Clinical UM Guideline


Subject:  Ambulance Services: Ground; Non-Emergent
Guideline #:  CG-ANC-06Current Effective Date:  07/15/2014
Status:NewLast Review Date:  05/15/2014

Description

An ambulance is a specially equipped vehicle designed and supplied with materials and devices to provide life-saving and supportive treatments or interventions. Wheelchair vans or other such vehicles are not so equipped and are not addressed in this document.

This document addresses the use of ground ambulances in non-emergency situations only.

Note: Please see the following related documents for additional information.

Clinical Indications

Medically Necessary:

The use of non-emergency ground ambulance services is considered medically necessary when the following criteria are met (1, 2, AND 3 must be met):

  1. The ambulance must have the necessary equipment and supplies to address the needs of the individual; and
  2. The individual's condition must be such that any other form of transportation would be medically contraindicated; and
  3. Either of the following circumstances exists:
    1. Transportation to or from one hospital or medical facility to another hospital or medical facility, skilled nursing facility, or free-standing dialysis center in order to obtain medically necessary diagnostic or therapeutic services is required (for example magnetic resonance imaging, computed tomography scan, acute interventional cardiology, intensive care unit [ICU] services [including neonatal ICU], Cobalt therapy, etc.) provided such services are unavailable at the facility where the individual initially resides; or
    2. Transfer from an acute care facility to an individual's home or a skilled nursing facility is required.

Non-emergency ground ambulance services for deceased individuals are considered medically necessary when the criteria above have been met and when either of the following is present:

  1. The individual was pronounced dead while in route or upon arrival at the hospital or final destination; or
  2. The individual was pronounced dead by a legally authorized individual (physician or medical examiner) after the ambulance call was made, but prior to pick-up. In these circumstances the response to call is considered medically necessary.

Not Medically Necessary:

The use of non-emergency ground ambulance services is considered not medically necessary when:

  1. The criteria and circumstances above have not been met; or
  2. The services are primarily for the convenience of the individual or the individual's family or physician; or
  3. The services are for a transfer of a deceased individual to a funeral home, morgue, or hospital, when the individual was pronounced dead at the scene.
Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

HCPCS 
A0380BLS mileage (per mile)
A0390ALS mileage (per mile)
A0425Ground mileage, per statute mile
A0426Ambulance service, advanced life support, non-emergency transport, Level 1 (ALS1)
A0428Ambulance service, basic life support, non-emergency transport (BLS)
A0432Paramedic intercept (PI), rural area, transport furnished by a volunteer ambulance company which is prohibited by state law from billing third party payers
A0434Specialty care transport (SCT)
A0998Ambulance response and treatment, no transport
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
 All diagnoses
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2015]
 All diagnoses
  
Discussion/General Information

Ambulance transport services involve the use of specially designed and equipped vehicles to transport ill or injured individuals. Ambulance transport may involve the movement of an individual to the nearest hospital for treatment of an individual's illness or injury, non-emergency medical transport of an individual to another location to obtain medically necessary specialized diagnostic or treatment services, or non-emergency medical transport to a hospital or to an individual's home. Although wheelchair vans are specially equipped to accommodate physically challenged individuals, they do not have the proper equipment to qualify as an ambulance. Proper equipment may include ventilation and airway equipment, cardiac equipment (monitoring and defibrillation), immobilization devices, bandages, communication equipment, obstetrical kits, infection control, injury prevention equipment, vascular access equipment, and medications.

An ambulance may be either a ground transportation vehicle, such as a specially equipped truck or van, but may also be a properly equipped aircraft or boat. This document specifically addresses only ground transportation-type ambulances.

Non-emergency medical transport via ambulance may be necessary if an individual's condition is such that any other form of transportation would be medically contraindicated such as being bed-confined (unable to get up from bed without assistance, unable to ambulate, and unable to sit in a chair or wheelchair) and can only be moved by stretcher or having severe vertigo causing inability to remain upright.

References

Government Agency, Medical Society, and Other Authoritative Publications: 

  1. American College of Emergency Physicians. Guidelines for Ambulance Diversion (1999, reaffirmed 2012). Available at: http://www.acep.org/practres.aspx?id=29080. Accessed on March 31, 2014.
  2. American College of Emergency Physicians/National Association of EMS Physicians. Alternate Ambulance Transportation and Destination (2001; reaffirmed 2008). Available at: http://www.acep.org/practres.aspx?id=29078. Accessed on March 31, 2014.
  3. American College of Surgeons Committee on Trauma/American College of Emergency Physicians/National Association of EMS Physicians/American Academy of Pediatrics/National Association of EMS physicians. Equipment for Ambulances (2009). Available at: www.facs.org/trauma/publications/ambulance.pdf. Accessed on March 31, 2014.
  4. Cahaba Government Benefit Administrators®. Local Coverage Determination for Transportation Services: Ambulance (L30022). Revised 08/01/2012. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on March 31, 2014.
  5. Novitas Solutions, Inc. Local Coverage Determination for Ambulance (Ground) Services (L32252). Revised 06/20/2013. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on March 31, 2014.
  6. Palmetto GBA. Local Coverage Determination for Ambulance Services (L31604). Revised 07/11/2013. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on March 31, 2014.
  7. Thomson DP, Thomas SH; 2002-2003 Air Medical Services Committee of the National Association of EMS Physicians. Guidelines for air medical dispatch. Prehosp Emerg Care. 2007; (2):265-271.
Index

Ambulance
Non-Emergency Ambulance Transport

Document History

Status

Date

Action

New05/15/2014Medical Policy & Technology Assessment Committee (MPTAC) review. Initial document development created from CG-ANC-01 Ambulance Services: Ground.