Use of Medical Condition Codes on Ambulance Claims
Ambulance suppliers may voluntarily submit medical condition codes on claims. 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 Fee Schedule-Medical Conditions List found at:
http://www.cms.hhs.gov/transmittals/downloads/R1185CP.pdf 
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 Medicare Claims Processing Manual, 100-4, Chapter 15, section 30.3 of the CMS Internet Only Manual (IOM) at:
http://www.cms.hhs.gov/manuals/downloads/clm104c15.pdf
Note: Diagnosis (ICD-9) codes are updated every year in October.
The above information is effective for dates of service provided on or after the Medicare Administrative Contractor (MAC) transition dates:
- Iowa- February 1, 2008, transition date to the MAC.
- Nebraska, Kansas, Western Missouri- March 1, 2008 transition date to the MAC.
- Eastern Missouri- June 1, 2008 transition date to the MAC.
For services provided on or after the MAC transition dates, WPS will process claims based on the Medicare coverage guidelines published in the CMS Internet Only Manuals (IOM). See the Website references below to locate the ambulance regulations in the CMS IOM manuals.
For dates of service prior to the MAC transition date:
Iowa
Since there is no Local Coverage Decision (LCD) on the CMS Website, for dates of service prior to February 1, 2008, WPS will process claims based on the Medicare coverage guidelines published in the CMS Internet Only Manuals (IOM). See the Website references below to locate the ambulance regulations in the CMS IOM manuals.
Nebraska, Kansas, Western Missouri
For dates of service prior to March 1, 2008 WPS will process claims based on processing guidelines from the previous contractor (Wheatlands). Refer to Local Coverage Decision (LCD) - L22201- Ambulance policy in effect until February 29, 2008.
Eastern Missouri
Since there is no Local Coverage Decision (LCD) on the CMS Website, for dates of service prior to June 1, 2008, WPS will process claims based on the Medicare coverage guidelines published in the CMS Internet Only Manuals (IOM). See the Website references below to locate the ambulance regulations in the CMS IOM manuals.
CMS Internet Only Manual, 100-2, Medicare Benefit Policy Manual, Chapter 30, § 30.1.1 and 30.1.2 at: http://www.cms.hhs.gov/manuals/Downloads/bp102c10.pdf
CMS Internet Only Manual, 100-4, Medicare Claims Processing Manual, Chapter 15, § 10.3 for additional definitions at: http://www.cms.hhs.gov/manuals/downloads/clm104c15.pdf
Use of Diagnosis (ICD-9) codes on ambulance claims
Diagnosis ICD-9 codes are not required on ambulance claims. WPS does not recommend use of diagnosis (ICD-9) codes on ambulance claims. 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 codes on ambulance claims, they must bill valid ICD-9 codes or their services will be denied. Examples would include diagnosis codes that were mis-typed or truncated. Providers must also correctly link one diagnosis submitted in item 21 using an indicator to that diagnosis in item 24e.
Page Last Updated: Monday, 16-Jun-2008 12:40:49 CDT
