Background

In an effort to reduce the Part B CERT error rate, the MR Department conducted a service specific post payment review of CPT codes A0425-A0428 (Ambulance Transport). The primary focus of these audits was to determine whether the medical necessity of the services billed was at the correct code per Medicare guidelines.

NGS randomly selected 120 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, nonemergency transport (ALS)
• A0428  Ambulance service, basic life support, nonemergency transport (BLS)

Results

Decision	Number of Claims
Allow	61
Deny	56
Nonresponse Denial	3

 

• 110 claims from Illinois with 59 allowed and 51 denied for a claims error rate of 46%
• One claim from Minnesota was denied for a claims error rate of 100%
• Nine claims from Wisconsin with two allowed and seven denied for a claims error rate of 78%

Key reasons services were denied

• Documentation was insufficient or incomplete
• Documentation did not support medically necessity due to one or more of the following: missing a signed CMN or PCS; evidence that the patient is bed-confined; an injury or illness that prevents the patient from being transported safely by other means; and/or that service could not be rendered at the sending facility
• Failure to respond to the request for documentation

Recommendations

• Send the requested records within the requested time frame to avoid a denial for no documentation
• Familiarize yourself with available Ambulance Transport and Mileage guidelines and other CMS publications listed below
• Share this information with your coding personnel to ensure they are properly billing before sending the claim to Medicare.
• If you feel your application of this code is correct, ensure your documentation supports your usage.

Related Content

• CMS 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 Nonemergency, Scheduled, Repetitive Ambulance Services - 42 CFR 410.40(d)(2)

Posted 1/22/2021