Effective Date:
June 01, 2019

Last Revised:
February 16, 2020

Purpose:
Provide guidelines for coverage and reimbursement of ambulance services including ground and air ambulance transports.

Scope:
Products included:

• NJ FamilyCare/Medicaid Plan
• Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

Definitions:
Ground ambulance transports include the following:

• Advanced Life Support, Level 1 (ALS1): Includes the provision of medically necessary supplies and services and the provision of an ALS assessment or at least one ALS intervention. An ALS intervention is a procedure that must be performed by an emergency medical technician-intermediate (EMT Intermediate) or an EMT-Paramedic in accordance with State and local laws.

• Advanced Life Support, Level 2 (ALS2): Includes the provision of medically necessary supplies and services and: At least three separate administrations of one or more medications by intravenous push/bolus or by continuous infusion (excluding crystalloid fluids); or At least one of the following procedures:
  • Manual defibrillation/cardioversion;
  • Endotracheal intubation;
  • Central venous line;
  • Cardiac pacing;
  • Chest decompression;
  • Surgical airway; or
  • Intraosseous line

• Basic Life Support (BLS): Includes the provision of medically necessary supplies and services and BLS ambulance transportation, as defined by the State where the transport is provided.

• Paramedic Intercept (PI): Refers to an entity that provides ALS services but does not supply the ambulance transport. PI (A0432) may be required when only a BLS level of service is provided and the member requires an ALS level of service (such as electrocardiogram monitoring, chest decompression, or intravenous therapy).

• Specialty Care Transport (SCT): Includes the provision of medically necessary supplies and services at a level of service beyond the scope of an EMT-Paramedic. SCT (A0434) is the inter-facility transportation of a critically ill or injured member that is necessary because the member’s condition requires ongoing care furnished by one or more professionals in an appropriate specialty (such as emergency or critical care nursing, emergency medicine, respiratory or cardiovascular care, or a paramedic with additional training);

Air Ambulance is defined as follows:

• Air Ambulance Transport: Includes the provision of medically necessary supplies and services to a member transported by fixed wing (airplane) or rotary wing (helicopter) aircraft as defined by the State where the transport is provided.

• Emergency response: The ambulance responds immediately.

• Hospital-based Ambulance Provider: A hospital-based ambulance provider is owned and/or operated by a hospital and provides ambulance services as an adjunct to its institutionally-based operations. Services by these providers are billed on an institutional claim (837I).

• Independent Ambulance Supplier: An ambulance supplier may be a licensed, independently owned and operated ambulance service company that is enrolled as an independent ambulance supplier. These providers bill their services on a professional claim (837P).

• Non-emergency response: Can generally be scheduled in advance.
  Note: For non-Emergency ambulance transportation certain plans may require the member or the provider to call in for prior approval. Please see the member-specific plan documents for details on notification requirements.

• Same Ambulance Provider or Supplier: Ambulance Providers or Suppliers of the same specialty reporting the same Federal Tax Identification number (TIN).

Policy:
This policy addresses reimbursement of ambulance transportation service, ambulance modifier usage, provider specialty reporting ambulance services, the requirements for reporting Basic and Advanced Life Support ambulance transportation and inpatient ambulance transportation services. The ambulance transport benefit covers the medically necessary transport of a member by ground or air ambulance to the nearest appropriate facility that can treat a member’s condition when any other methods of transportation are contraindicated.

Ambulance Providers and Suppliers:
Horizon NJ Health shall consider for reimbursement procedure codes A0021 and A0225–A0999 when submitted by an Ambulance Provider or Supplier. Ambulance services and supplies must be submitted with a Place of Service 41 (Ambulance – Land) or 42 (Ambulance – Air or Water). An ambulance provider may be an independent ambulance supplier or a hospital-based ambulance service.

Origin and Destination Modifiers:
In accordance with Centers for Medicare and Medicaid Services (CMS) guidelines, Horizon NJ Health requires all ambulance providers or suppliers to report an origin and destination modifier for all billed services on each trip provided. Each ambulance modifier is comprised of a single digit alpha character identifying the origin of the transport in the first position, and a single digit alpha character identifying the destination of the transport in the second position.

Ambulance origin and destination modifier definitions are:

• D - Diagnostic or therapeutic site, other than P or H
• E - Custodial facility
• G - Hospital based dialysis facility
• H - Hospital
• I - Site of transfer (i.e. helipad) between ambulances
• J - Non-hospital dialysis facility
• N -Skilled nursing facility
• P -Physician's office
• R -Residence
• S -Scene of accident or acute event
• X - Intermediate stop at physician’s office on way to hospital (destination code only)
  Note: When “X” is present within the 2 digit modifier combination, “X” must be in the second digit position preceded by a valid origin digit in the first position. “X” may not be submitted in the first position as the origin of the transport.

When billing for round/multiple trips, bill each leg of the trip on a separate line with the appropriate origin and destination modifier. Claim lines should only contain a single origin and a single destination modifier (see also Pronouncement Services - Transport of Deceased Individuals below).

Non-Covered Origins and Destinations:
Certain origins and destinations are not covered when billed with ambulance service and transport codes.

For example, a Physician’s office (P) is not a valid destination, except, under certain circumstances, 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 (See ‘X’), therefore any modifier where P is the destination shall not be considered for reimbursement.

Non-covered origin/destinations include, but are not limited to: DD, DE, DG, DJ, DP, DS, ED, EE, EP, ES, GD, GG, GJ, GP, GS, HP, HS, ID, IE, IG, IJ, IN, IP, IR, IS, JD, JJ, JP, JS, NP, NS, PD, PE, PG, PJ, PP, PR, PS, RD, RE, RP, RR, RS, SD, SE, SG, SJ, SN, SP, SR, SS, XD, XE, XG, XH, XI, XJ, XN, XP, XR, XS, XX

In accordance with CMS guidelines, Horizon NJ Health shall consider for reimbursement ground ambulance services (Procedure Codes A0427, A0429, or A0433) submitted with destination of hospital (Modifier -H), site of transfer (Modifier -I), or intermediate stop at physician's office on way to hospital (Modifier -X).

Air Ambulance Origin and Destination:
The following are the only valid origin and destination modifiers for air ambulance service and transport codes:

• DH (Diagnostic, therapeutic site to hospital)
• EH (Custodial facility to hospital)
• GH (Hospital based dialysis facility to hospital)
• HH (Hospital to hospital)
• HI (Hospital to Site of transfer between modes of ambulance)
• IH (Site of transfer to hospital)
• JH (Non-hospital based dialysis facility to hospital)
• NH (Skilled nursing facility to hospital)
• PH (Physician's office to hospital)
• RH (Residence to hospital)
• SH (Scene of accident to hospital)
• SI (From scene of accident or acute event to Site of transfer between modes of ambulance transport)

Specialty Care Transport Origin and Destination:
The following is the only valid origin and destination modifiers for specialty care service and transport codes:

• HH (Hospital to hospital)

Services Included in Ambulance Transportation not Separately Payable:
Horizon NJ Health shall not separately reimburse for the use of medical supplies and/or equipment. (A0382, A0384, A0392, A0394, A0396), lodging and meals (A0180, A0190, A0200, A0210), parking fees and tolls (A0170) and waiting time (A0420). Exception: Oxygen (A0422) is reimbursable on a per occurrence basis when provided to a member during an ambulance trip.

Non-Covered Transports:
Ambulance services, both ground and air, shall not be considered for reimbursement under the following circumstances:

• Transports in which some other means of transportation could be used without endangering the member’s health, regardless of whether the other means of transportation is actually available.
• Transports to a more distant hospital solely to avail the member to services of a specific physician or physician specialist.
• Transports for medical repatriation services from a foreign country back to the United States are non-covered, unless the member’s contract benefits state otherwise.
• Transport to the member’s home is not reimbursed, unless covered under the member’s contract.
• Transport from an appropriate facility (capable of providing the services necessary to support the required medical care) to another facility due to patient or family preference is non-covered.
• Non-emergent ALS and BLS ambulance transport (Procedure Codes A0426 and A0428) and paramedic intercept (PI) (Procedure Code A0432) transports shall not be considered for reimbursement.
• Non-emergent transport provided by a volunteer, individual, taxi, bus, intrastate carrier, interstate carrier, wheelchair van, or private or commercial air transport or transport from a case/social worker (Procedure Codes A0080, A0090, A0100, A0110, A0120, A0130, A0140, A0160) shall not be considered for reimbursement.

ALS/BLS Joint Responses:
In certain emergent situations, both BLS and ALS providers are called to a scene. In situations where a BLS provider transports a member and an ALS provider renders a service that meets the ALS criteria, Horizon NJ Health will only reimburse the ALS provider. In joint ALS/BLS responses, Horizon NJ Health will not reimburse the BLS provider. The ALS provider must submit a claim to Horizon NJ Health for the ALS service. BLS providers may bill the ALS provider directly for reimbursement and shall not bill Horizon NJ Health. If a BLS provider submits a claim for BLS services to Horizon NJ Health after ALS has submitted, Horizon NJ Health will deny the claim for BLS services.

Specialty Care Transport:
Specialty care transport is expected to be billed with an appropriate diagnosis, supported in the ambulance trip log and submitted with the claim.

Examples of diagnoses appropriate for specialty care transport:

• Hypokalemia (ICD-10 code E87.6)
• Tracheostomy status (ICD-10 code Z93.0)
• Dependence on respirator {ventilator} status (ICD-10 code Z99.11)
• Dependence on other enabling machines and devices (ICD-10 code Z99.89)

Inpatient transportation:
When a transportation provider renders a round trip service to a member in a general hospital whose status remains "inpatient", the transportation provider must bill the hospital for the service. With the exception of the admission and discharge date, no further reimbursement is allowed for ambulance service during an inpatient stay. These ambulance services must be included on the inpatient claim and reimbursed to the ambulance provider by the inpatient provider.

If a nursing facility transports a member, reimbursement is considered as part of the per diem rate. No further reimbursement is allowed.

Mileage & Transport:
Generally, each ambulance trip will require a minimum of two (2) procedure codes, one (1) for the service and one (1) for the mileage. Charges for mileage must be based on loaded (patient onboard) mileage only, e.g., from the pickup of a patient to the arrival at destination. Mileage is reported under the code, A0425. Units reflect statute miles traveled. Mileage procedure codes A0888, A0380 and A0390 are not acceptable mileage codes and not reimbursable.

The air ambulance mileage rate is calculated per actual loaded miles flown and is to be expressed in statute miles (not nautical miles).

Ambulance Mileage Billed Without Transport or Service Codes

Actual transport of the member must occur for related ambulance services to be covered.When ambulance mileage (A0425 is billed and there is no ambulance transport code (Procedure Codes A0225, A0427, A0429, A0433 or A0434) billed for the same date of service, the ambulance mileage code shall not be considered for reimbursement. In addition, when ambulance mileage is reported with response and treatment only (A0998) since there is no ambulance transport code, then the ambulance mileage shall not be considered for reimbursement.

Ambulance Service or Transport Codes Billed Without Mileage Codes

When ambulance services and/or transport codes (Procedure Codes A0225, A0427, A0429, A0433 or A0434) are billed and there are no mileage code (A0425) billed for the same date of service, then the ambulance services and transport codes shall not be considered for reimbursement.

Pronouncement Services - Transport of Deceased Individuals:
In the case where the member was pronounced dead after the ambulance is called and dispatched but before the ambulance arrives at the scene, reimbursement shall be considered for a BLS service if a ground vehicle or air ambulance is dispatched. In this case, mileage shall not be considered for reimbursement. Services should be submitting using procedure code A0428 with modifier -QL (Patient pronounced dead after ambulance called) instead of the origin and destination modifier. If a provider bills Advanced Life Support services (Procedure Codes A0225, A0426, A0247, A0433, and A0434) and/or Emergency Basic Life Support service (A0429), with modifier -QL, Horizon NJ Health shall reimburse as BLS non-emergent transport (A0428). Any additional ambulance services and supplies billed with modifier -QL shall be denied.

The procedure codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Procedure:
Horizon NJ Health shall consider Professional and Facility claims for ambulance services only if submitted with valid origin and destination modifiers from ambulance providers and suppliers coded with the correct Place of Service for reimbursement.

Horizon NJ Health shall deny non-Ambulance Providers or Suppliers for rendering of ambulance services.

Horizon NJ Health shall deny ambulance services with a Place of Service other than 41 (Ambulance – Land) or 42 (Ambulance – Air or Water).

Horizon NJ Health shall deny ground ambulance transportation services reported without a valid two (2) digit ambulance modifier; when “X” is the first digit of the two (2) digit modifier combination; or when Emergency transport (Procedure codes A0427, A0429 or A0433) is submitted without a destination modifier of H, I, or X.

Horizon NJ Health shall deny air ambulance transportation services not submitted with an appropriate modifier as defined above.

Horizon NJ Health shall deny procedure codes for supplies and/or additional ambulance services when transport services are not submitted or have been denied for the same date of service by the same ambulance provider or supplier for the same patient.

Horizon NJ Health shall deny non-emergent ALS and BLS transport services (Procedure codes A0426 and A0428).

Horizon NJ Health shall deny specialty transport services (Procedure code A0434) that do not meet the diagnosis criteria as defined above.

Horizon NJ Health shall deny ambulance mileage billed without transport or service codes. Horizon NJ Health shall only reimburse the mileage code A0425, other mileage codes will be denied. Horizon NJ Health shall deny ambulance service or transport codes billed without mileage code A0425, except as noted above (see Pronouncement Services - Transport of Deceased Individuals).

Horizon NJ Health shall recode transport codes submitted with modifier -QL to A0428 and shall deny other ambulance services submitted with modifier -QL.

Horizon NJ Health shall only pay for one (1) claim in emergent joint ALS/BLS transports. (Procedure codes A0427 and A0429)

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

• Benefit Limitations
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

References:
New Jersey Administrative Code N.J.A.C. 10:50-1.6., Chapter 10, Human Services, Chapter 50, Transportation Services Manual, Subchapter ¹
http://www.lexisnexis.com/hottopics/njcode

Medicare Benefit Policy Manual, Chapter 10- Ambulance Services
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c10.pdf

Centers for Medicare and Medicaid Services (CMS) Local Coverage Determination – L35162 (Ambulance Services (Ground Ambulance))
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35162&ver=58&Date=&DocID=L35162&bc=iAAAABAAAAAA&

Centers for Medicare and Medicaid Services (CMS) MLN – Medicare Ambulance Transports ICN 903134, December 2017

American Medical Association, Current Procedural Terminology (CPT®) Professional Edition and associated publications and services

History:

Ambulance Procedure Code list: