Ambulance Automated Prepayment Edits

Effective August 25, 2014, Noridian will implement automated prepayment edits to deny claims billed by specialty 59 (Ambulance Service Supplier) with the following modifier combinations:

Modifier combination II will be restricted to fixed wing transport codes.

CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. To meet this requirement, Noridian Part B Medical Review (MR) analyzes national and local data in conjunction with the findings from the Office of Inspector General (OIG) and other CMS contractors such as Comprehensive Error Rate Testing (CERT) and Recovery Auditor (RA) to identify atypical billing. After data analysis, MR must verify if billing problems exist through claim reviews to validate provider compliance with Medicare coverage as well as coding and billing guidelines. If issues are identified, MR then determines the severity of problems and develops interventions to correct the problem.

Noridian has determined these modifier combinations to have a high probability of not meeting CMS coverage requirements for ambulance services.

Per CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 10, Section 20, payment may be made for expenses incurred by a patient for ambulance services for transports between the following points:

From patient's residence (or other place where need arose) to hospital or Skilled Nursing Facility (SNF).
Skilled nursing facility to a hospital or hospital to a skilled nursing facility.
Hospital to hospital or SNF to SNF.
From a hospital or SNF to patient's residence.
Round trip for hospital or participating SNF inpatients to the nearest hospital or nonhospital treatment facility.
- Condition met if the reasonable and necessary diagnostic or therapeutic service required by patient's condition is not available at the institution where the beneficiary is an inpatient.

Per CMS IOM, Publication 100-02, Chapter 10, Section 10.3.8, ambulance service to a physician's office or a physician-directed clinic is not covered except under the following circumstances:

The ambulance transport is enroute to a Medicare covered destination; and
During the transport, the ambulance stops at a physician's office because of the patient's dire need for professional attention, and immediately thereafter, the ambulance continues to the covered destination.

In such cases, the patient will be deemed to have been transported directly to a covered destination and payment may be made for a single transport and the entire mileage of the transport, including any additional mileage traveled because of the stop at the physician's office.

Full coverage requirements must be met, including medical necessity of the transport. Medical necessity is established when the patient's condition is such that use of any other method of transportation is contraindicated.

Providers will have full appeal rights for claims denied by these automated prepayment edits by following the redeterminations process.

Effective Date: August 25, 2014

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