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.