Medicare ambulance services are typically a Part B covered benefit; however, in some situations, it may be covered by Part A. Medicare considers the ambulance benefit as a transport so if there is no transport provided there is no payable service. See the guides below for further details on ambulance covered services.
Medical Necessity of Service
The CMS Internet Only Manual (IOM), Publication 100-02, Chapter 10, Section 10.2.1 is the basis for Medical Review decisions.
"Medical necessity is established when the patient's condition is such that use of any other method of transportation is contraindicated. In any case in which some means of transportation other than an ambulance could be used without endangering the individual's health, whether or not such other transportation is actually available, no payment may be made for ambulance services. In all cases, the appropriate documentation must be kept on file and, upon request, presented to the carrier/intermediary. It is important to note that the presence (or absence) of a physician's order for a transport by ambulance does not necessarily prove (or disprove) whether the transport was medically necessary. The ambulance service must meet all program coverage criteria in order for payment to be made.
In addition, the reason for the ambulance transport must be medically necessary. That is, the transport must be to obtain a Medicare covered service, or to return from such a service."
No reimbursement will be made if a different means of transportation, other than an ambulance, could be used without endangering the individual's health, whether or not such other transportation is actually available.
Ambulance benefit is defined in title XVIII of the Social Security Act (the Act) in §1861(s)(7) : Ambulance service where the use of other methods of transportation is contraindicated by the individual's condition but only to the extent provided in regulations.
Medicare covers transports to the nearest appropriate facility to obtain necessary diagnostic and/or therapeutic services as well as the return transport. In addition to all other coverage requirements, this situation is covered only to the extent of the payment that would be made for bringing the service to the patient.
Transports (that meet all other program requirements for coverage) may be covered when made to the following destinations only:
- Critical Access Hospital (CAH)
- Skilled Nursing Facility (SNF)
- Beneficiary's home
- Dialysis facility for ESRD patient who requires dialysis (Medicare covers transports for patients with ESRD from their place of residence to a hospital or free standing dialysis facility.)
- A physician's office is not a covered destination. Under special circumstances an ambulance transport may temporarily stop at a physician's office without affecting coverage status of transport.
Patient Refuses Transport
Although the CPT A0998 definition states "Ambulance response and treatment, no transport," this code has a Medicare Physician Fee Schedule (MPFS) status indicator of "I." Status "I" codes are not valid for Medicare reimbursement. To receive a proper denial from Medicare to bill the patient when treatment was not provided and a transport was not provided, ambulance suppliers may: Submit the claim with unlisted CPT A0999; append the GY modifier, and include the comment "Patient refused transport" or "No transport" in Item 19 on the CMS-1500 paper claim form or its electronic equivalent
Scheduled / Repetitive Medically Necessary Nonemergency
Medicare covers medically necessary nonemergency, scheduled, repetitive ambulance services if the ambulance provider or supplier, before furnishing the service to the beneficiary, obtains a written order from the beneficiary's attending physician certifying that the medical necessity requirements of paragraph (d)(1) of this section are met. The physician's order must be dated no earlier than 60 days before the date the service is furnished. Source Code of Federal Regulations, section 410.40(d)(2), Vol. 67, dated February 27, 2002.
- CMS Medicare Learning Network (MLN) Matters (MM) 7161 - Air Ambulance Services
- CMS MM8269 - Ambulance Payment Reduction for Non-Emergency Basic Life Support (BLS) Transports to and from Renal Dialysis Facilities
- CMS MM7058 - Ambulance Service Definitions
- CMS MM6700 - Ensuring the Denial of Claims for Ambulance Services Rendered to Beneficiaries in Part A Skilled Nursing Facility Stays
- CMS Special Edition (SE)1029 - 5010 Requirement for Ambulance Suppliers
- CMS MM7363 - Additional Provider and Supplier Enrollment Requirements for Fixed Wing and Helicopter Air Ambulance Operators
- CMS MM7489 - Instructions to Accept and Process All Ambulance Transportation Healthcare Common Procedure Coding System (HCPCS) Codes
- CMS MM7065 - Fractional Mileage Amounts Submitted on Ambulance Claims
- CMS Ambulance Fee Schedule
- IOM, Publication 100-02, Medicare Benefit Policy Manual, Publication, Chapter 10 - Ambulance Services
- IOM, Publication 100-04, Medicare Claims Processing Manual Chapter 15 - Ambulance
- IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 3 - Inpatient Hospital Billing
Last Updated May 23, 2016