Coding Instructions for Paper and Electronic Claim Forms

30.1.2 - Coding Instructions for Paper and Electronic Claim Forms (Rev. 4205, Issued: 01-18-19, Effective: 02-19-19, Implementation: 02-19-19) The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes. Except as otherwise noted, beginning with dates of service on or after January 1, 2001, the following coding instructions must be used. Origin Electronic billers should refer to the Implementation Guide to determine how to report the origin information (e.g., the ZIP Code of the point of pickup). Beginning with the early implementation of version 5010 of the ASC X12 837 professional claim format on January 1, 2011, electronic billers are required to submit, in addition to the loaded ambulance trip’s origin information (e.g., the ZIP Code of the point of pickup), the loaded ambulance trip’s destination information (e.g., the ZIP code of the point of drop-off). Refer to the appropriate Implementation Guide to determine how to report the destination information. Only the ZIP Code of the point of pickup will be used to adjudicate and price the ambulance claim, not the point of drop-off. However, the point of drop-off is an additional reporting requirement on version 5010 of the ASC X12 837 professional claim format. Where the CMS-1500 Form is used the ZIP code is reported in item 23. Since the ZIP Code is used for pricing, more than one ambulance service may be reported on the same paper claim for a beneficiary if all points of pickup have the same ZIP Code. Suppliers must prepare a separate paper claim for each trip if the points of pickup are located in different ZIP Codes. Claims without a ZIP Code in item 23 on the CMS-1500 Form item 23, or with multiple ZIP Codes in item 23, must be returned as unprocessable. The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two. Group Code: CO CARC: 16 RARC: N53 MSN: N/A ZIP Codes must be edited for validity. The format for a ZIP Code is five numerics. If a nine-digit ZIP Code is submitted, the last four digits are ignored. If the data submitted in the required field does not match that format, the claim is rejected. Mileage Generally, each ambulance trip will require two lines of coding, e.g., one line for the service and one line for the mileage. Suppliers who do not bill mileage would have one line of code for the service. Beginning with dates of service on or after January 1, 2011, mileage billed must be reported as fractional units in the following situations: • Where billing is by ASC X12 claims transaction (professional or institutional), and • Where billing is by CMS-1500 paper form. Electronic billers should see the appropriate Implementation Guide to determine where to report the fractional units. Item 24G of the Form CMS-1500 paper claim is used. Fractional units are not required on Form CMS-1450. Beginning with dates of service on or after January 1, 2026, mileage billed must be reported as fractional units in the following situations: • Where billing is by ASC X12 claims transaction (professional or institutional), and • Where billing is by CMS-1500 paper form. Electronic billers should see the appropriate Implementation Guide to determine where to report the fractional units. Item 24G of the Form CMS-1500 paper claim is used. Fractional units are not required on Form CMS-1450. For trips totaling up to100 covered miles suppliers must round the total miles up to the nearest tenth of a mile and report the resulting number with the appropriate HCPCS code for ambulance mileage. The decimal must be used in the appropriate place (e.g., 99.9). For trips totaling 100 covered miles and greater, suppliers must report mileage rounded up to the next whole number mile without the use of a decimal (e.g., 998.5 miles should be reported as 999). For trips totaling less than 1 mile, enter a “0” before the decimal (e.g., 0.9). For mileage HCPCS billed on the ASC X12 837 professional transaction or the CMS-1500 paper form only, contractors shall automatically default to “0.1” units when the total mileage units are missing. For mileage HCPCS billed on the ASC X12 837 professional transaction or the CMS-1500 paper form only, contractors shall automatically default to “0.1” units when the total mileage units are missing. Multiple Patients on One Trip Ambulance suppliers submitting a claim using the ASC X12 professional format or the CMS- 1500 paper form for an ambulance transport with more than one patient onboard must use the “GM” modifier (“Multiple Patients on One Ambulance Trip”) for each service line item. In addition, suppliers are required to submit documentation to A/B MACs (Part B) to specify the particulars of a multiple patient transport. The documentation must include the total number of patients transported in the vehicle at the same time and the Medicare beneficiary identifiers for each Medicare beneficiary. A/B/MACs (Part B) shall calculate payment amounts based on policy instructions found in Pub.100-02, Medicare Benefit Policy Manual, Chapter 10 – Ambulance Services, Section 10.3.10 – Multiple Patient Ambulance Transport. Ambulance claims submitted on or after January 1, 2011, in version 5010 of the ASC X12 837 professional claim format require the presence of a diagnosis code and the absence of diagnosis code will cause the ambulance claim to not be accepted into the claims processing system. The presence of a diagnosis code on an ambulance claim is not required as a condition of ambulance payment policy. The adjudicative process does not take into account the presence (or absence) of a diagnosis code, but a diagnosis code is required on the ASC X12 837 professional claim format.