the implementation of ICD-10 October 1, 2013. More information will be published later.