A new waiver was issued by the Centers for Medicare and Medicaid Services (CMS) for ground ambulance services providing treatment in place as part of a COVID-19 protocol.
Under authority provided through the American Rescue Plan Act of 2021, the new policy waives any requirements that an ambulance service must include the transport of an individual to receive Medicare payment. Instead, Medicare payment will be made for ground ambulance services during the COVID-19 public health emergency (PHE) in cases where both of the following apply:
- The ground ambulance service was furnished in response to a 911 call (or the equivalent in areas without a 911 call system).
- The patient would have been transported to a destination permitted under Medicare regulations but such transport didn’t occur as a result of community-wide emergency medical service (EMS) protocols due to the COVID-19 PHE.
CMS is implementing the waiver because over the past year, some ground ambulance providers and suppliers have been restricted from transporting some patients because of state, local, or hospital EMS protocols, and instead, have treated those patients in place. But in doing so, they have become ineligible to submit claims for Medicare payment because they didn’t provide a “medically necessary ground ambulance transport.”
The waiver is retroactively effective to March 1, 2020. For services provided under this waiver from March 1, 2020, through May 5, 2021 (the day the waiver was published), the deadline to submit claims is May 5, 2022. For services provided after May 5, 2021, through the end of the COVID-19 PHE (currently slated to expire on July 20, 2021 unless it is renewed again), ambulance providers and suppliers must file claims within one calendar year after the date of service.
In addition to the requirements above, claims submitted under this waiver must also meet existing Medicare ambulance services coverage criteria had the community-wide EMS protocols due to the COVID-19 PHE not been in place. Those criteria are as follows:
- The beneficiary would have required a medically necessary ground ambulance transport to the nearest appropriate facility able to treat the patient’s condition;
- Any other means of transportation would have been contraindicated (meaning that traveling to the destination by other means would have endangered the patient’s health);
Medicare won’t pay for claims when:
- The ambulance provider didn’t transport the patient based solely on the patient’s decision, including when a patient refused transport “against medical advice.”
- The ambulance service would not have been medically necessary.
- The ambulance provider can’t provide documentation, upon request, to support that a community-wide EMS protocol (as described above) was in place.
To submit claims under the waiver, ambulance providers should include one of the following HCPCS codes:
- A0429 (Ambulance service, basic life support, emergency transport (BLS-emergency))
- A0427 (Ambulance service, advanced life support, emergency transport, level 1 (ALS1))
- A valid origin/destination modifier combination (in the first modifier position) that would have been appropriate if you had transported the patient
- The CR modifier to distinguish these waiver claims from other claims, including claims for interventions covered under the Emergency, Triage, and Transport (ET3) model
Do not report codes for mileage since the patient wasn’t transported.
You must also maintain (and submit upon request) documentation that:
- Supports medical necessity. You must demonstrate that the patient’s condition required the level of service provided and would normally require ambulance transport (without the community-wide EMS protocol).
- Establishes that community-wide EMS protocol was in effect for the area at the time ambulance services were provided to the patient and required, or allowed with patient consent, that ambulance providers and suppliers not transport certain patients.
For more information about the waiver for ground ambulance services for treatment in place, check out this CMS Fact Sheet.
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