- Ambulance Billing Guide
- Ambulance Duplicate Claim Denials
- Ambulance Transports Included in SNF Consolidated Billing
- Ambulance Physician Certification Statement Guidelines
- Prior Authorization of Repetitive Scheduled Non-Emergent Ambulance Transport
- New York State Ambulance Services in Rural Areas (for JK providers only)
- Coverage of Rural Air Ambulance Services
- Ambulance Transports Excluded from SNF Consolidated Billing
- Ambulance Medical Necessity Reminder for ESRD Patients
- Related Content
- Related Articles
- Claim Denials for Medically Unnecessary Ambulance Transports: Avoiding Reason Code 55B10
- Ambulance Medical Necessity
- Ambulance Rural ZIP Code Search
- Billing for A0426 or A0428
- Medical Necessity of Ambulance Services
- Proper Claim Submission for Repetitive, Scheduled, Non-Emergent Ambulance Transports
- Responsibility of Providing a Properly Executed Physician Certification Statement/Certificate of Medically Necessity
Ambulance Medical Necessity Reminder for ESRD Patients
National Government Services receives a significant amount of dialysis facility ambulance transports that do not meet medical necessity criteria. Documentation must explicitly describe the patient’s condition was such that they could not be transported by any other means.
Although ICD-10-CM codes are not a requirement on ambulance claims, including them does assist in the decision-making process in determining medical necessity. Diagnoses such as depression, weakness, anemia or hypertension do not justify the medical necessity requirement of providing transportation by ambulance. Patients with those symptoms could have been transported in a prone or seated position, resulting in a gurney or wheelchair van transport.
Medical necessity is established when the patient's condition is such that use of any other method of transportation is contraindicated. In any case in which some means of transportation other than an ambulance could be used without endangering the individual's health, whether or not such other transportation is actually available, no payment may be made for ambulance services. In all cases, the appropriate documentation must be kept on file and, upon request, presented to the carrier/intermediary. It is important to note that the presence (or absence) of a physician’s order for a transport by ambulance does not necessarily prove (or disprove) whether the transport was medically necessary. The ambulance service must meet all program coverage criteria in order for payment to be made.
National Government Services will reimburse ambulance transports for an ESRD patient for renal dialysis from his home/residence/custodial care facility to a hospital-based or nonhospital-based facility (free-standing dialysis) provided the service meets the medical necessity requirements.
Please ensure the ambulance service is medically necessary and no other means of transportation could be provided without endangering the patient’s health.
Reviewed 10/23/2023