Ambulance Mileage

Per the CMS Internet Only Manual (IOM), Publication 100-02, Chapter 10, Section 10.3 it states, "As a general rule, only local transportation by ambulance is covered, and therefore, only mileage to the nearest appropriate facility equipped to treat the patient is covered."

Medicare pays for "loaded" miles only. In other words, miles traveled while the patient was on board. Medicare does not pay for miles traveled to the point of pick up.

Air Ambulance

HCPCS Mileage Determination
A0435 (Fixed Wing), A0436 (Rotary Wing)
  • Suppliers must report mileage rounded up to nearest whole number mile
  • If mileage not indicated, defaults "0.1"

 

Ground/Water Ambulance

HCPCS Mileage Determination
A0425
  • Mileage totaling less than 1 mile, providers/suppliers must include a "0" prior to decimal point. For ambulance mileage HCPCS only, Medicare contractors automatically default "0.1" unit when total mileage units are missing in Item 24G of CMS-1500 claim form
  • Trips totaling 100 miles and less, suppliers must report mileage rounded up to nearest tenth of a mile - Fractional mileage
  • Trips totaling 100 miles and greater, suppliers must report mileage rounded up to nearest whole number mile Medicare contractors will truncate mileage units totaling 100 and greater that are reported with fractional mileage

 

Reimbursable Situations Which May Cause Additional Mileage

There are occasions when a beneficiary may be transported beyond what is to be considered "the closest facility." If/when this occurs, the ambulance supplier must document the exceptions on the claim. Note in the patient's documentation the circumstances of this transport and include such comments in Item 19 of the CMS-1500 claim form or its equivalent.

  • Blizzard conditions or heavy fog
  • Extensive road construction
  • Specialist/equipment not available at closest hospital (orthopedic surgeon; neurologist)
  • Hospital on diversion (no beds, weather, not taking new patients, etc.)
  • No Fly/Restricted Zone/Medivac - This must be supported by official federal aviation administration (FAA) message of Notice To Airmen (NOTAM) or documented refusal by Air Traffic Controller (ATC)

Non Reimburseable Situations Which May Cause Additional Mileage

There are also transports that go beyond the closest facility but its reasoning does not fall within the above medically necessary or justified reasons.

  • Beneficiary's family would like him/her to be closer to them causing additional mileage to incur.
  • Beneficiary and/or family does not like the closest facility available

Submit Claim Containing the Below.

  • Bill HCPCS A0425 for covered miles
    • Append Origin/Destination modifier
  • Bill HCPCS A0888 for "non-covered ambulance mileage per mile, e.g., for miles traveled beyond the closest appropriate facility"
    • Append Origin/Destination modifier
    • Append GY modifier, if beneficiary is liable
    • Do not append GY modifier, if ambulance supplier is liable

Remote Rescues

What if a beneficiary is injured rock climbing, snowmobiling, on an all-terrain vehicle (ATV), toboggans, hiking, etc. and the EMT/Paramedic provides a rescue in the back country or other remote areas?

Although such a rescue is necessary, the cost of the rescue is bundled into the ambulance base rate, in the same way that oxygen and IV supplies are bundled. Medicare covers mileage from "time patient loaded in Ambulance" for transport only. No additional allowed from site to Ambulance. Distance traveled by toboggan/snowmobile is not counted as "loaded mileage" as it is considered the same as a stretcher and there is no benefit for such modality until it reaches the ambulance proper.

Resources

 

Last Updated Mon, 21 Nov 2022 15:54:23 +0000