201.100
Ground Ambulance Providers
Ground Ambulance Transportation providers must meet the
Provider Participation and enrollment requirements contained within Section
140.000 of the Arkansas Medicaid provider manual as well as the following
criteria in order to be eligible for participation in the Arkansas Medicaid
Program:
A. A current copy of the
ambulance license issued by the Arkansas Department of Health (instate
providers) or the applicable licensing authority (out-of-state and bordering
state providers) must accompany the provider application and Medicaid contract.
Medicaid will accept approved electronic signatures provided the signatures
comply with Arkansas Code §
25-31-103 et seq.
B. Ambulance transportation providers who
wish to be reimbursed for Advanced Life Support services must submit a current
copy of the ambulance license that reflects Paramedic or Advanced Emergency
Medical Technician (EMT) licensure from the Arkansas Department of Health (for
in-state providers) or the applicable licensing authority (out-of-state
providers). Please refer to Section 252.410 for special billing instructions
regarding Advanced Life Support.
C.
The ambulance company must be enrolled in the Title XVIII (Medicare)
Program.
204.000
Physician's Role in Non-Emergency Ambulance Services
Physician certification statements (PCS) are required for
patients who are under the direct care of a physician and are required
for:
A. Scheduled non-emergency
ambulance transports
B. Unscheduled
non-emergency ambulance transports
Ambulance suppliers must obtain certification from the
patient's attending physician verifying the medical necessity of ambulance
transportation in certain circumstances. The physician certification must be
accurate and timely as it enables billing Medicaid to receive payment.
The attending physician is responsible for supervising the
medical care of the patient by:
A. Reviewing the patient's program of
care;
B. Ordering
medications;
C. Monitoring changes
in the patient's medical status; and,
D. Signing and dating all orders.
NOTE: The signed PCS does not, by itself, demonstrate the
transport was medically necessary and does not absolve the ambulance provider
from meeting all other coverage criteria.
Scheduled Repetitive
Transports
Definition of Repetitive Ambulance Service:
A repetitive ambulance service is defined as medically
necessary ambulance transportation that is furnished three (3) or more times
during a 10-day period, or at least once per week for at least three (3) weeks.
For example, members receiving dialysis or cancer treatment may need repetitive
ambulance services.
PCS requirements for non-emergency scheduled repetitive
ambulance transportation include the following:
A. The PCS for repetitive transports must be
signed and dated by the attending physician before furnishing the services to
the patient.
B. The PCS must be
dated no earlier than sixty (60) days in advance of the transport for those
patients who require repetitive ambulance services and whose transportation is
scheduled in advance.
C. The PCS
may include the expected length of time ambulance transport would be required
not to exceed sixty (60) days.
Non-Repetitive
Transports
A. PCS
requirements for non-emergency (whether scheduled, or not) on a non-repetitive
basis ambulance transportation include the following rules:
1. The PCS must be obtained from the
attending physician within forty-eight (48) hours after the transport
2. If the ambulance provider is unable to
obtain the PCS from the attending physician within forty-eight (48) hours of
transport, the provider may submit a claim within twenty-one (21) days if a
certification has been obtained from one (1) of the following who is
knowledgeable about the patient's condition and who is employed by either the
attending physician or the facility to which the patient is admitted:
a. Physician Assistant;
b. Nurse Practitioner;
c. Clinical Nurse Specialist;
d. Registered Nurse; or,
e. Discharge Planner.
B. If the ambulance provider is
unable to obtain the written order within the 48-hour limit, the supplier may
submit the claim after twenty-one (21) days if there is documentation of
attempts to obtain the order and certification. The provider may send a letter
via U.S. Postal certified mail using the return and/or proof of mailing or
other similar service demonstrating delivery of the letter as evidence of the
attempt to obtain the PCS.
Non-emergency ambulance service claims are subject to
review and recoupment by DHS or its designated representatives.
205.000
Records
Ambulance Providers Are Required to Keep
A. Ambulance providers are required to keep
the following records and, upon request, to immediately furnish the records to
authorized representatives of the Arkansas Division of Medical Services and the
State Medicaid Fraud Control Unit and to representatives of the Department of
Human Services:
1. The beneficiary's
diagnosis, ICD code, if known, or the conditions or symptoms requiring
non-emergency ambulance service. (Diagnosis is not required for emergency
ground ambulance service.)
2. Copy
of the Physician Certification Statement (PCS) for non-emergency ambulance
service to include the ICD diagnosis code, if known, or the conditions or
symptoms establishing medical necessity.
3. Documentation required by Medicare for
ambulance services provided to dual-eligible beneficiaries.
4. Number of miles traveled - Mileage at
transport origin and mileage at transport destination, while loaded, must be
documented. Mileage is paid only for that part of the trip the patient is a
passenger in the ambulance. The loaded miles must be recorded on the Patient
Care Report (PCR). The provider is still responsible for ensuring trip mileage
is
measured and reported accurately, even in cases where the
ambulance personnel fail to reset the trip odometer at the beginning of the
trip. Detailed explanation of what occurred must be documented. Acceptable
tools used to measure mileage include:
a.
Odometer readings (both beginning and ending mileage must be
documented);
b. Global Positioning
Systems (GPS) (GPS printout must be included in documentation); and,
c. Map mileage documented by using an
electronic mapping system (such as Google Maps or MapQuest)
The provider is responsible for ensuring any tools used to
measure trip mileage are in working order. Ambulance providers are required to
use the shortest route in time between point "A" to "B". If the shortest route
cannot be used, the reason why must be documented.
5. The Patient Care Report (PCR) is
documentation used in both non-emergency and emergency transports and should
contain at a minimum:
a. Origin of the call
(i.e., 911, hospital, nursing home, private residence);
b. Origin of transport or pick-up (on
occasion the origin of the call and the pick-up location are
different);
c. Date and times
inclusive of time call received, unit in route to scene, arrival on scene, en
route to destination, arrival at destination;
d. The Arkansas Department of Health (ADH)
vehicle permit number or the unit call sign of the responding unit/ambulance
(if licensed in Arkansas);
e. The
patient's name;
f.
Certification/licensure of all crew members responding, unit and the level of
ambulance service provided; and,
g.
A complete subjective and objective assessment of patient being transported,
monitoring of patient's condition, and supplies used in transport.
B. All required records
must be kept for a period of five (5) years from the ending date of service; or
until all audit questions, appeal hearings, investigations, or court cases are
resolved, whichever period is longer.
C. Furnishing medical records on request to
authorized individuals and agencies listed above in subpart A is a contractual
obligation of providers enrolled in the Medicaid Program. Failure to furnish
medical records upon request may result in the imposition of
sanctions.
D. The provider must
contemporaneously establish and maintain records that completely and accurately
explain all assessments and aspects of care, including the response, interview,
physical exam, any diagnostic procedures performed, any non-invasive or
invasive procedures performed, diagnoses, supplies used, and any other
activities performed in connection with any Medicaid beneficiary.
E. At the time of an audit by the Office of
Medicaid Inspector General, all documentation must be available at the
provider's place of business during normal business hours. There will be no
more than thirty (30) days allowed after the date of any recoupment notice in
which additional documentation will be accepted.
213.200
Exclusions 8-3-20
Ambulance service to a doctor's office or clinic is not
covered, except as described in Section 204.000.
214.000
Covered Ground Ambulance
Services 8-3-20
The following services are covered by Medicaid during the trips
listed in Sections 213.000 through 213.200:
A. Non-Emergency Pick Up Base
Service;
B. Emergency Pick Up Base
Service;
C. Mileage Rate - One Way
(in addition to basic); and,
D.
Disposable Supplies and Drugs as described in Section 252.100. Mileage must be
calculated in accordance with Section 205.000.
216.000
Ambulance Trips with Multiple
Medicaid Beneficiaries 8-3-20
There will be occasions when more than one (1) eligible
Medicaid beneficiary is picked up and transported in an ambulance at the same
time. When this situation exists, the procedures listed below must be
followed:
A. A separate claim must be
filed for each eligible Medicaid beneficiary. Each claim must have a physician
certification, except in situations when multiple patients are transported as a
result of an emergency response. All documentation supporting the medical
necessity of transporting multiple patients in an ambulance must be kept for
retrospective review.
B. If there
is a mileage charge, it must be charged on only one (1) of the eligible
beneficiary's claims.
C. The base
service and other procedures that are used and appropriately documented may be
charged on each eligible beneficiary's claim.
NOTE: If an eligible beneficiary and her newborn child
are transported at the same time, the above procedures will apply. However, if
the newborn has not been certified Medicaid eligible, it will be the
responsibility of the parent(s) to apply and meet the eligibility requirements
for the newborn to be certified as Medicaid eligible. If the newborn is not
certified as Medicaid eligible, the parent(s) will be responsible for the
charges incurred by the newborn.
241.000
Method of Reimbursement
8-3-20
Ambulance services are reimbursed based on the lesser of the
amount billed or the Title XIX (Medicaid) charge allowed.
251.000
Introduction to Billing
8-3-20
Ambulance transportation providers use the CMS-1500 claim
format to bill the Arkansas Medicaid Program for services provided to eligible
Medicaid beneficiaries. Each claim must contain charges for only one (1)
beneficiary. For a date of service where more than one (1) ambulance service
was provided, all service runs must be billed on one (1) claim.
Section III of this manual contains information about Provider
Electronic Solutions (PES) and other available options.
252.100
Ambulance Procedure Codes
8-3-20
The covered ambulance procedure codes are listed below.
Drug procedure codes require National Drug Codes (NDC) billing
protocol. See Section 252.110 below.
|
A0382
|
A0398
|
A0422
|
A0425
|
A0426
|
A0427
|
A0428
|
A0429
|
|
J0150*
|
J0171*
|
J0280*
|
J0461*
|
J1094*
|
J1100*
|
J1160*
|
J1200*
|
|
J1265
|
J1940*
|
J2060*
|
J2175*
|
J2270*
|
J2310*
|
J2550*
|
J2560*
|
|
J3360*
|
J3410*
|
J3475*
|
J3480*
|
J3490*
|
93041*
|
|
|
*Procedure code can be billed only in
conjunction with procedure codeA0426 and A0427 (please keep all
documentation supporting the medical necessity of all codes billed for
retrospective review of claims).
Arkansas Medicaid follows the billing protocol per the Federal
Deficit Reduction Act of 2005 for drugs.
A. Multiple units may be billed when
applicable. Take-home drugs are not covered. Drugs loaded into an infusion pump
are not classified as "take-home drugs." Refer to payable CPT code ranges 96365
through 96379.
B. When submitting
Arkansas Medicaid drug claims, drug units should be reported in multiples of
the dosage included in the HCPCS procedure code description. If the dosage
given is not a multiple of the number provided in the HCPCS code description
the provider shall round up to the nearest whole number in order to express the
HCPCS description number as a multiple.
1.
Single-Use Vials: If the provider must discard the remainder of a
single-use vial or other package after administering the
prescribed dosage of any given drug, Arkansas Medicaid will cover the amount of
the drug discarded along with the amount administered.
2.
Multi-Use Vials: Multi-use
vials are not subject to payment for any discarded amounts of the drug. The
units billed must correspond with the units administered to the
beneficiary.
3.
Documentation: The provider must clearly document in the patient's
medical record the actual dose administered in addition to the exact amount
wasted and the total amount the vial is labeled to contain.
4.
Paper Billing: For drug
HCPCS/CPT codes requiring paper billing (i.e., for manual review), complete
every field of the
DMS-664 "Procedure Code/NDC Detail Attachment
Form." Attach this form and any other required documents to your claim when
submitting it for processing.
Remember to verify the milligrams given to the patient and then
convert to the proper units for billing.
Follow the Centers for Disease Control (CDC) requirements for
safe practices regarding expiration and sterility of multi-use vials.
|
Procedure Code
|
Required Modifier
|
Description
|
|
A0422
|
U1
|
Emergency, oxygen, helicopter air ambulance
|
|
A0425
|
|
Ground mileage per statute mile
|
|
A0431
|
|
Ambulance service, emergency, basic pick-up,
helicopter, one unit per day
|
|
A0434
|
|
Air Ventilator/Respiratory Therapist, one unit equals
one hour (Round to the nearest hour)
|
|
A0435
|
U1, UB
|
Piston propelled fixed wing air ambulance per
mile
|
|
U2, UB
|
Turboprop fixed wing air ambulance per mile
|
|
U3, UB
|
Jet (fixed wing) one unit equals one mile
|
|
U4, UB
|
Piston propelled fixed wing air ambulance per hour
(Round to the nearest hour)
|
|
U5, UB
|
Turboprop fixed wing air ambulance per hour (Round to
the nearest hour)
|
|
U6, UB
|
Jet (fixed wing) one unit equals one hour (Round to the
nearest hour)
|
|
A0436
|
|
Emergency, per mile, loaded, helicopter air
ambulance
|
252.410
Levels of Ambulance Life
Support (ALS) and Basic Life Support (BLS)
Levels of ambulance life support are not applicable to
transports by air ambulance and apply to ground ambulance transportation only.
Ambulance transportation providers who bill advanced life support (ALS)
services must be licensed as advanced emergency medical technicians (EMTs) or
paramedics. All ambulance transports must be made and billed to Medicaid
appropriately according to the licensure level of the provider. The level of
services billed to Medicaid must be in compliance with the level of care
provided and reflected by the license of the provider.
Basic Life Support (BLS) services are supportive and
non-definitive in nature. BLS assessment includes brief and limited patient
assessment and management procedures including evaluation of vital signs,
mental and neurologic states, and hemodynamic stability.
To bill at the ALS level of service, the transportation event
must include provision of an ALS assessment or at least one (1) ALS
intervention. An ALS assessment is performed by an advanced EMT or paramedic as
part of an emergency response that is necessary because the beneficiary's
reported condition at the time of the service indicates only an advanced EMT or
paramedic is qualified to perform the assessment. In the case of an
appropriately dispatched ALS emergency service and if the ALS crew
appropriately completes an ALS assessment, the services provided by the
provider during that transportation event are covered at the ALS level of
service.
