1.0 HCPCS 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 Medical Treatment Facility
(MTF), or Veterans Health Administration (VHA) hospital and transfers
between Markets/MTFs, VHA hospitals and civilian hospitals whether
ordered by civilian or military personnel.
3.2 Ambulance
transfers from a hospital-based emergency room (ER) 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 an 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 Ambulance transfer to and from
skilled nursing facilities when medically indicated. See the TRICARE Reimbursement
Manual (TRM),
Chapter 8, Section 1.
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.
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.