01-022 Emergency Ambulance Findings of Medical Review

Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, has conducted post-payment review of claims for Medicare Part B emergency ambulance services billed on dates of service from January 1, 2018 through July 1, 2019. Below are the review results:

Project Number Project Title Error Rate
01-022 Emergency Ambulance 92%

Background

The Office of Inspector General (OIG), under Report A-09-17-03017 external link, dated August 2018, titled “Medicare Made Improper and Potentially Improper Payments for Emergency Ambulance Transports to Destinations Other Than Hospitals or Skilled Nursing Facilities (SNFs)” focused on Calendar Years

(CY) 2014 through 2016 to determine whether Medicare payments to providers for emergency

ambulance transports complied with Federal requirements. The OIG found that Medicare payments to providers for emergency ambulance transports did not comply or potentially did not comply with Federal requirements, resulting in potentially improper payments. The report indicated that potentially improper payments were made for transports that may not have met Medicare coverage requirements or might have been paid by Medicare as nonemergency ambulance transports. The CMS tasked the SMRC to analyze claims from the OIG and perform medical review to ensure claims met the requirements for emergency ambulance transports.

Reason for Review

In response to the OIG study, the CMS provided the SMRC a file of national provider identifiers (NPI) specifically identified by the OIG while conducting the original study. The SMRC performed medical record review for the specified NPIs to determine if the emergency ambulance transports were reasonable and necessary for the level of service billed in accordance with applicable statutory, regulatory, and sub-regulatory guidance.

Common Reasons for Denial

  • Level of Service
    • The documentation received did not support an emergency level of service was provided. CMS Internet-Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 10, Section 10.2.2 indicates that “payment is made according to the level of medically necessary services actually furnished.” This must be sufficiently documented in the medical records submitted for review.
  • Dispatch Status
    • The documentation submitted did not support the level of service billed. CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 15, Section 20.1.3 relays that “Occasionally, local jurisdictions require the dispatch of an ambulance that is above the level of service that ends up being provided to the Medicare beneficiary. In this, as in most instances, Medicare pays only for the level of service provided, and then only when the service provided is medically necessary.”
  • No Response to the Documentation Request
    • The documentation was not submitted or not submitted timely. CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 requires providers/suppliers to respond to requests for documentation within 45 calendar days of the additional documentation request.
  • Ambulance Modifiers
    • The documentation submitted did not support the modifiers billed on the claim. CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 15, Section 30 (A), “For ambulance service claims, institutional-based providers and suppliers must report an origin and destination modifier for each ambulance trip provided in HCPCS/Rates.”
  • Billed in Error
    • The documentation submitted included information from the provider that the claim was billed in error as an emergent transport. The Social Security Act (SSA), Title XVIII, Section 1833(e) states, “No payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.”

References/Resources

  • Social Security Act (SSA), Title XVIII, §§1833(e). Payment of Benefits
  • SSA, Title XVIII, §§1861(s)(7). Medical and Other Health Services; Ambulance
  • SSA, Title XVIII, §§1862(a)(1)(A). Exclusions from Coverage and Medicare as Secondary Payer
  • SSA, Title XVIII, §§1879(a)(1). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
  • SSA, Title XVIII, §§1893(f)(7)(A)(B)(i-iv). Medicare Integrity Program
  • SSA, Title XVIII, §§1893(h)(4)(B). Medicare Integrity Program
  • 42 Code of Federal Regulations (C.F.R.) §40. Coverage of Ambulance Services
  • 42 C.F.R. §5(a)(6). Basic Conditions
  • 42 C.F.R. §106(c)(1). Criteria for Determining Whether the Hospital Was the Most Accessible
  • 42 C.F.R. §24(c). Condition of Participation: Medicare Record Services
  • CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 10, Sections 10.1-10.3, 20, 30. Ambulance Services
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 20. Services Not Reasonable and Necessary
  • CMS IOM, Publication 100-04, Claims Processing Manual, Chapter 15, Sections 10.3, 10.4, 20, 20.2, 20.5, 30(A). Ambulance
  • CMS IOM, Publication 100-04, Claims Processing Manual, Chapter 30, Section 50.3. Financial Liability Protections
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Sections 3.3.2.1, 3.3.2.4, 3.6.2.2. Verifying Protentional Errors and Taking Corrective Actions
  • Local Coverage Determination (LCD) L34302. Transportation Services. Effective October 1, 2015; Retired February 25, 2018
  • LCD L34549. Ambulance Services. Effective October 1, 2015
  • LCD L35162. Ambulance Services. Effective October 1, 2015
  • LCD L37697. Emergency and Non-Emergency Ground Ambulance Services. Effective date June 28, 2018
  • Local Coverage Article A52588. Billing for Ground Ambulance Services When the Beneficiary is Pronounced Deceased. Effective October 1, 2015
  • Local Coverage Article A52883. Ambulance Billing When Patient Refuses Transport. Effective October 1, 2015; Retired December 6, 2018
  • Local Coverage Article A54574. Ambulance Services (Ground Ambulance). Effective October 1, 2015
  • Local Coverage Article A55096. Reminder Regarding Ambulance Transports-dual diagnoses (Provider Bulletin). Effective June 9, 2016

Last Updated Mar 17, 2020