A/B MAC (A) Bill Processing Guidelines Effective April 1, 2002, as a

30.2.1 - A/B MAC (A) Bill Processing Guidelines Effective April 1, 2002, as a Result of Fee Schedule Implementation (Rev. 3076, Issued: 09-24-14, Effective: Upon Implementation of ICD-10 ASC X12: 01-01- 12, Implementation: ICD-10: Upon Implementation of ICD-10 ASC X12: 09-16-14) For SNF Part A, the cost of medically necessary ambulance transportation to receive most services included in the RUG rate is included in the cost for the service. Payment for the SNF claim is based on the RUGs, which takes into account the cost of such transportation to receive the ancillary services. Refer to IOM Pub. 100-04, Medicare Claims Processing Manual, chapter 6 - SNF Inpatient Part A Billing, Section 20.3.1 - Ambulance Services for additional information on SNF consolidated billing and ambulance transportation. Refer to IOM Pub. 100-04, Medicare Claims Processing Manual, chapter 3 - Inpatient Hospital Billing, section 10.5 - Hospital Inpatient Bundling, for additional information on hospital inpatient bundling of ambulance services. In general, the A/B MAC (A) processes claims for Part B ambulance services provided by an ambulance supplier under arrangements with hospitals or SNFs. These providers bill A/B MACs (A) using only Method 2. The provider must furnish the following data in accordance with A/B MAC (A) instructions. The A/B MAC (A) will make arrangements for the method and media for submitting the data: • A detailed statement of the condition necessitating the ambulance service; • A statement indicating whether the patient was admitted as an inpatient. If yes the name and address of the facility must be shown; • Name and address of certifying physician; • Name and address of physician ordering service if other than certifying physician; • Point of pickup (identify place and completed address); • Destination (identify place and complete address); • Number of loaded miles (the number of miles traveled when the beneficiary was in the ambulance); • Cost per mile; • Mileage charge; • Minimum or base charge; and • Charge for special items or services. Explain. A. Revenue Code Reporting on Form CMS-1450 Providers report ambulance services under revenue code 540 in FL 42 “Revenue Code.” B. HCPCS Codes Reporting on Form CMS-1450 Providers report the HCPCS codes established for the ambulance fee schedule. No other HCPCS codes are acceptable for the reporting of ambulance services and mileage. The HCPCS code must be used to reflect the type of service the beneficiary received, not the type of vehicle used. Providers must report one of the following HCPCS codes in FL 44 “HCPCS/Rates” for each base rate ambulance trip provided during the billing period: A0426; A0427; A0428; A0429; A0430; A0431; A0432; A0433; or A0434. These are the same codes required effective for services January 1, 2001. In addition, providers must report one of HCPCS mileage codes: A0425; A0435; or A0436. Since billing requirements do not allow for more than one HCPCS code to be reported per revenue code line, providers must report revenue code 540 (ambulance) on two separate and consecutive line items to accommodate both the ambulance service and the mileage HCPCS codes for each ambulance trip provided during the billing period. Each loaded (e.g., a patient is onboard) 1-way ambulance trip must be reported with a unique pair of revenue code lines on the claim. Unloaded trips and mileage are NOT reported. For Form CMS-1450 claims submission prior to August 1, 2011, providers code one mile for trips less than a mile. Miles must be entered as whole numbers. If a trip has a fraction of a mile, round up to the nearest whole number. Beginning with dates of service on or after January 1, 2011, for Form CMS-1450 hard copy claims submissions August 1, 2011 and after, mileage must be reported as fractional units. When reporting fractional mileage, providers must round the total miles up to the nearest tenth of a mile and the decimal must be used in the appropriate place (e.g., 99.9). For trips totaling less than 1 mile, enter a “0” before the decimal (e.g., 0.9). For electronic claims submissions prior to January 1, 2011, providers code one mile for trips less than a mile. Miles must be entered as whole numbers. If a trip has a fraction of a mile, round up to the nearest whole number. Beginning with dates of service on or after January 1, 2011, for electronic claim submissions only, mileage must be reported as fractional units for trips totaling up to 100 covered miles. When reporting fractional mileage, providers must round the total miles up to the nearest tenth of a mile and the decimal must be used in the appropriate place (e.g., 99.9). For trips totaling 100 covered miles and greater, providers must report mileage rounded up to the nearest whole number mile (e.g., 999) and not use a decimal when reporting whole number miles over 100 miles. For trips totaling less than 1 mile, enter a “0” before the decimal (e.g., 0.9). C. Modifier Reporting Providers must report an origin and destination modifier for each ambulance trip provided and either a QM (Ambulance service provided under arrangement by a provider of services) or QN (Ambulance service furnished directly by a provider of services) modifier in FL 44 “HCPCS/Rates". D. Service Units Reporting For line items reflecting HCPCS codes A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434, providers are required to report in “Service Units” for each ambulance trip provided. Therefore, the service units for each occurrence of these HCPCS codes are always equal to one. In addition, for line items reflecting HCPCS code A0425, A0435, or A0436, providers must also report the number of loaded miles. E. Total Charges Reporting For line items reflecting HCPCS codes A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434, providers are required to report in Total Charges the actual charge for the ambulance service including all supplies used for the ambulance trip, but excluding the charge for mileage. For line items reflecting HCPCS codes A0425, A0435, or A0436, providers are to report the actual charge for mileage. NOTE: There are instances where the provider does not incur any cost for mileage, e.g., if the beneficiary is pronounced dead after the ambulance is called but before the ambulance arrives at the scene. In these situations, providers report the base rate ambulance trip and mileage as separate revenue code lines. Providers report the base rate ambulance trip in accordance with current billing requirements. For purposes of reporting mileage, they must report the appropriate HCPCS code, modifiers, and units. For the related charges, providers report $1.00 in non- covered charges. A/B MACs (A) should assign remittance adjustment Group Code OA to the $1.00 non-covered mileage line, which in turn informs the beneficiaries and providers that they each have no liability. F. Edits (A/B MAC (A) Claims with Dates of Service On or After 4/1/02) For claims with dates of service on or after April 1, 2002, FISS performs the following edits to assure proper reporting: • Edit to assure each pair of revenue codes 540 have one of the following ambulance HCPCS codes - A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434; and one of the following mileage HCPCS codes - A0425, A0435, or A0436. • Edit to assure the presence of an origin, destination modifier, and a QM or QN modifier for every line item containing revenue code 540; • Edit to assure that the unit’s field is completed for every line item containing revenue code 540; • Edit to assure that service units for line items containing HCPCS codes A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434 always equal “1"; and • Edit to assure on every claim that revenue code 540, a value code of A0 (zero), and a corresponding ZIP Code are reported. If the ZIP Code is not a valid ZIP Code in accordance with the USPS assigned ZIP Codes, A/B MACs (A) verify the ZIP Code to determine if the ZIP Code is a coding error on the claim or a new ZIP Code from the USPS not on the CMS supplied ZIP Code File. • Beginning with dates of service on or after April 1, 2012, edit to assure that only non- emergency trips (i.e., HCPCS A0426, A0428 [when A0428 is billed without modifier QL]) require an NPI in the Attending Physician field. Emergency trips do not require an NPI in the Attending Physician field (i.e., A0427, A0429, A0430, A0431, A0432, A0433, A0434 and A0428 [when A0428 is billed with modifier QL]) G. CWF (A/B MACs (A)) A/B MACs (A) report the procedure codes in the financial data section. They include revenue code, HCPCS code, units, and covered charges in the record. Where more than one HCPCS code procedure is applicable to a single revenue code, the provider reports each HCPCS code and related charge on a separate line, and the A/B MAC (A) reports this to CWF. Report the payment amount before adjustment for beneficiary liability in “Rate” and the actual charge in “Covered Charges.”