Bulletin Michigan Department of Community Health Distribution: Ambulance 02-01 Hospital 02-01 Medicaid Health Plans 02-01 Issued: January 2, 2002 Subject: Ambulance Chapter III, Correction to Billing Instructions Effective: Upon Receipt Programs Affected: Medicaid, Children's Special Health Care Services Purpose The attached Chapter III has been revised to incorporate changes due to the Uniform Billing Project and changes due to the new HCPCS ambulance procedure codes that have been previously issued in bulletins. The revised chapter also provides clarifications of existing ambulance policy. NOTE: MSA 01-04 "Uniform Billing Project for Ambulance Providers" erroneously referenced fields 43J or 43 K as the appropriate fields on the HCFA 1500 to enter modifiers. As stated in MSA 01-01 "Uniform Billing, Revised Chapter IV…", field 24D "Procedures, Services, or Supplies (CPT Codes plus Modifiers)," is the correct field on the HCFA 1500 to enter modifiers when they are necessary. Manual Maintenance Discard your old Chapter III and insert the new Chapter III in your Ambulance Manual. Discard MSA 01-04 Uniform Billing Project for Ambulance Providers. The information in this bulletin has been incorporated into Chapters III and IV. Discard MSA 01-05, Revised List of Diagnosis Codes for Emergency Ambulance Transport. This list is being reissued along with Chapter III, as the Diagnosis Codes for Emergency Ambulance Transport Appendix. MSA 02-01 MSA 02-01 Page 2 of 2 Questions Any questions regarding this bulletin should be directed to: Provider Inquiry, Medical Services Administration, P.O. Box 30479, Lansing, Michigan 48909-7979, or e-mail at [email protected]. When you submit an e-mail, be sure to include your name, affiliation, and a phone number so you may be contacted if necessary. Providers may phone toll-free I-800-292-2550. a& Robert M. Smedes Deputy Director for Medical Services Administration MANUAL TITLE CHAPTER PAGE AMBULANCE III i CHAPTER TITLE DATE TABLE OF CONTENTS MSA 02-01 01-02-02 SECTION 1 - INTRODUCTION GENERAL:................................................................................................................................................1 AMBULANCE SERVICES:.........................................................................................................................1 MEDICAL NECESSITY:.............................................................................................................................2 DIAGNOSIS CODING:...............................................................................................................................2 USUAL AND CUSTOMARY CHARGES:....................................................................................................2 MEDICARE/MEDICAID COVERAGES:.......................................................................................................3 SECTION 2 - GLOSSARY SECTION 3 - COVERED SERVICES AIR AMBULANCE:....................................................................................................................................1 FIXED WING AIR AMBULANCE SERVICES:........................................................................................1 HELICOPTER AIR AMBULANCES:......................................................................................................1 BASE RATE:.............................................................................................................................................2 ADVANCED LIFE SUPPORT (ALS):..........................................................................................................3 ADVANCED LIFE SUPPORT 1 (ALS1) NON-EMERGENCY:.................................................................3 ADVANCED LIFE SUPPORT 1 (ALS1) EMERGENCY:.........................................................................3 ADVANCED LIFE SUPPORT 2 (ALS2):................................................................................................3 BASIC LIFE SUPPORT (BLS):...................................................................................................................3 BLS NON-EMERGENCY:.....................................................................................................................4 BLS EMERGENCY:.............................................................................................................................4 DRUGS AND SOLUTIONS:.......................................................................................................................4 EMERGENCY:...........................................................................................................................................4 MILEAGE:.................................................................................................................................................4 NEONATAL: .............................................................................................................................................5 NON-EMERGENCY:..................................................................................................................................5 UNLISTED AMBULANCE SERVICE:.........................................................................................................6 WAITING TIME:.........................................................................................................................................6 WATER AMBULANCE:.............................................................................................................................6 SECTION 4 - SPECIAL SITUATIONS INTERCEPTS:...........................................................................................................................................1 BRIDGE TOLL:.........................................................................................................................................1 CONTINUOUS OR ROUND TRIP TRANSPORT:........................................................................................1 LTC NURSING FACILITIES:......................................................................................................................1 MULTIPLE ARRIVALS:.............................................................................................................................2 MULTIPLE BENEFICIARIES PER TRANSPORT:.......................................................................................2 MULTIPLE TRANSPORTS PER BENEFICIARY:........................................................................................2 OUT OF STATE NON-BORDERLAND TRANSPORTS:..............................................................................3 PRONOUNCEMENT OF DEATH:...............................................................................................................4 SECTION 5 - AMBULANCE QUICK REFERENCE GUIDE AMBULANCE COVERAGE EXCLUSIONS:................................................................................................1 APPENDIX - DIAGNOSIS CODES FOR EMERGENCY AMBULANCE TRANSPORTS MANUAL TITLE CHAPTER PAGE AMBULANCE III ii CHAPTER TITLE DATE TABLE OF CONTENTS MSA 02-01 01-02-02 This page is intentionally left blank. MANUAL TITLE CHAPTER SECTION PAGE AMBULANCE III 1 1 CHAPTER TITLE SECTION TITLE DATE COVERED SERVICES INTRODUCTION MSA 02-01 01-02-02 GENERAL: The primary objective of the Michigan Medicaid Program is to ensure that essential medical/health services are made available to those who would not otherwise have the financial resources to purchase them. The policies of the Program are aimed at minimizing the cost of medically necessary health care services provided to Medicaid beneficiaries. Reimbursement for ambulance services is restricted to medically necessary and appropriate services when: • Medical/surgical or psychiatric emergencies exist, or • No other effective and less costly mode of transportation for medical treatment can be used because of the beneficiary's medical condition. Services that have been excluded from direct reimbursement to ambulance providers are: • Services which are not medically necessary. • Services included as a part of the base rate. • Services for beneficiaries in a LTC nursing facility that are reimbursed as part of the per diem or are billed separately by the facility. • Services reimbursed as part of the DRG rate for beneficiaries who are inpatients at a hospital and are sent to another facility for services and returned to the originating hospital without being discharged from the originating hospital. • Services to MHP enrollees, except for medically necessary ambulance transports related to dental, substance abuse and community mental health services. • Non-ambulance, non-emergency medical transportation which is provided by a Medicaid health plan, or the Family Independence Agency reimburses the beneficiary or the transportation provider directly. The section on Covered Services (Section 3) describes, in alphabetical order, the coverages and limitations for payment of ambulance services by the Medicaid Program. Billing instructions follow the various coverages, where applicable. These instructions will assist the ambulance provider in obtaining reimbursement and should be used along with the completion instructions in Chapter IV and the HCPCS coding for ambulance. AMBULANCE SERVICES: The Michigan Department of Community Health recognizes different levels of medical services provided by qualified ambulance staff according to the standards established by law and regulation through Michigan Public Act 368 of 1978, as amended. The standards established for each level of service are detailed in the Base Rate sub-section of Section 3. The Ambulance Quick Reference Guide (Section 5) may be used as a guide to Medicaid coverage for ambulance services. MANUAL TITLE CHAPTER SECTION PAGE AMBULANCE III 1 2 CHAPTER TITLE SECTION TITLE DATE COVERED SERVICES INTRODUCTION MSA 02-01 01-02-02 All services identified as covered "if medically necessary" must be ordered by a physician, and a copy of the physician's order must be retained in the beneficiary's file. The physician's order must contain, at a minimum, the following information: • Beneficiary's name and Medicaid I.D. number, • Medical necessity of an ambulance transport, and • Physician's signature and Medicaid Provider I.D. number. Emergency services do not require a physician's order, but documentation must be kept by the ambulance provider in the beneficiary's file supporting the emergency nature of the service. When a beneficiary who is an inpatient in a hospital is transported to another hospital or to another facility for testing or treatment not available at the originating hospital, and is returned to the originating hospital without being discharged, the originating hospital is responsible for the cost of the transport. MEDICAL NECESSITY: Determination of medical necessity and appropriateness of service is the responsibility of the medical care personnel in attendance, including the emergency medical technician (EMT) at the scene of an emergency, within the scope of currently accepted medical practice and the limitations of the Program. Medical necessity for non-emergency transports must be substantiated by/with a physician's written order. Documentation of the medical necessity and appropriateness of service must be maintained by the ambulance provider in the beneficiary's file. DIAGNOSIS CODING: Providers must enter the appropriate diagnosis code on all ambulance claims using the International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM). Providers must report the most specific diagnosis code available that identifies the reason for the service. When billing for emergency transports providers should refer to the Diagnosis Codes for Emergency Ambulance Transports Appendix. Documentation supporting the diagnosis code must be retained in the ambulance provider's records for audit purposes. USUAL AND CUSTOMARY CHARGES: The Program must be billed the provider's usual and customary "fee" charged to the public. If the public receives a service without charge, an ambulance provider cannot bill the Program for the same service. If one charge is made to tax paying residents in a given township, and a higher charge is made to nonresidents, the same charge formula should be applied for Medicaid beneficiaries. Refer to the Third Party Billing instructions located in Chapter IV when the beneficiary also has Medicare or other insurance. MANUAL TITLE CHAPTER SECTION PAGE AMBULANCE III 1 3 CHAPTER TITLE SECTION TITLE DATE COVERED SERVICES INTRODUCTION MSA 02-01 01-02-02 MEDICARE/MEDICAID COVERAGES: The Michigan Department of Community Health will reimburse the ambulance provider for the coinsurance and deductible amounts subject to the Program's reimbursement limitations on all Medicare approved claims, even if the Program does not normally cover the service. The ambulance provider should refer to Chapter IV for instructions on completing the claim after Medicare has approved the services. MANUAL TITLE CHAPTER SECTION PAGE AMBULANCE III 1 4 CHAPTER TITLE SECTION TITLE DATE COVERED SERVICES INTRODUCTION MSA 02-01 01-02-02 This page is intentionally left blank. MANUAL TITLE CHAPTER SECTION PAGE AMBULANCE III 2 1 CHAPTER TITLE SECTION TITLE DATE COVERED SERVICES GLOSSARY MSA 02-01 01-02-02 Ambulance: A motor vehicle, watercraft, or aircraft that is primarily used or designated as available to provide transportation and basic life support or advanced life support. Continuous or Round Trip: An ambulance service in which the patient is transported to the hospital, the physician deems it medically necessary for the ambulance to wait, and the beneficiary is then transported to a more appropriate facility for care or back to the place of origin. Cooperating Hospital: A licensed hospital which supports an advanced mobile emergency care service as required by sections 20761(a) and 20763(b) of Public Act 368 of 1978, as amended. Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate attention to result in: • Placing the health of the individual (or, with respect to pregnant women, the health of the woman or her unborn child) in serious jeopardy • Serious impairment of bodily functions • Serious dysfunction of any bodily organ or part. Emergency Patient: An individual whose physical or mental condition is such that it meets the definition of "emergency medical condition". Emergency Response: A response that, at the time the ambulance provider is called, is provided after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity such that in the absence of immediate medical attention could reasonably be expected to result in placing the beneficiary's health in serious jeopardy; in impairment to bodily functions; or in serious dysfunction to any bodily organ or part. Emergency Transport: An emergency, pre-hospital service in which no physician has yet seen the patient, e.g., a transport from the scene of an accident to an emergency department. Fixed Wing Air Ambulance: Transportation by a fixed wing aircraft that is certified as a fixed wing air ambulance and such ancillary services as may be medically necessary. Helicopter (Rotary Wing) Air Ambulance: Transportation by a helicopter that is certified as an ambulance and such ancillary services as may be medically necessary. Loaded Mileage: The number of miles for which the Medicaid beneficiary is transported in the ambulance vehicle. Medically Necessary Transport: An ambulance transport which is required because no other effective and less costly mode of transportation can be used due to the patient's medical condition. The transport is required to transfer the patient to and/or from a medically necessary service not available at the primary location. Psychiatric Emergency: Any condition that must be treated to prevent the patient from inflicting injury to self or others. MANUAL TITLE CHAPTER SECTION PAGE AMBULANCE III 2 2 CHAPTER TITLE SECTION TITLE DATE COVERED SERVICES GLOSSARY MSA 02-01 01-02-02 Transfer: A non-emergency transport in which the patient is moved from one facility to another for care that is not available at the originating facility.