Ambulance Scenarios

The below scenarios have been acquired from our provider and supplier communities. Each set of circumstances are unique, so if there are any additional questions, call our Provider Contact Center for additional guidance and refer to the Case Number of the scenario.

The information in these scenarios is subject to change.

ABN

Case Number Scenario Solution
A1 An ABN is needed/desired but patient is unable to sign ABN Form and their representative is not available An ABN is rarely required by an ambulance provider/supplier. Ask below questions
  1. Is this service a covered ambulance benefit?
  2. Will payment for part or all this service be denied because it is not reasonable and necessary? And
  3. Is the patient stable and the transport non-emergent (not under duress)?
If "yes" to all questions above, issue an ABN

See CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Section 50.15.2 for additional information
A2 ABN requirements when hospital case management reviews patient documentation and believes there is medical necessity to support a non-emergent ground transport but ambulance is saying "No, we're not going to transport" Hospitals must educate discharge planners regarding Medicare ambulance benefits, along with working with local ambulance company. Per regulations, if a patient could safely travel by any means other than an ambulance, the ambulance trip is not covered. This includes if a patient can safely transfer in a gurney van, wheelchair van, taxi or a private car. Typically, when medical necessity for an ambulance service is not met, an ABN is not required

 

Deceased Beneficiary

Case Number Scenario Solution
B1 Ambulance responds to a patient's home and finds patient in cardiac arrest. Paramedics provide a lot of medication services in trying to save that patient and patient ultimately does pass away without receiving billing authorization In an emergency, authorization is not necessary. To bill Medicare, a patient representative, legal guardian, relative or a person that receives social security, or other government benefits on their behalf; or, someone that arranges treatment for a patient sign on behalf of the beneficiary. The beneficiary may also have a representative of an agency or institution (i.e. person who called ambulance) sign

Signature requirements are outlined in the CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 10, Section 20.1.2
B2 Defining medical necessity to bill a beneficiary who is pronounced dead on scene. A0428 was billed for BLS non-emergency with QL modifier. Our practice was under pre-payment audit review process for scheduled transport to a hospital and this claim was denied for no medical necessity If a patient was pronounced dead before ambulance was called, it will not be a covered service. If a patient is pronounced dead after call, or before transport, bill A0428 and append QL modifier. If all other criteria are met, claim should pay. If patient died en-route, bill as a normal transport. If documentation supports service, it should be paid

 

Signature Requirements

Case Number Scenario Solution
C1 Timeliness requirements for signature from beneficiary, or their representative, when a signature cannot be obtained during transport, and a crew member did not sign during transport If beneficiary is unable to sign authorizing billing and assignment regulation lists alternative signers. Item 6 states that representative of ambulance company can sign, but must be a person that was on site when service was rendered; not that they (ambulance provider) sign it while on site

The signature rules are outlined in the CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 10, Section 20.1.2(6)
C2 Billing a patient because crew did not obtain a signature and did not sign Patient Care Report (PCR) on scene See Solution to Case C1

 

Transports

Case Number Scenario Solution
D1 Freestanding wound care center (affiliated with a hospital) that uses hospital NPI for inpatients. Wound patient requires ambulance transport back and forth for hyperbaric treatment If hospital is calling for transportation to hyperbaric oxygen chamber location and patient is maintaining inpatient status, bill procedure to hospital itself. That's not a transport that is covered separately
D2 Transporting from patient's residence to hospital's clinic on hospital grounds (per hospital directive), instead of going to ER (which is full) and billing this transport as RH (residence-hospital) when transporting emergency patients to a clinic on hospital grounds, as an overflow for their ER, using hospital's NPI If it's considered an urgent care center, this is same as taking patients to a physician's office. Your other option, is that if a particular hospital is on diversion status because they are full, then travel to the next available hospital facility. A clinic, whether on hospital grounds or not, is not a covered destination. If call is an emergency, it must be handled as such. Take patient to hospital emergency department
D3 A transport claim is denied from hospital to Skilled Nursing Facility (SNF) and patient requires isolation because of a Methicillin-resistant Staphylococcus aureus (MRSA) infection. Patient is bed confined, non-ambulatory, cannot sit for transport time in a wheelchair, on oxygen that cannot be administered by patient and requires additional personnel due to weight or obesity Medicare does not typically cover a return trip back to a patient's residence or SNF. If services are medically necessary and patient's life was in danger, if transported any other way than via ambulance, appeal rights may be used to send supporting documentation
D4 Out-of-state transfer that was denied stating that there was a closer facility available and was not supported by documentation to show justification for transfer Documentation must support reason transfer was not to nearest hospital. Perhaps this was necessary due to equipment or personnel; this must be documented thoroughly in medical record
D5 Ambulance provider continuously transports patients that are homeless; however, records indicate they are incarcerated. Providers are having a hard time getting a hold of patient to update their records because they are transient Beneficiary's incarceration file may need to be updated. This can be reviewed by correctional facility

See definition of how CMS interprets custody and incarceration in CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 50.3.3(3)

 

Last Updated Dec 09 , 2023