National Government Services' Part B Medical Review Department analyzes national and local data to identify possible improper payment for Medicare services. MR will be conducting a service specific review of CPT codes A0425-A0428 (Ambulance Transport).

In an effort to reduce the Part B CERT error rate, the MR Department will be conducting a service specific post payment review of the services mentioned. The primary focus of these audits will be to determine whether the medical necessity of the services billed is at the correct code per Medicare guidelines.

NGS has randomly selected claims billed for CPT A0425-A0428 for post payment review in Jurisdiction 6 for Part B providers in the states of Illinois, Minnesota and Wisconsin.

• A0425 Ground mileage, per statue mile
• A0426 Ambulance service, advanced life support, non-emergency transport (ALS)
• A0428 Ambulance service, basic life support, non-emergent transport (BLS)

If a claim is selected for review, the provider will receive an ADR letter. Providers with claims selected for review must submit the requested documentation within 45 days of the date of the ADR letter. Failure to submit the requested documentation in a timely manner may result in a denial of the billed services.

Medicare covers ambulance transports when a beneficiary’s medical condition at the time of transport is such that other means of transportation would endanger the beneficiary’s health. 

Ambulance Requirements

• The transport must be to receive a medically necessary Medicare service or to return from such a service.
• Ambulance services are not covered if the beneficiary could be safely transported by other means such as a private vehicle or wheelchair van.
• Medicare only covers ambulance transport to the nearest facility equipped to provide the skilled care required to treat the beneficiary’s condition. If a bed is not available at the nearest appropriate facility, the provider must provide documentation that a bed was not available at the time the transport was provided. 
• The signature of the beneficiary, or that of his or her representative, is required for the purpose of accepting assignment and submitting a claim to Medicare.
• A run sheet which clearly documents the beneficiary’s name and date of service, name and credentials of crew members, monitoring required during transport, and mileage associated with transport which includes the point of pick up and destination (place and address) is required for review.
• Documentation should also include a description of the beneficiary’s condition and functional status or physical assessment at time of transport and why other methods of transportation are contraindicated. 

Please ensure all documentation to support medical necessity of the billed service is submitted for review. 

Related Content

• Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 10, Section 10.2.2 – Reasonableness of Ambulance Trip) Section 20.1.2 (Beneficiary Signature Requirements)

• CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 (Signature Requirements)
• MLN Booklet: Medicare Ambulance Transports
• Special Rule for Non-Emergency, Scheduled, Repetitive Ambulance Services - 42 CFR 410.40(d)(2)

Posted 8/12/2020