01-012 Emergency Ambulance Notification of Medical Review

Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of claims for Medicare Part B emergency ambulance services billed on dates of service from January 1, 2016, through December 31, 2016. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.

Background

The Office of Inspector General (OIG), under Report A-09-17-03017, 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)” noted that Medicare improperly paid $2.7 million during the first half of calendar year (CY) 2012 for emergency ambulance transports that providers indicated were to non-hospital destinations. The OIG activities focused on Medicare payments for emergency ambulance transports to destinations other than hospitals or SNFs for CYs 2014 through 2016. The objective of the report was to determine whether Medicare payments to providers for emergency ambulance transports complied with Federal requirements.

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 will perform 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 subregulatory guidance.

Claim Sample Detail

HCPCS
  • A0425: Ground Mileage, per statute mile
  • A0427: Ambulance service, ALS, emergency transport, level 1
  • A0429: Ambulance service, BLS, emergency transport

Access related project details below.

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review. Documentation requested has been made specific to assist the provider in collecting and submitting pertinent information to decrease provider burden.

  1. Ambulance dispatch report/trip log to support the beneficiary’s medical condition for the billed service and to provide documentation of the level of care provide by ambulance personnel including, but not limited to:
    1. Documentation to support the emergent transport of the beneficiary
    2. Reason for the transport
    3. Assessment and clinical evaluations which describe the beneficiary’s condition and functional status at the time of transfer
    4. Description of monitoring and treatments required and performed/administered
    5. Point of pick up/destination (place and complete address)
    6. Identification of crew members and credentials
    7. Documentation supporting the number of loaded miles billed
    8. Documentation to support that the beneficiary was transported to the nearest appropriate facility
    9. Documentation to support assignment of benefits including beneficiary signature or signature of representative
  2. Valid electronic or handwritten signatures, when applicable
  3. Copies of any patient notices given (e.g., Advance Beneficiary Notice of Noncoverage), if applicable

References/Resources

  • Social Security Act (SSA) Title XVIII, Section §1833(e). Payment of Benefits
  • Social Security Act (SSA) Title XVIII, Section §1861(s)(7). Medical and Other Health Services; Ambulance
  • Social Security Act (SSA) Title XVIII, Sections §1862(a)(1)(A). Exclusions from Coverage and Medicare as Secondary Payer
  • Social Security Act (SSA) Title XVIII, Sections §1879(879(a)(1), (g)(2). Limitation on Liability of Beneficiary where Medicare Claims are Disallowed
  • Code of Federal Regulations Title 42, Section 410.40(a-f). Coverage of Ambulance Services
  • Medicare General Information, Medicare Benefit Policy Manual, Publication 100-02, Chapter 10. Ambulance Service
  • Medicare Claims Processing Manual, Publication 100-04, Chapter 15
  • Local Coverage Determination (LCD) L35162. Ambulance Services. Effective 10/01/2015
  • Local Coverage Determination (LCD) L34302. Transportation Services: Ambulance. Effective 10/01/2015
  • Local Coverage Determination (LCD) L34549. Ambulance Services. Effective 10/01/2015
  • Local Coverage Article (LCA) A52883. Ambulance Billing When Patient Refuses Transport. Effective 10/01/2015
  • Local Coverage Article (LCA) A54574: Ambulance Services (Ground Ambulance). Effective 10/01/2015
  • Local Coverage Article (LCA) A55096: Reminder Regarding Ambulance Transports- Dual Diagnoses (Provider Bulletin). Effective 6/9/2016
  • Local Coverage Article (LCA) A52588: Billing for Ground Ambulance Services When the Beneficiary is Pronounced Deceased. Effective 10/01/2015

 

Last Updated Feb 20, 2019