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 Veterans Health
Administration (VHA)
hospital and transfers between MTFs/eMSMs, VHA
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, VHA
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.