WPS Medicare Provider Part B

Policy Regarding the Implementation of the Ambulance Fee Schedule

During the implementation of the Ambulance Fee Schedule, issues concerning the interpretation of Medicare policy have arisen which require clarification. This article provides additional guidance on these issues, and supplements previously issued instructions regarding the implementation of the Ambulance Fee Schedule.

Please note that this article is a reminder of current Medicare policy regarding the Ambulance Fee Schedule, which was implemented on April 1, 2002. It is not intended to replace previously issued instructions and does not encompass all issues that have been addressed to date.

The following clarifications reflect Medicare's policy regarding the implementation of the Ambulance Fee Schedule.

Ambulance Fee Schedule amounts may not be appealed.

Inherent Reasonable (IR) Adjustments:
1. Prospective payment systems, including the Ambulance Fee Schedule, are exempt from IR. Therefore, IR applies only to the reasonable charge portion of the blended payment for ambulance services during the transition period.
2. The criteria for applying IR, specified in the final rule, includes a threshold of 15 percent that must be met before IR adjustments may be made. That is, if a payment allowance is determined to be either deficient or excessive by an amount that is less than 15 percent, then no IR adjustment may be made.
3. CMS has not yet developed contractor processes for applying IR. Until these processes are in place, contractors may not make any IR adjustments.

Suppliers may not change their billing methods during the transition period, April 1, 2002 through December 31, 2005.

Advance Beneficiary Notices (ABNs)
1. Providers/suppliers may not routinely issue ABNs to beneficiaries for ambulance services.
2. ABNs should be issued to beneficiaries for non-emergency transports in the following situations:
  1. A transport by air ambulance when the transporting entity has a reasonable basis to believe that the transport can be done safely and effectively by ground ambulance transportation.
  2. A level of care downgrade, e.g., from ALS-2 to ALS-1, or from ALS to BLS, when the transport at the lower level of care is a covered transport.
3. ABNs should not be issued, but NEMBs may be issued, to beneficiaries in the following situations to beneficiaries in the following situations:
  1. Any denial where the patient could be transported safely by other means (these are denials under §1861(s)(7) of the Act.
  2. Any denial that is based on not meeting an origin or destination requirement (these denials are inconsistent with 42 CFR §410.40 and generally also constitute §1861(s)(7) denials).
  3. A denial for mileage that is beyond the nearest appropriate facility (for the same reason as "b" above).
  4. A denial where the PCS or accepted alternative (e.g., certified mail) is not obtained (these denials are inconsistent with 42 CFR §410.40 and generally also constitute §1861(s)(7) denials).
  5. A convenience discharge, e.g., where the patient is an inpatient at one hospital that can care for their needs, but wants to be transferred to a second hospital to be closer to family (these denials are inconsistent with 42 CFR §410.40 and generally also constitute §1861(s)(7) denials).
4. ABNs should not be issued, but NEMBs may be issued, to beneficiaries when the point of pickup of the ambulance transport is outside of the United States, including a point of pickup outside of the U.S. territories.
5. Providers/suppliers should issue ABNs to beneficiaries for non-emergency international flights when the provider/supplier has a reasonable basis to believe that the domestic portion of the flight would not be covered because it is not reasonable and necessary under Medicare rules.

Physician Certification Statement (PCS) Requirements:
1. Providers and suppliers may use computer-generated PCS forms, as well as computer-generated physician signatures to meet the PCS requirements of 42 CFR §410.40(d).
2. When a PCS cannot be obtained in accordance with 42 CFR §410.40(d)(3)(iv), provider/supplier's may use the following items as evidence of the attempt to obtain the PCS:
  1. An U.S. Postal Service Certified Mail Return Receipt, or other similar commercial service demonstrating delivery of the letter.
  2. An U.S. Postal Service Certificate of Mailing (Form 3817).

Medicare allows payment for all necessary mileage from the point of pickup, including where applicable: ramp to taxiway, taxiway to runway, takeoff run, air miles, roll out upon landing and taxiing after landing.

Mandated Advanced Life Support (ALS) Interventions:
1. During the transition period, in areas where ALS-only response is mandated, Medicare allows the ALS-Level payment for emergency and non-emergency transports when an ALS vehicle is used but no ALS service is furnished.
2. The use of an ALS vehicle to furnish only BLS-level services would most often occur in local jurisdictions that mandate all ambulances to be ALS.
3. A contract with a government agency to furnish general ambulance services in one or more specific political jurisdictions, the terms of which require an ALS-only response for all requests for service may qualify as a "mandated ALS response."
4. WPS had discretion in determining whether, in the totality of the circumstances, any particular contractual requirement is tantamount to a "mandated ALS response". However, a contractual requirement for ALS-only service in a contract either with a private entity, or with a government agency for less than general, jurisdiction-wide ambulance services, would not qualify as a "mandated ALS response."
5. The ALS vehicle must meet the crew requirements specified in 42 CFR §410.41.
6. The policy of paying according to the medically necessary services actually furnished continues under the Ambulance Fee Schedule. That is, payment is based on the level of service provided, not on the vehicle used. Even if a local government requires an ALS response to all calls, Medicare pays only for the level of service provided and then only when the service is medically necessary.
7. The temporary HCPCS established for billing these services, Q3019 and Q3020, are effective only during the transition period.
8. In addition, if an ALS response was made because no BLS-level service was available, then the Q3019 and Q3020 may be used. Medicare will watch for a pattern of abuse.

It is improper to bill Medicare for physician services furnished as part of an ambulance transport when these services are covered under the Medicare ambulance benefit. The costs of such services are bundled into the base rate amount for the ambulance transport.

Page Last Updated: Tuesday, 04-Dec-2007 13:19:31 CST