- 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
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- 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
According to the Centers for Medicare & Medicaid Services’ (CMS) Internet Only Manual (IOM) 100-02, Medicare Benefit Policy Manual, Chapter 10, Ambulance Services; (400 KB)
10.2 - Necessity and Reasonableness (Rev. 1, 10-01-03)
B3-2120.2, A3-3114.B, HO-236.2
To be covered, ambulance services must be medically necessary and reasonable.
10.2.1 - Necessity for the Service (Rev. 1, 10-01-03)
B3-2120.2.A, A3-3114.B, HO-236.2
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 A/B MAC (A) or (B). 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.
In addition, the reason for the ambulance transport must be medically necessary. That is, the transport must be to obtain a Medicare covered service, or to return from such a service.
10.2.3 - Medicare Policy Concerning Bed-Confinement (Rev. 1, 10-01-03)
As stated above, medical necessity is established when the patient’s condition is such that the use of any other method of transportation is contraindicated. A/B MACs (A) and (B) may presume this requirement is met under certain circumstances, including when the beneficiary was bed-confined before and after the ambulance trip (see Section 20 for the complete list of circumstances).
A beneficiary is bed-confined if he/she is:
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- Unable to get up from bed without assistance;
- Unable to ambulate; and
- Unable to sit in a chair or wheelchair.
The term "bed confined" is not synonymous with "bed rest" or "nonambulatory". Bed-confinement, by itself, is neither sufficient nor is it necessary to determine the coverage for Medicare ambulance benefits. It is simply one element of the beneficiary's condition that may be taken into account in the A/B MAC (A)’s or (B)’s determination of whether means of transport other than an ambulance were contraindicated.
Given the above information, it is important the medical necessity of the ambulance transportation be spelled out in as much detail as possible. This can be done by utilizing the appropriate ICD-10 diagnosis codes that describe the patient’s condition. Additionally, utilization of the Extra Narrative Field (Item 19 of the CMS-1500 Claim Form or Loop/segment 5300/5400 of EMC claims). This field allows you the opportunity to provide details on the patient’s condition.
Section 10.2.3 “Medicare Policy Concerning Bed-Confinement” (as indicated above) explains that the term “bed confined” is not sufficient to determine medical necessity. You should indicate why the patient is bed confined and cannot sit in a wheelchair, cannot ambulate on their own, or are unable to get up from a bed without assistance.
Lastly, you should utilize the Transportation Indicator codes, if applicable. These codes help to communicate why it was necessary for the patient to be transported in a particular way or circumstance. The codes are also placed in the Extra Narrative field of the claim form.
By following these simple steps, your claims explain to Medicare the medical necessity of the ambulance transportation and should help to avoid the Medicare appeal process altogether.
Reviewed 10/23/2023