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, Market/Military
Treatment Facility (MTF), or Veterans
Health Administration (VHA) hospital and transfers between Market/MTFs,
VHA hospitals and civilian hospitals whether ordered by civilian
or military personnel.
3.2 Ambulance
transfers from a hospital based emergency room to a
Market/MTF, VHA hospital
or other civilian hospital more capable of providing the required
care whether ordered by civilian or military personnel.
3.3 Transfers
between a Market/MTF, 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
a
Market/MTF
as outlined
in
paragraph 3.5.
3.5 A
claim for ambulance service to a Market/MTF
shall not be denied on the grounds that there is a nearer civilian
institution (hospital) having appropriate facilities to treat the
patient.
3.6 Ground
transportation from an airfield to the accepting medical facility
is authorized and will be reimbursed at Civilian Health and Medical
Program of the Uniformed Services (CHAMPUS) Maximum Allowable Charge
(CMAC) rates in the Continental United States (CONUS). In overseas regions
that are not subject to CMAC rates, the negotiated reasonable and
customary rate will be used.
3.8 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 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.
3.9 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 3.6.6.
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.