1.0 HCPCS
PROCEDURE CODES
Level II Codes
A0225, A0382, A0384, A0392, A0394, A0396, A0398, A0422, A0424 - A0436, A0998, A0999,
S0207, S0208
2.0 DESCRIPTION
Transportation by means of a specifically designed
vehicle for transporting the sick and injured that contains a stretcher,
linens, first aid supplies, oxygen equipment, and such other safety
and life saving equipment as is required by state and local law
and is staffed by personnel trained to provide first aid treatment.
3.0 POLICY
Coverage is limited to the following:
3.1 Emergency
transfers to or from a beneficiary’s place of residence, accident
scene, or other location to a civilian hospital, Military Treatment
Facility (MTF)/Enhanced Multi-Service Market (eMSM), or Department
of Veterans Affairs (VA) hospital and transfers between MTFs/eMSMs,
VA hospitals and civilian hospitals whether ordered by civilian
or military personnel.
3.2 Ambulance transfers from a
hospital based emergency room to an MTF/eMSM, VA hospital or other
civilian hospital more capable of providing the required care whether
ordered by civilian or military personnel.
3.3 Transfers
between an MTF/eMSM, or civilian hospital or skilled nursing facility
and a freestanding or another hospital based outpatient therapeutic
or diagnostic department/facility whether ordered by civilian or
military personnel.
3.4 Ambulance services by other
than land vehicles (such as a boat or airplane)
shall be
considered only when the pickup point is inaccessible by a land
vehicle, or when great distance or other obstacles are involved
in transporting the patient to the nearest hospital with appropriate
facilities and the patient’s medical condition warrants speedy admission
or is such that transfer by other means is contraindicated. Transporting
to the nearest hospital does not apply when transporting to an MTF/eMSM
as outlined in
paragraph 3.5.
3.5 A
claim for ambulance service to a Uniformed Services Medical Treatment
Facility (USMTF) shall not be denied
on the grounds that there is a nearer civilian institution (hospital)
having appropriate facilities to treat the patient.
3.7 Payment
of services and supplies provided by ambulance personnel at an accident
scene shall be allowed when the patient’s
condition warrants transfer to an inpatient acute setting and medical services
and/or supplies are provided solely to stabilize the patient’s condition
while awaiting the arrival of a more urgent means of transfer; e.g.,
air ambulance services.
3.8 Effective
for services provided on or after September 13, 2018, medically
necessary services rendered by the ambulance on-scene although the
patient did not receive transport (“treat-and-release”) is a benefit
under the ambulance benefit. Payment for services and supplies provided
by ambulance personnel when no transport is provided shall be authorized
so long as those services and supplies are medically necessary.
Payment shall be made for services and supplies if the ambulance personnel
determine after treatment that the patient is stabilized and does
not require hospitalization, or if the patient refuses transport
after being treated. Payment shall only be made to TRICARE-authorized
ambulance companies; paramedics and other first responders may not
independently bill for treat-and-release services. See TRM, Chapter 1, Section 14, paragraph 3.6.8.
4.0 EXCLUSIONS
4.1 Ambulance
service used instead of taxi service when the patient’s condition
would have permitted use of regular private transportation.
4.2 Transport
or transfer of a patient primarily for the purpose of having the
patient nearer to home, family, friends, or personal physician.
Except as described in
paragraph 3.3, transport
shall be
to the closest appropriate facility by the least costly means.
Note: The exclusion of ambulance coverage “primarily
for the purpose of having the patient nearer to home, family, friends,
or personal physician” does not apply when the ambulance transfer
is medically necessary and appropriate. If there is documentation
that the ambulance transfer is for reasons of medical necessity
(e.g., the need for parental nurturing of an infant as a component
of or in furtherance of medical treatment; the need to place a child
in an appropriate level of care) then the ambulance service is not
“primarily” driven by considerations of family/patient convenience
and the exclusion does not apply.
4.3 Medicabs or ambicabs which
function primarily as public passenger conveyances transporting patients
to and from their medical appointments.