Subject:
Ambulance and Medical Transport Services/ Ancillary Ambulance Items and Supplies
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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Ambulance and medical transport services involve the use of specially designed and equipped vehicles to transport ill or injured patients. These services may be utilized in the emergency transport of a patient to the nearest hospital with appropriate facilities for the treatment of the patient's illness or injury, or in the nonemergency transport of a registered hospital inpatient to another location to obtain medically appropriate specialized diagnostic or therapeutic services.
Eligible ancillary ambulance items and supplies are nonreusable items and disposable supplies that are required in patient care during air, ground, rail or sea ambulance transport. They include oxygen, gauze, dressing, injectable medications, and intravenous solutions. They do not include reusable items or devices such as backboards, neck boards, inflatable leg and arm splints, etc. which are part of general ambulance services and included in the charge for the trip.
Policy:
[Please note that Ambulance and Medical Transport Services may be subject to specific contract limitation or exclusion which takes precedence over this medical policy.
NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance..]
I. Ambulance services involving ground transportation for the emergency transport of a member is considered medically necessary when all of the following criteria are met:
A. it is rendered by an approved ambulance services supplier;
B. use of any other form of ground transportation is medically contraindicated due to the member's illness or injury; and
C. the member is transported to the nearest hospital with the appropriate facilities for the treatment of the member's illness or injury.
II. Ambulance services involving rail or sea transportation for the emergency transport of a member is considered medically necessary when all of the following criteria are met:
A. it is rendered by an approved ambulance services supplier;
B. use of any other form of transportation is medically contraindicated due to the member's illness or injury, and the point of pickup is inaccessible by ground ambulance; and
C. the member is transported to the nearest hospital with the appropriate facilities for the treatment of the member's illness or injury.
III. Ambulance services involving air ambulance transportation for the emergency transport of a member is considered medically necessary when all of the above criteria under ambulance services are met including any one of the following:
A. the time needed to transport a member by other forms of emergency transportation, or the instability of other forms of emergency transportation poses a threat to the member's condition or survival; or
B. when the point of pickup is inaccessible by other forms of emergency transportation.
[INFORMATIONAL NOTE: According to the NJ Department of Health, Office of Emergency Medical Services, when someone is seriously injured, EMS personnel need to decide whether transportation by ambulance or helicopter will get the patient to the trauma center sooner. There are several considerations in making this decision:
- Ground travel time to the nearest trauma center (e.g., distance, traffic congestion).
- The helicopter's estimated time of arrival (ETA), the transfer time, and flight time to the trauma center.
- Whether multiple patients are involved.
Generally, the factors which should be taken into account are:
- Ground transport should be used for an un-entrapped patient who is within 30 minutes ground travel time from a trauma center.
- Entrapped patients are an exception to the 30 minute-rule, if the helicopter can reach the scene while the patient is being rescued or extricated.
- The helicopter should generally be called to a scene which is more than 30 minutes by ground from a trauma center. You should consider factors such as the helicopter's estimated time of arrival, in-flight time, extrication time, etc.
- Keep in mind that, while a helicopter is fast once in the air, getting to the landing zone and loading the patient can easily add 5 to 10 minutes, or more, to onscene time.
- Consider requesting a helicopter for incidents involving more than three critical patients. Additional manpower, communication with medical control, and transport options can be obtained by using the air medical helicopter system.
For additional information, please access the guideline at http://www.nj.gov/health/ems/special-services/fly-or-drive-criteria/]
IV. Nonemergency transport is considered medically necessary when all of the following criteria are met:
A. the member is a registered hospital inpatient who is transported to another hospital to obtain medically necessary specialized diagnostic or therapeutic services;
B. the member's condition contraindicates the use of any other form of transportation;
C. the services are not available in the hospital in which the member is registered; and
D. the hospital providing the services is the nearest one with the appropriate facilities.
[Please note that Ambulance and Medical Transport Services, including but not limited to air ambulance, may be subject to specific contract limitation or exclusion which takes precedence over this medical policy.]
V. The following reimbursement guidelines apply to ambulance services:
A. Base reimbursement rate for emergency ambulance transport services includes services of ambulance attendants, provision of reusable equipment and devices (e.g., stretchers, restraints, backboards, neck boards, inflatable leg and arm splints, etc.) and when applicable, provision of equipment and devices necessary for the performance of advanced life support.
B. When appropriately billed and itemized, separate reimbursement (in addition to the base reimbursement rate) may be made for ambulance mileage and for nonreusable items and disposable supplies (i.e., oxygen, gauze, dressings, injectable medications, intravenous solutions) that are required in member care during the transport.
(NOTE: For additional information on the eligibility of nonreusable items and disposable supplies, please refer to item VII below.)
C. No additional or separate reimbursement will be made for waiting time or special handling charges (i.e., weekend, night or risk factors).
D. When the member could have been treated at a nearer hospital than the one to which the member was transported, reimbursement is limited to the distance to the nearest hospital.
VI. Ancillary ambulance nonreusable items and disposable supplies that are considered medically necessary in member care during air, ground, rail or sea ambulance transport, are eligible for separate reimbursement unless they are specifically excluded from the member's contract. To clarify further, these items are eligible for reimbursement even if they are utilized or administered during a contractually excluded ambulance transport (e.g., air ambulance).
VII. The following guidelines specifically pertain to ambulance services for deceased members:
A. If the member is legally pronounced dead while the ambulance is enroute to pickup the member, ambulance service may be eligible for reimbursement but only up to the point where the ambulance is notified.
B. If the member is legally pronounced dead while the ambulance is enroute to the hospital, the entire ambulance service may be eligible for reimbursement.
C. However, if the member is legally pronounced dead before the ambulance is called, no payment may be made for the ambulance service.
Medicare Coverage:
Ground Ambulance Transports
All of these coverage requirements apply to ground ambulance transports:
1. The transport is medically reasonable and necessary
2. A Medicare beneficiary is transported
3. The destination is to the nearest appropriate facility equipped to treat the beneficiary
4. The facility is appropriate.
*An appropriate facility is an institution that is generally equipped to provide the needed hospital or skilled nursing care for the beneficiary’s illness or injury. An appropriate hospital must have a physician or a physician specialist available to provide the necessary care required to treat the beneficiary’s condition.
Medicare covers ground ambulance services only if furnished to a beneficiary whose medical condition at the time of transport is such that transportation by other means would endanger the patient’s health. Per LCD L35162, Ambulance transportation is covered when the patient’s condition requires the vehicle itself or the specialized services of the trained ambulance personnel and LCD L35162 criteria is met. A requirement of coverage is that the needed services of the ambulance personnel were provided and clear clinical documentation validates their medical need and their provision in the record of the service (usually the run sheet). For additional information and eligibility, refer to Local Coverage Determination (LCD): Ambulance Services (Ground Ambulance) (L35162). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35162&ver=39&Date=06%2f16%2f2017&DocID=L35162&bc=iAAAABAAAAAAAA%3d%3d&
Local Coverage Article: Billing and Coding: Ambulance Services (Ground Ambulance) (A54574). Available to be accessed at Novitas Solutions, Inc., Medical Policy Search page: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/LcdSearch?_afrLoop=90769712476969#!%40%40%3F_afrLoop%3D90769712476969%26centerWidth%3D100%2525%26leftWidth%3D0%2525%26rightWidth%3D0%2525%26showFooter%3Dfalse%26showHeader%3Dfalse%26_adf.ctrl-state%3D63y7eftob_46
Air Ambulance
An air ambulance transport to transfer a beneficiary from one hospital to another hospital must meet all of the following:
● A ground ambulance transport endangers the beneficiary’s health
● The transferring hospital does not have the needed hospital or skilled nursing care for the beneficiary’s illness or injury
● The second hospital is the nearest appropriate facility
For additional information and eligibility, refer to CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 10, Ambulance Services (Air Ambulance Chapter 10.4 et al.). Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS012673.
Physician Certification Statement (PCS)
For scheduled and non-scheduled non-emergency ambulance transports, providers of ambulance transportation must obtain a written statement (PCS) from the patient’s attending physician certifying that medical necessity requirements for ambulance transportation are met.
Medicaid Coverage:
FIDE-SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Ambulance and Medical Transport Services
Air Ambulance
Ambulance, Air
Ambulance-Related Items and Supplies
Ancillary Ambulance Items and Supplies
Emergency Transport Services
Non-Emergency Transport Services
Supplies, Ambulance-Related
Transport Services, Emergency and Non-Emergency
References:
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
HCPCS
A0021
A0080
A0090
A0100
A0110
A0120
A0130
A0140
A0160
A0170
A0180
A0190
A0200
A0210
A0225
A0380
A0382
A0384
A0390
A0392
A0394
A0396
A0398
A0420
A0422
A0424
A0425
A0426
A0427
A0428
A0429
A0430
A0431
A0432
A0433
A0434
A0435
A0436
A0888
A0998
A0999
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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