01-022 Emergency Ambulance Notification of Medical Review

Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare & Medicaid Services (CMS), is conducting post-payment review of claims for Medicare Part B emergency ambulance services billed on dates of service from January 1, 2018, through May 31, 2019. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request letter, and resources providers 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)” 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 has 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 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 sub-regulatory 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, §§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 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 Jul 25, 2019