Widespread Probe Review Results of HCPCS A0426-Non Emergency ALS Transport- Edit Number 5140V

Alabama Medical Review Part A has recently completed the prepay probe review of HCPCS A0426-Non Emergency ALS Transport, Edit Number 5140V.  The claims were randomly selected across the provider community billing this service that met the parameters of the edit. The review results are as follows:

Providers Reviewed:   6         
Claims Reviewed:       103                 
Claims Approved:       69                   
Claims Denied:           34       
Charges Reviewed:    $58,802.50                 
Charges Approved:     $39,102.50     
Charges Denied:         $19,700.00
Error Rate:                 34%                

* Error rate is based on the charges denied divided by the charges reviewed

The medical review decisions were based on the LCD for Ambulance Services (L12792) on the Active LCDs page.

Non Emergency Ambulance Service (Ground)

For non-emergency ambulance transportation, transportation by ambulance is appropriate if the beneficiary is bed-confined and it is documented that the beneficiary's medical condition is such that other methods of transportation are contraindicated, or if his or her medical condition, regardless of bed-confinement, is such that transportation by ambulance is medically required.

Medicare coverage for non-emergency ambulance services is available:

  • Only when transportation by any other means is contraindicated by the medical condition of the patient;
  • Only to specific destinations; and
  • Only when certified as medically necessary by a physician directly responsible for the patient's care

    NOTE: All three of the above criteria must be met.


Medical Necessity

Ambulance transport in non-emergency situations must meet medical necessity guidelines.

Medical necessity is established for non-emergency ambulance services when the patient's condition is such that the use of any other method of transportation (such as: taxi, private car, wheelchair van, or other type of vehicle) is contraindicated. If the condition contraindicating other means of transportation is "bed confined", the patient must meet the following condition of "bed confined." The inability to:

  • Get up from bed without assistance; AND
  • Ambulate; AND
  • Sit in a chair (including a wheelchair).

NOTE: All three components must be met in order for the patient to be considered "bed-confined." It does not include a patient who is restricted to bed rest on a physician's instructions due to a short-term illness. Examples of situations in which patients are bed confined and cannot be moved by wheelchair, but must be moved by stretcher include:

  • Contractures creating non-ambulatory status and patient cannot sit.
  • Severe generalized weakness.
  • Severe vertigo causing inability to remain upright.
  • Immobility of lower extremities (patient in spica cast, fixed hip joints, or lower extremity paralysis) and unable to be moved by wheelchair.

If some means of transportation other than an ambulance (such as: private car, wheel chair van, etc.) could be utilized without endangering the individual's health, whether or not such other transportation is actually available, no payment may be made for ambulance service.

If transportation is for the purpose of receiving an excluded service (such as a routine dental examination) then the transportation is also excluded even if the patient could only have gone by ambulance.

If transportation is for the purpose of receiving a service that could have been safely and effectively provided in the point of origin (residence, SNF, hospital, etc.) then the transport is not covered even if the patient could only have gone by ambulance.

Ambulance transportation for services excluded from SNF consolidated billing must meet the criteria as reasonable and necessary (i.e. other means contraindicated).

Destination

Covered destinations for "non-emergency" transports include:

  • Acute care hospitals (Appropriate facility)
  • Skilled Nursing Facilities
  • Dialysis Facilities- ambulance services furnished to a maintenance dialysis patient should show that the patient's condition requires ambulance services
  • From a SNF to the nearest supplier of medically necessary services not available at the SNF where the beneficiary is a resident, including the return trip
  • The patient's residence (only if this is a return from an "appropriate facility")

In order for ambulance services to be a covered benefit the transport must be to the nearest institution with appropriate facilities for the treatment of the illness or injury involved. The term "appropriate facilities" means that the institution is generally equipped to provide the needed hospital or skilled nursing care for the illness or injury involved. It is the institution, its equipment, its personnel and its capability to provide the services necessary to support the required medical care that determine whether it has appropriate facilities.

The fact that a more distant institution is better equipped, either qualitatively or quantitatively, to care for the patient does not warrant a finding that a closer institution does not have “appropriate facilities." However, a legal impediment barring a patient's admission would permit a finding that the institution did not have "appropriate facilities." For example, the nearest appropriate specialty hospital may be in another State and that State's law precludes admission of nonresidents

In the case of ambulance services that are to a facility other than the closest appropriate facility, only those miles to the closest facility are eligible for coverage.

NOTE: If the transport is for the purpose of receiving a non-covered service, then the transport is also non-covered, even if the destination is an "appropriate facility."

Certification

Providers of ambulance transportation must obtain a written certification from the physician for all scheduled transports certifying the medical necessity of the ambulance services. Requirements for non-emergency ambulance transportation include:

  • Scheduled, repetitive ambulance services:
  • The certification must be dated no earlier than 60 days in advance of the transport, for repetitive patients whose transportation is scheduled in advance.

Unscheduled or scheduled on a non-repetitive basis:

  • For residents in facilities who are under the direct care of a physician, written certification of medical necessity can be obtained within 48 hours after the transport.
  • If the ambulance provider or supplier is unable to obtain a signed physician certification statement from the beneficiary’s attending physician, a signed certification statement must be obtained from either the physician assistant (PA), nurse practitioner (NP), clinical nurse specialist, a registered nurse (RN), or discharge planner, who has personal knowledge of the beneficiary’s condition at the time the ambulance transport is ordered or the service is furnished. This individual must be employed by the beneficiary’s attending physician or by the hospital or facility where the beneficiary is being treated and from which the beneficiary is transported. Medicare regulations for PAs, NPs, and CNSs apply and all applicable State licensure laws apply; or
  • The ambulance provider is responsible for obtaining the signed certification with the appropriate signatures as expeditiously as possible, and must obtain the signed order before billing for the service.
  • If the ambulance provider is unable to obtain the written certification with appropriate signatures within 21 days after delivery of service the supplier may bill only if there is documentation of good faith effort to obtain the order and certification. Acceptable documentation includes a signed return receipt from the U.S. Postal Service or other similar service that evidences that the ambulance supplier attempted to obtain the required signature.

A physician certification is not required prior to emergency transports or unscheduled transports of a patient residing at home or in a facility, who is not under the direct care of a physician.

NOTE: It is important to note that the presence of the signed physician certification statement does not necessarily demonstrate that the transport was medically necessary. The ambulance supplier must meet all coverage criteria in order for payment to be made.

Review of the submitted documentation indicated denials were due to one of the following reasons:

  • Lack of timely submission of requested documentation (Denial Reason 56900):  Claims were denied due to a lack of record submission in a timely manner.  According to The Medicare Program Integrity Manual, PUB 100-8, Chapter 3, § 3.4.1.2, if a coverage or coding determination cannot be made based upon the information on the claim, the Fiscal Intermediary (FI) may solicit additional documentation from the provider by issuing an Additional Documentation Request (ADR) and must notify the provider of the 30 day time-period to respond.  If the ADR-requested information is not is received within 45 days after the date of the request, then the claim must be denied. 

To eliminate 56900 denials, please review the following elements to ensure appropriate and timely record processing:

  • Beginning January 1, 2007, Cahaba no longer sends letters to inform providers of Additional Development Requests (ADRs).  Instead, providers will need to access the Fiscal Intermediary Standard System (FISS) to identify claims selected for ADR.  Claims selected for ADR can be identified by accessing FISS Inquiry Option 12, and will appear in status location S B6001.  Pages 07 and 08 of the claim will contain the date your documentation is due, and the elements of documentation requested.
  • Print screen the ADR letter and attach the copy to the front of the requested medical documentation
  • Send requested information to the address on the ADR letter
  • Do NOT send certified mail or overnight mail
  • Include ALL requested documentation outlined in the ADR
  • Submit the above information via regular mail in a timeframe to ensure the FI receives the information by the 45th day after the date of the request.
  • Transportation from one appropriate facility to another appropriate facility is not covered by Medicare.  Services denied are not covered by Medicare (Denial Reason 55652):  This denial reason was due to the documentation submitted indicated that the patient was transported from one appropriate facility to another.  The documentation did not indicate the reason for the transport and/or support the patient could not be effectively and appropriately treated at the current facility. 
  • The ambulance services are not covered by Medicare.  Ambulance transport coverage criteria not met. (Denial Reason 55650):  Claims were denied due to the patient not meeting the benefit category requirements for the services provided.  The documentation submitted did not support medical necessity for ambulance transport.  The documentation did not support that transport by any other means would be contraindicated. 
  • Land ambulance services are allowed only to the closest appropriate facility (55653).  Additional mileage is not covered by Medicare.  Services denied are not covered by Medicare.
  • Ambulance transport to a physician’s office is not covered by Medicare.  Services denied are not covered (55655).  The documentation submitted indicated that the reason for transport was for a physician visit.
  • The services were deemed not medically necessary based on the lack of documentation (55520).  This service was denied because information required to make payment was missing. 
  • The medical record does not validate that the service provided by the billing of a HCPCS code was provided (53603).  Review of the record did not support that ambulance transport was provided as submitted on the claim. 

As a result of this prepay probe review; Alabama Part A Medical Review will continue to monitor data through ongoing data analysis.  Also, providers identified through data analysis as driving this aberrancy may warrant provider-specific medical review.

Page last updated: March 26, 2008

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