Part B Ambulance Condition Indicators

Cahaba Government Benefit Administrators®, LLC, would like to encourage Medicare Part B Ambulance providers in Jurisdiction 10 (Alabama, Georgia and Tennessee) to use the Medical Condition List indicators and/or a narrative in the narrative field.  ICD9 codes will also be accepted as additional information to support coverage for the transport.  All of the information will be taken into consideration when processing a claim for payment. 

When filing Ambulance condition indicators, it is very important to indicate the appropriate code that best identifies the condition of the patient at the time of transport.  When submitting condition codes, you should remember to place a space between each code.  For example a patient with severe abdominal pain and difficulty breathing would be submitted as 53550 78605 on the claim form, not 5355078605.  If the condition codes are submitted without spaces or with commas our claims processing system will not be able to clearly determine the condition code. 

Note:  Use of the condition codes in no way changes the requirements that apply to ambulance transports.  If your office decides to not use condition codes indicators, please submit a narrative supporting the medical necessity for the ambulance transport for your claim to be considered for payment. 

Ambulance providers and suppliers must retain adequate documentation of dispatch instructions, patient’s condition, other on-scene information, and details of the transport (e.g., medications administered, changes in the patient’s condition, and miles traveled), all of which may be subject to medical review by the Medicare contractor or other oversight authority.  Medicare contractors will rely on medical record documentation to justify coverage, not simply the Healthcare Common Procedure Coding System (HCPCS) code or the condition code by themselves.  All current Medicare ambulance policies remain in place. 

Special Note:  ICD-10 codes will replace ICD-9 codes for all health care services provided on or after October 1, 2014. 

5010 Requirement for Ambulance Services

Ambulance providers who choose to submit claims in the version 5010 837p electronic format must comply with the requirement to include a diagnosis code.  Additional information can be found in Change Request 7863 – Medicare Contractor Annual Update of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM).   

Emergency Conditions-Non-Traumatic and Emergency & Non-Emergency

The list of Contractor Medical Conditions/Indicators are located in the Medicare Claims Processing Manual, Chapter 15, Section 40The Medical Conditions List is set up with an initial column of primary ICD-9-CM codes, followed by an alternative column of ICD-9-CM codes. The primary ICD-9-CM code column contains general ICD-9-CM codes that fit the transport conditions as described in the subsequent columns.

Page last updated: December 7, 2012


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