Differences between Chapter V (F) of ICD-10 and Chapter V of ICD-9 Mental and Behavioural Disorders

ICD-10 is larger than ICD-9. Numeric codes (001-999) were used in ICD-9, whereas an alphanumeric coding scheme, based on codes with a single letter followed by two numbers at the three-character level (A00-Z99), has been adopted in ICD-10. This has significantly enlarged the number of categories available for the classification. Further detail is then provided by means of decimal numeric subdivisions at the four-character level.

The chapter that dealt with mental disorders in ICD-9 had only 30 three-character categories (290-319); Chapter V (F) of ICD-10 has 100 such categories. A proportion of these categories have been left unused for the time being, so as to allow the introduction of changes into the classification without the need to redesign the entire system.

ICD-10 as a whole is designed to be a central ("core") classification for a family of disease and health related classifications. Some members of the family of classifications are derived by using a fifth or even sixth character to specify more detail. In others, the categories are condensed to give broad groups suitable for use, for instance, in primary health care or general medical practice. There is a multiaxial presentation of Chapter V (F) of ICD-10 and a version for child psychiatric practice and research. The "family" also includes classifications that cover information not contained in the ICD, but having important medical or health implications, e.g. the classification of impairments, disabilities and handicaps, the classification of procedures in medicine, and the classification of reasons for encounter between patients and health workers.

Definition Differences

Neurosis and psychosis

The traditional division between neurosis and psychosis that was evident in ICD-9
(although deliberately left without any attempt to define these concepts) has not been used in ICD-10. However, the term "neurotic" is still retained for occasional use and occurs, for instance, in the heading of a major group (or block) of disorders F40-F48, "Neurotic, stress-related and somatoform disorders". Except for depressive neurosis, most of the disorders regarded as neuroses by those who use the concept are to be found in this block, and the remainder are in the subsequent blocks. Instead of following the neurotic-psychotic dichotomy, the disorders are now arranged in groups according to major common themes or descriptive likenesses, which makes for increased convenience of use.

For instance, cyclothymia (F34.0) is in the block F30-F39, Mood [affective] disorders, rather than in F60-F69, Disorders of adult personality and behaviour; similarly, all disorders associated with the use of psychoactive substances are grouped together in F10-F19, regardless of their severity.

"Psychotic" has been retained as a convenient descriptive term, particularly in F23, Acute and transient psychotic disorders. Its use does not involve assumptions about psychodynamic mechanisms, but simply indicates the presence of hallucinations, delusions, or a limited number of severe abnormalities of behaviour, such as gross excitement and overactivity, marked psychomotor retardation, and catatonic behaviour.

All disorders attributable to an organic cause are grouped together in the block F00-F09, which makes the use of this part of the classification easier than the arrangement in the ICD-9.

The new arrangement of mental and behavioural disorders due to psychoactive substance use in the block F10-F19 has also been found more useful than the earlier system. The third character indicates the substance used, the fourth and fifth characters the psychopathological syndrome, e.g. from acute intoxication and residual states; this allows the reporting of all disorders related to a substance even when only three-character categories are used.

The block that covers schizophrenia, schizotypal states and delusional disorders (F20-F29) has been expanded by the introduction of new categories such as undifferentiated schizophrenia, postschizophrenic depression, and schizotypal disorder. The classification of acute short-lived psychoses, which are commonly seen in most developing countries, is considerably expanded compared with that in the ICD-9.

Classification of affective disorders has been particularly influenced by the adoption of the principle of grouping together disorders with a common theme. Terms such as "neurotic depression" and "endogenous depression" are not used, but their close equivalents can be found in the different types and severities of depression now specified (including dysthymia (F34.1)).

The behavioural syndromes and mental disorders associated with physiological dysfunction and hormonal changes, such as eating disorders, nonorganic sleep disorders, and sexual dysfunctions, have been brought together in F50-F59 and described in greater detail than in ICD-9, because of the growing needs for such a classification in liaison psychiatry.

Block F60-F69 contains a number of new disorders of adult behaviour such as pathological gambling, fire-setting, and stealing, as well as the more traditional disorders of personality.

Disorders of sexual preference are clearly differentiated from disorders of gender identity, and homosexuality in itself is no longer included as a category.

Differences on Disorders with onset specific to childhood

F80-F89 Disorders of psychological development Disorders of childhood such as infantile autism and disintegrative psychosis, classified in ICD-9 as psychoses, are now more appropriately contained in F84.-, pervasive developmental disorders. While some uncertainty remains about their nosological status, it has been considered that sufficient information is now available to justify the inclusion of the syndromes of Rett and Asperger in this group as specified disorders. Overactive disorder associated with mental retardation and stereotyped movements (F84.4) has been included in spite of its mixed nature, because evidence suggests that this may have considerable practical utility.

F90-F98 Behavioural and emotional disorders with onset usually occurring in childhood and adolescence

Hyperkinetic disorder is now defined more broadly in ICD-10 than it was in ICD-9. The ICD-10 definition is also different in the relative emphasis given to the constituent symptoms of the overall hyperkinetic syndrome; since recent empirical research was used as the basis for the definition, there are good reasons for believing that the definition in ICD-10 represents a significant improvement.
Hyperkinetic conduct disorder (F90.1) is one of the few examples of a combination category remaining in ICD-10, Chapter V (F). The use of this diagnosis indicates that the criteria for both hyperkinetic disorder (F90.-) and conduct disorder (F91.-) are fulfilled.
These few exceptions to the general rule were considered justified on the grounds of clinical convenience in view of the frequent coexistence of those disorders and the demonstrated later importance of the mixed syndrome.

Oppositional defiant disorder (F91.3) was not in ICD-9, but has been included in ICD-10 because of evidence of its predictive potential for later conduct problems. There is, however, a cautionary note recommending its use mainly for younger children.

The ICD-9 category 313 (disturbances of emotion specific to childhood and adolescence) has been developed into two separate categories for ICD-10, namely emotional disorders with onset specific to childhood (F93.-) and disorders of social functioning with onset specific to childhood and adolescence (F94.-). This is because of the continuing need for a differentiation between children and adults with respect to various forms of morbid anxiety and related emotions. The frequency with which emotional disorders in childhood are followed by no significant similar disorder in adult life, and the frequent onset of neurotic disorders in adults are clear indicators of this need. The key defining criterion used in ICD-10 is the appropriateness to the developmental stage of the child of the emotion shown, plus an unusual degree of persistence with disturbance of function. In other words, these childhood disorders are significant exaggerations of emotional states and reactions that are regarded as normal for the age in question when occurring in only a mild form. If the content of the emotional state is unusual, or if it occurs at an unusual age, the general categories elsewhere in the classification should be used.

In spite of its name, the new category F94.- (disorders of social functioning with onset specific to childhood and adolescence) does not go against the general rule for ICD-10 of not using interference with social roles as a diagnostic criterion. The abnormalities of social functioning involved in F94.- are of a limited number and contained within the parent-child relationship and the immediate family; these relationships do not have the same connotations or show the same cultural variations as those formed in the context of work or of providing for the family, which are excluded from use as diagnostic criteria.

Users of blocks F80-F89 and F90-F98 also need to be aware of the contents of the neurological chapter of ICD-10 (Chapter VI (G)). This contains syndromes with predominantly physical manifestations and clear "organic" etiology, of which the Kleine-Levin syndrome (G47.8) is of particular interest to child psychiatrists.

Terminology differences

Disorder

The term "disorder" is used throughout the classification, so as to avoid even greater problems inherent in the use of terms such as "disease" and "illness". "Disorder" is not an exact term, but it is used here to imply the existence of a clinically recognizable set of symptoms or behaviour associated in most cases with distress and with interference with personal functions. Social deviance or conflict alone, without personal dysfunction, should not be included in mental disorder as defined here.

Psychogenic and psychosomatic

The term "psychogenic" has not been used in the titles of categories, in view of its different meanings in different languages and psychiatric traditions. It still occurs occasionally in the text, and should be taken to indicate that the diagnostician regards obvious life events or difficulties as playing an important role in the genesis of the disorder.

"Psychosomatic" is not used for similar reasons and also because use of this term might be taken to imply that psychological factors play no role in the occurrence, course and outcome of other diseases that are not so described.

Disorders described as psychosomatic in other classifications can be found in;

           F45.- somatoform disorders
           F50.- eating disorders
           F52.- sexual dysfunction
           F54.- psychologicalor behavioural factors associated with disorders or diseases classified                    elsewhere

It is particularly important to note category F54.- (category 316 in ICD-9) and to remember to use it for specifying the association of physical disorders, coded elsewhere in ICD-10, with an emotional causation.

A common example would be the recording of psychogenic asthma or eczema by means of    both F54 from Chapter V (F) and the appropriate code for the physical condition from other             chapters in ICD-10.

Dissociative and somatoform disorders, in relation to hysteria

The term "hysteria" has not been used in the title for any disorder in Chapter V (F) of ICD-10 because of its many and varied shades of meaning. Instead, "dissociative" has been preferred, to bring together disorders previously termed hysteria, of both dissociative and conversion types. This is largely because patients with the dissociative and conversion varieties often share a number of other characteristics, and in addition they frequently exhibit both varieties at the same or different times. It also seems reasonable to presume that the same (or very similar) psychological mechanisms are common to both types of symptoms.

Two categories that have been included here but were not present in ICD-9 are F68.0, elaboration of physical symptoms for psychological reasons, and F68.1, intentional production or feigning of symptoms or disabilities, either physical or psychological [factitious disorder]. Since these are, strictly speaking, disorders of role or illness behaviour, it should be convenient for psychiatrists to have them grouped with other disorders of adult behaviour. Together with malingering (Z76.5), which has always been outside Chapter V of the ICD, the disorders from a trio of diagnoses often need to be considered together. The crucial difference between the first two and malingering is that the motivation for malingering is obvious and usually confined to situations where personal danger, criminal sentencing, or large sums of money are involved.

                                  Source World Health Organization (WHO)

When ambulance services are covered? (Part II Documentation Requirements)

Documentation Requirements

It is the responsibility of the ambulance supplier to maintain (and furnish upon request) complete and accurate documentation of the beneficiary's condition to demonstrate the ambulance service being furnished meets the medical necessity criteria. Documentation must be legible. The documents required for this purpose include the following:

1. Physician Certification Statement (PCS)

For scheduled and non-scheduled non-emergency ambulance transports, providers of ambulance transportation must obtain a written statement (PCS) from the patient’s attending physician, PA, NP, CNS, RN or discharge planner certifying that medical necessity requirements for ambulance transportation are met. The signature of the medical professional completing the PCS must be legible (or accompanied by a typed or printed name) and include credentials. Furthermore, signatures on the PCS must be dated at the time they are completed. A PCS is not required for emergency transports or for non-scheduled non-emergency transports of patients residing at home or in facilities where they are not under the direct care of a physician. It is important to note that the mere presence of the signed provider certification statement does not, by itself, demonstrate that the transport was medically necessary and does not absolve the ambulance provider from meeting all other coverage and documentation criteria.

For non-repetitive non-emergency transports, the following apply:

• If the ambulance provider is unable to obtain the PCS from the attending physician within 48 hours of transport, the ambulance provider may submit a claim if a certification has been obtained from a Physician Assistant (PA), Nurse Practitioner (NP), Clinical Nurse Specialist (CNS), Registered Nurse (RN) or discharge planner who is knowledgeable about the patient’s condition and who is employed by either the attending physician or the facility in which the patient is admitted. (Please note, that the term admitted does not necessarily mean admission to inpatient status. It also includes acceptance for care at an Emergency Room, ESRD Facility, etc., implying transfer of care).

• Alternatively, the provider may submit the claim after 21 days if there is documentation of attempt(s) to obtain the order and certification. The ambulance supplier must document efforts to obtain certification. When the PCS cannot be obtained the provider/supplier may send a letter via U.S. Postal Service certified mail with return receipt and/OR proof of mailing and/OR other similar service (FedEx, UPS) demonstrating delivery of the letter as evidence of the attempt to obtain the PCS.

For repetitive non-emergency transports, the following apply:

• A PCS for repetitive transports must be signed by the patient’s attending provider.

• The PCS must be dated no earlier than 60 days in advance of the transport for those patients who require repetitive ambulance services and whose transportation is scheduled in advance.

Additional PCS requirements

• A particular form or format is not required for the certification. Suppliers and physicians may develop their own certification form.

• Ambulance company employees should not complete forms on behalf of these individuals.

• Signature of the medical professional completing the PCS must also be legible (or accompanied by a typed or printed name) and include credentials.

• Signatures on the PCS must be dated at the time they are completed.

2. Trip record must include:

• A detailed description of the patient’s condition at the time of transport. Coverage will not be allowed if the trip record contains an insufficient description of the patient's condition at the time of transfer for the insurance to reasonably determine that other means of transportation are contraindicated. If the description of the patient’s condition is limited to conclusory statements and/or opinions, such as the following, the Contractor may base reimbursement on the supporting medical record documentation instead:

"Patient is non-ambulatory."

"Patient moved by drawsheet."

"Patient could only be moved by stretcher."

"Patient is bed-confined."

"Patient is unable to sit, stand or walk."

• The trip record must "paint a picture" of the patient's condition and must be consistent with documentation found in other supporting medical record documentation (including the physician's certification). The trip record must include the following, where possible:

• A concise explanation of symptoms reported by the patient and/or other observers and details of the patient's physical assessments that clearly demonstrate that the patient requires ambulance transportation and cannot be safely transported by an alternate mode.

• An objective description of the patient's physical condition in sufficient detail to demonstrate that the patient’s condition or functional status at the time of transport meets Medicare limitation of coverage for ambulance services.

• Description of the traumatic event when trauma is the basis for suspected injuries.

• A detailed description of existing safety issues.

• A detailed description of special precautions taken (if any) and explanation of the need for such precautions.

• A description of specific monitoring and treatments required, ordered and performed/administered. That a treatment (such as oxygen) and/or monitoring (such as cardiac rhythm monitoring) were performed absent sufficient description of the patient's condition (to demonstrate that the treatment and/or monitoring was medically necessary) is inadequate on its own merit to justify payment for the ambulance service. For example, when oxygen is supplied as a basis for ambulance transportation, the patient’s pretreatment capillary blood oxygen saturation and clinical respiratory description must be recorded. The two must be consistent with oxygen need.

• Statements such as the following, absent supporting information in relevant bullets above, are insufficient to justify payment for ambulance services:

Patient complained of shortness of breath.

History of stroke.

Past history of knee replacement.

Hypertension.

Chest pain.

Generalized weakness.

Is bed-confined.

• Signatures, including credentials, from the provider(s) who renders the services documented:

• Services provided/ordered must be authenticated by the author. The method used must be a handwritten or electronic signature.

• If the signature is found to be illegible or missing from the medical documentation, a signature log or attestation statement to determine the identity of the author may be requested.

• A signature log includes the typed or printed name and usual signature of the author associated with initials or an illegible signature.

• An attestation statement is required when a signature is missing from the documentation; it must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary, date of service and be specific to the service documented.

• Providers should not add late signatures to the documentation.

• Point of pick-up/destination (identify place and complete address).
• 
  
• For hospital-to-hospital transports, the trip record must clearly indicate the precise treatment or procedure (or medical specialist) that is available only at the receiving hospital. Non-specific or vague statements such as "needs cardiac care" or "needs higher level of care" are insufficient.

3. Any additional available documentation

• Documentation that supports medical necessity of ambulance transport (for example, emergency room report, SNF record, End Stage Renal Disease (ESRD) facility record, hospital record).

• Documentation supporting the number of loaded miles billed.

• Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.

• All documentation must be maintained in the patient's medical record and available upon request.

Source CMS National And Local coverage determinations.

When Ambulance Services are Covered? (PART I)

Ambulance services are covered only if furnished to a beneficiary whose medical condition at the time of transport is such that transportation by other means would endanger the patient’s health. A patient whose condition permits transport in any type of vehicle other than an ambulance does not qualify for payment. Payment for ambulance transportation depends on the patient’s condition at the actual time of the transport regardless of the patient’s diagnosis. To be deemed medically necessary for payment, the patient must require both the transportation and the level of service provided.

Emergency response means responding immediately at the Basic Life Support (BLS), Advanced Life Support 1 (ALS1) level of service or Advanced Life Support 2 (ALS-2) to a 911 call or the equivalent. An immediate response is one in which the ambulance supplier begins as quickly as possible to take the steps necessary to respond to the call.

Common Ground Ambulance Transport Types

A beneficiary may be transported on land or on water for a ground ambulance transport. Ground ambulance transports include the following:

Basic Life Support (BLS) – Includes the provision of medically necessary supplies and services and BLS ambulance transportation as defined by the State where you provide the transport.

**Every state has different guidelines regarding BLS interventions**

**Check with your state regulatory agency for approved BLS interventions**

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 assessment is performed by an ALS crew as part of an emergency response that is necessary because the beneficiary’s reported condition at the time of dispatch indicates that only an ALS crew is qualified to perform the assessment. An ALS assessment does not necessarily result in a determination that the beneficiary requires an ALS level of transport. 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.

MEDICAL NECESSITY

Ambulance transportation is covered when the patient’s condition requires the vehicle itself and/or the specialized services of the trained ambulance personnel. A requirement of coverage is that the needed services of the ambulance personnel were provided and clear clinical documentation in the patient’s medical record validates their medical need and their provision.

COVERAGE

Emergency ambulance services will be covered when:

1. The services are medically necessary (As described above)
2. The destination limits of closest appropriate facilities

As a general rule, the ground ambulance transport destination must be local, which means that only mileage to the nearest appropriate facility equipped to treat the beneficiary is covered. If two or more facilities meet this requirement and can appropriately treat the beneficiary, the full mileage to any of these facilities is covered.

Some circumstances that may justify ambulance transport to a more distant institution include:

• The beneficiary’s condition requires a higher level of trauma care or other specialized service that is only available at the more distant hospital.  

• A specialized service is a covered service that is not available at the facility where the beneficiary is a patient.

• No beds are available at the nearest institution.

 

If a beneficiary is initially transported to an institution that is not equipped to provide the needed hospital or skilled nursing care for the beneficiary’s illness or injury and is then transported to a second institution that is adequately equipped, both ground ambulance transports will be covered provided the second transport is to the nearest appropriate facility.

A ground ambulance transport from an institution to the beneficiary’s home is covered when the home is:

• Within the locality of the institution. Locality is the service area surrounding the institution to which individuals normally travel or are expected to travel to receive hospital or skilled nursing services; or
• Outside the locality of the institution but in relation to the beneficiary’s home, it is the nearest appropriate facility.

3. The service is provided by an ambulance service that complies with all State and local laws governing an emergency transportation vehicle.

Coverage requirements for air ambulance transports:

1. The Transport Is Medically Reasonable and Necessary

A medically reasonable and necessary air ambulance transport must meet the following requirements:

• The beneficiary’s medical condition requires immediate and rapid ambulance transport
• It cannot be furnished by BLS or ALS ground ambulance transport because one of the following pose a threat to the beneficiary’s survival or seriously endangers his or her health:
• The point-of-pick-up (POP) is not accessible by ground vehicle (this requirement may be met in Hawaii, Alaska, and other remote or sparsely populated areas of the continental United States). POP is the location of the beneficiary at the time he or she is placed on board the ambulance.
• The distance to the nearest appropriate facility or the time a ground ambulancetransport will take (generally more than 30 – 60 minutes)
• The instability of ground transportation.

• The medical conditions that may justify air ambulance transport include, but are not limited to, the following (this list is not intended to justify air ambulance transport in all localities):

• Intracranial bleeding that requires neurosurgical intervention;
• Cardiogenic shock;
• Burns that require treatment in a burn center;
• Conditions that require treatment in a Hyperbaric Oxygen Unit;
• Multiple severe injuries; or
• Life-threatening trauma.

Specialized medical services that are generally not available at all facilities include, but are not limited to, the following:

• Burn care
• Cardiac care
• Trauma care
• Critical care

Ground Ambulance Coverage When the Beneficiary Dies

Time of Death Pronouncement	Coverage
Before Dispatch	None
After dispatch and before the beneficiary is loaded on board the ambulance (before or after arrival at the POP).	•  Your BLS base rate •  No mileage or rural adjustment •  Use QL modifier, “Patient pronounced dead after ambulance called,” on claim.
After pickup and prior to or upon arrival at the receiving facility.	A medically reasonable and necessary level of service has been furnished.

Air Ambulance Coverage When the Beneficiary Dies

Time of Death Pronouncement	Coverage
Before the beneficiary is loaded on board the ambulance: • The dispatcher receives the pronouncement of death and has a reasonable opportunity to notify the pilot to abort the flight • The aircraft has taxied but has not taken off or, at a controlled airport, the aircraft has been cleared to take off but has not actually taken off.	None
After takeoff to the POP and before the beneficiary is loaded on board the air ambulance.	Appropriate air base rate with no mileage or rural Adjustment Use QL modifier on claim.
After the beneficiary is loaded on board the air ambulance and before or upon arrival at the receiving facility.	As if the beneficiary had not died.

Air Ambulance Aborted Flight Scenarios

The chart below provides payment information for two air ambulance transport scenarios in which the flight is aborted due to bad weather or other circumstances beyond the pilot’s control.

Aborted Flight Scenario	Coverage
Before the beneficiary is loaded on board the air ambulance (prior to or after takeoff to the POP).	None
After the beneficiary is loaded on board the air ambulance.	Appropriate air base rate, mileage, and rural adjustment.

Covered destinations for emergency ambulance services include:

• Hospitals 
• Physician’s office

(only if during an emergency transportation to a hospital the ambulance stops at a physician’s office en route due to a dire need for professional attention and thereafter continues to the hospital. In such cases, the patient is deemed not to have been transported to the physician’s office and payment may be made for the entire trip).

Covered destinations for “non-emergency” transports include:

• Hospitals (“appropriate facility”). 
• Skilled nursing facilities. 
• Dialysis facilities – Ambulance services furnished to a maintenance dialysis patient only when the patient’s condition at the time of transport requires ambulance services. 
• From an SNF to the nearest supplier of medically necessary services not available at the SNF where the beneficiary is a resident, including the return trip.
• The patient’s residence only if the transport is to return from an “appropriate facility” and the patient’s condition at the time of transport requires ambulance services.

Tables of Medical Conditions

The following diagnoses tables illustrate the severity of the patient’s condition to justify payment for ambulance transportation services when all other coverage and payment conditions are met. Though not all-inclusive, the following table lists medical conditions for which ambulance transportation is commonly required and can be used to judge relative severity of conditions not listed.

The run report must include a description of the patient’s symptoms and physical findings in sufficient detail as to demonstrate conditions such as those described in the tables.

I. Medical Conditions

Complaint or Symptom	Condition Requirement	Examples of Systems and Findings Necessary (and Documented) For Coverage
Abdominal pain	Accompanied by other signs or symptoms	Associated symptoms include nausea, vomiting, fainting. Associated signs include tender or pulsatile mass, distention, rigidity, rebound tenderness on exam, guarding.
Abnormal cardiac rhythm/cardiac dysrhythmia	Symptomatic or potentially life-threatening arrhythmia	Necessary symptoms include syncope or near syncope, chest pain and dyspnea. Signs required include severe bradycardia or tachycardia (rate < 60 or > 120), signs of congestive heart failure. Examples include junctional and ventricular rhythms, non-sinus tachycardias, PVCs > 6/min, bi- and trigeminy, ventricular tachyarrhythmias, PEA, asystole. Patients are expected to have conditions that require monitoring during and after transportation.
Abnormal skin signs		Includes diaphorhesis, cyanosis, delayed capillary refill, diminished skin turgor, mottled skin. Presence of other emergency conditions
Alcohol or drug intoxication	Severe intoxication	Unable to care for self. Unable to ambulate. Altered level of consciousness. Airway may or may not be at risk.
Allergic reaction	Potentially life-threatening manifestations	Includes rapidly progressive symptoms, prior history of anaphylaxis, wheezing, oral/facial/laryngeal edema
Animal bites/sting/ envenomation	Potentially life- or limb- threatening	Symptoms of specific envenomation, significant face, neck, trunk and extremity involvement. Special handling and/or monitoring required. Presence of other emergency conditions.
Sexual assault	With significant external and/or internal injuries
Blood glucose	Abnormal <80 or >250 with symptoms	Signs include altered mental status (altered beyond baseline function), vomiting, significant volume contraction, significant cardiac dysfunction.
Back pain (see general pain listing below)	Sudden onset, severe non-traumatic pain suggestive of cardiac or vascular origin or requiring special positioning only available by ambulance	7–10 on 10-point severity scale. Neurologic symptoms and/or signs, absent leg pulses, pulsatile abdominal mass, concurrent chest or abdominal pain
Respiratory arrest		Includes apnea or hypoventilation requiring ventilatory assistance and airway management
Respiratory distress, shortness of breath, need for supplemental oxygen	Objective evidence of abnormal respiratory function	Includes tachypnea, labored respiration, hypoxemia requiring oxygen administration. Includes patients who require advanced airway management such as ventilator management, apnea monitoring for possible intubation and deep airway suctioning. Includes patients who require positioning not possible in other conveyance vehicles. Note that oxygen administration absent signs or symptoms of respiratory distress is, by itself, an inadequate reason to justify ambulance transportation in a patient capable of self-administration of oxygen. Patient must require oxygen therapy and be so frail as to require assistance of medically trained personnel.
Cardiac arrest with resuscitation in progress
Chest pain (non-traumatic)	Cardiac origin suspected. Obvious non-emergent cause not identified	Pain characterized as severe, tight, dull or crushing, substernal, epigastric, left-sided chest pain. Especially with associated pain of the jaw, left arm, neck, back, GI symptoms (such as nausea, vomiting), arrhythmias, palpitations, difficulty breathing, pallor, diaphoresis, alteration of consciousness. Atypical pain accompanied by nausea and vomiting, severe weakness, feeling of impending doom or abnormal vital signs.
Choking episode	Respiratory or neurologic impairment
Cold exposure	Potentially life- or limb- threatening	Findings include temperature < 95º F, signs of deep frost bite or presence of other emergency conditions.
Altered level of consciousness (non-traumatic)	Neurologic dysfunction in addition to any baseline abnormality	Acute condition with Glasgow Coma Scale <15 or transient symptoms of dizziness associated with neurologic or cardiovascular symptoms and/or signs or abnormal vital signs
Convulsions/seizures	Active seizing or immediate post-seizure at risk of repeated seizure and requires medical monitoring/observation	Conditions include new onset or untreated seizures or history of significant change in baseline control of seizure activity. Findings include ongoing seizure activity, postictal neurologic dysfunction.
Non-traumatic headache	Associated neurologic signs and/or symptoms or abnormal vital signs
Heat exposure	Potentially life-threatening	Findings include hot and dry skin, core temperature >105º, neurologic dysfunction, muscle cramps, profuse sweating, severe fatigue.
Hemorrhage	Potentially life-threatening	Includes uncontrolled bleeding with signs of shock and active severe bleeding (quantity identified) ongoing or recent with potential for immediate rebleeding.
Infectious diseases requiring isolation procedures/public health risk	The nature of the infection or the behavior of the patient must be such that failure to isolate poses significant risk of spread of a contagious disease.	Infections in this category are limited to those infections for which isolation is provided both before and after transportation.
Hazardous substance exposure	The nature of the exposure should be such that potential injury is likely.	Toxic fume or liquid exposure via inhalation, absorption, oral, radiation, smoke inhalation
Medical device failure	Life- or limb-threatening malfunction, failure or complication	Malfunction of ventilator, internal pacemaker, internal defibrillator, implanted drug delivery device, O 2 supply malfunction, orthopedic device failure
Neurologic dysfunction	Acute or unexplained neurologic dysfunction in addition to any baseline abnormality	Signs include facial drooping, loss of vision without ophthalmologic explanation, aphasia, dysphasia, difficulty swallowing, numbness, tingling extremity, stupor, delirium, confusion, hallucinations, paralysis, paresis (focal weakness), abnormal movements, vertigo, unsteady gait/balance.
Pain not otherwise specified in this table	Pain is the reason for the transport. Acute onset or bed-confining.	Pain is severity of 7–10 on 10-point severity scale despite pharmacologic intervention. Patient needs specialized handling to be moved. Other emergency conditions are present or reasonably suspected. Signs of other life- or limb-threatening conditions are present. Associated cardiopulmonary, neurologic, or peripheral vascular signs and symptoms are present.
Poisons ingested, injected, inhaled or absorbed, alcohol or drug intoxication	Potentially life-threatening	Requires cardiopulmonary and/or neurologic monitoring and support and/or urgent pharmacologic intervention. Includes circumstances in which quantity and identity of agent known to be life-threatening; instances in which quantity and identity of agent are not known but there are signs and symptoms of neurologic dysfunction, abnormal vital signs, or abnormal cardiopulmonary function. Also, includes circumstances in which quantity and identity of agent are not known but life-threatening poisoning reasonably suspected.
Complication of pregnancy/childbirth and postoperative procedure complications	Requires special handling for transport	Includes major wound dehiscence, evisceration, organ prolapse, hemorrhage or orthopedic appliance failure
Psychiatric/behavioral	Is expressing active signs and/or symptoms of uncontrolled psychiatric condition or acute substance withdrawal. Is a threat to self or others requiring restraint (chemical or physical) or monitoring and/or intervention of trained medical personnel during transport for patient and crew safety. Transport is required by state law/court order.	Includes disorientation, suicidal ideations, attempts and gestures, homicidal behavior, hallucinations, violent or disruptive behavior, sign/symptoms or DTs, drug withdrawal signs/symptoms, severe anxiety, acute episode or exacerbation of paranoia. Refer to definition of restraints in the CFR, Section 482.13(e). For behavioral or cognitive risk such that patient requires attendant to assure patient does not try to exit the ambulance prematurely, see CFR, Section 482.13(f)(2) for definition.
Fever	Significantly high fever unresponsive to pharmacologic intervention or fever with associated symptoms	Temperature after pharmacologic intervention >102º (adult) Temperature after pharmacologic intervention >104º (child) Associated neurologic or cardiovascular symptoms/signs, other abnormal vital signs
Gastrointestinal distress	Accompanied by other signs or symptoms	Severe nausea and vomiting or severe, incapacitating diarrhea with evidence of volume depletion, abnormal vital signs or neurologic dysfunction
General mobility issues and bed confinement	Patient’s physical condition is such that patient risks injury during vehicle movement despite restraints or positioning and/or record demonstrates specialized handling required and provided	This may be due to any or multiple of the conditions listed above. All conditions that contribute to general mobility issues must be adequately described. Includes conditions such as: Decubitus ulcers on sacrum or buttocks that are grade 3 or greater for transfers requiring more than 60 minutes of sitting. Lower extremity contractures that are of sufficient degree as to prohibit sitting in a wheelchair (severe fixed contractures at or proximal to the knee). Unstable joints. Includes flail weight-bearing joints following joint surgery. Includes other patients who, in the expressed opinion of the operating surgeon, must absolutely bear no weight on a postoperative joint or patients who are incapable of protecting the joint without the assistance of the trained medical ambulance personnel. Patients who have undergone successful weight bearing joint repair/replacement and those who have successfully undergone long-bone fracture repair (and who are not otherwise immobilized in casts that prohibit sitting) will generally not be included. Severely debilitating chronic neurological conditions such as degenerative conditions or strokes with severe sequelae. Neurological deficits must be described. Morbid obesity (as a sole qualifying condition) causing the patient to meet the regulatory definition of bed-confined. Medicare does not expect this to occur with persons whose BMI is <80.

II. Conditions – Trauma

On-Scene Condition (General)	On-Scene Condition (Specific)	Comments and Examples (Not All-Inclusive)
Major trauma	As defined by ACS Field Triage Decision Scheme	Trauma with one of the following: Glasgow < 14; systolic BP < 90; RR < 10 or > 29; all penetrating injuries to head, neck, torso, extremities proximal to elbow or knee; flail chest; combination of trauma and burns; pelvic fracture; two or more long-bone fractures; open or depressed skull fracture; paralysis; severe mechanism of injury including: ejection, death of another passenger in same patient compartment, falls > 20 feet, 20-inch deformity in vehicle or 12-inch deformity of patient compartment, auto pedestrian/bike, pedestrian thrown/run over, motorcycle accident at speeds > 20 miles per hour and rider separated from vehicle
Other trauma	Need to monitor or maintain airway or immobilize head/neck	Decreased level of consciousness, bleeding into airway, significant trauma to head, face or neck
Hemorrhage	Potentially life-threatening hemorrhage	Includes uncontrolled bleeding with signs of shock and active severe bleeding (quantity identified), ongoing or recent, with potential for immediate rebleeding
Suspected fractures/dislocations	Suspected fracture or dislocation requires splinting/immobilization and renders patient unable to be transported by another vehicle	Includes suspected fractures or dislocations of spine and long bones and joints proximal to knee and elbow. The record will demonstrate history of significant trauma and or findings to support such suspicions.
Penetrating extremity injuries	Life-or limb-threatening injury	Uncontrolled hemorrhage, compromised neurovascular supply, uncontrollable pain requiring pharmacologic intervention
Traumatic amputations	Life-threatening injury or reattachment opportunity exists
Suspected internal, head, chest or abdominal injuries		Signs of closed head injury, open head injury, pneumothorax, hemothorax, abdominal bruising, positive abdominal signs on exam, internal bleeding criteria, evisceration
Burns	Major: per American Burn Association (ABA)	Partial thickness burns > 10 percent Total Body Surface Area (TBSA); involvement of face, hands, feet, genitalia, perineum or major joints; third-degree burns; electrical, chemical, inhalation burns with pre-existing medical disorders; burns and trauma
Lightning
Electrocution
Near-drowning
Eye injuries	Acute vision loss or blurring, severe pain or chemical exposure, penetrating, severe lid lacerations