Ambulance Fee Schedules: Documentation Is The Key For Correct Reimbursement


The basic requirement in ambulance fee schedule is that you have to document, document, and document every small intricacies. You have to really convince the FI, the carrier, whoever it is you're filling the claim to that they really should pay you for this service. This is one of these places where the presumption of payment is not present. You have to do the convincing.

Ambulance Fee Schedule asks for a whole lot of documentation requirements, and the documentation is not filed with the claim form. In case of critical access hospital, typically, if they have ambulance services, they will pull it under the cost base reimbursed process. Critical access hospitals don’t always assume that your cost base reimbursement will be more than for instance the reimbursement you might get under the ambulance fee schedule. Revenue code 540 is usually the one that is mostly used. There are two separate line items by which you get paid for the ambulance; one is loaded one way ambulance trip and you must report this with a payer of revenue code lines, all right, two lines, 540. And there are to be on two separate consecutive line items which usually is not a problem, plus you have to report the level of service. You have to be very careful here, level of service versus type of vehicle—you may have an ALS vehicle but you only needed to provide BLS services. Therefore you should use the BLS code. Now, this is where you should stop and ask yourself, “Okay, where in the process are we determining? Which codes to use? Which level of service has been provided? Was it medically necessary? And who's going to make that determination?” So, it’s very crucial that you have a process.

Once you have a process in place, you should be concerned about the modifiers, the origin destination modifier and then the under-arrangements are not. Now, the under-arrangements are probably going to stay the same based upon your circumstances. But the origin and destination modifier will have to be developed and attached into the billing system some place along the line. In many cases, we need to know about EMTALA because the nearest appropriate facility may not be able to accommodate the patient for whatever the reason, and suppose the nearest appropriate facility may be someplace else. But in the meantime, the patient may want to go to a different facility which is a little bit farther down the road. And so, those miles between the (parents) to appropriate facility to the facility to which they wanted to go, those are not covered. It is statutorily not covered. And therefore, you don't have to issue an ABN. You should theoretically issue an NEMB. But in many cases, you won't even know it until it actually occurs. So there's another HCPCS code that definitely should be in the charge master. And you would have to move the charge over for non covered column on the UB04.
In ambulance fee schedule, you cannot deny the importance of zip code reporting according to healthcare guideline articles. The zip code is very important as this could drive these rural adjustment factors, and the providers should make sure that if you are due some sort of a rural adjustment that you indeed get it. Remember the separate claims are necessary if there are different zip codes. So, if you're doing multiple ambulances billing on the same claim form and you have different zip codes, then you're going to have to file separate claims. For example, suppose the patient is transported from home to hospital and later in the day, patient was transported to a nursing facility; undoubtedly, you have to use two different zip codes. A unit reporting is not an issue. Based rate codes can have unit one. And the mileage codes will have units that are the number of the loaded miles.

In the 1500 claim form, there is an equivalent box where we can put the additional information, this is one of the most interesting things about ambulance coding and billing claims filing is that we get to use that form locator 80, the remarks. The ambulance provider should use that space as much as they can with details of condition necessitating the ambulance services; indicate a patient was admitted to the facility that you took them to, point of pickup, destination, any special items or services. Get as much as you can in the form locator 80 so that you can justify what's going on. In addition, the providers should have the general medical documentation. For e.g. the EMT documentation is typically very good. Date, time, pickup, destination, level of care, diagnoses - if you can do it, description of condition, hospital discharge summary, physician certification. We of course, have the ambulance record, supplemental documentation, ER admission documentation if we're going to the ER, ambulance pre-hospital care, ABN/NEMBs, billing information. In other words, we have to have just as much documentation as we can get. And it may come from different sources. Now, this documentation is what backs up the claim. And of course, this is the documentation that the RAC, the recovery audit contractors will go at.

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