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