WHO QUALIFIES? GENERAL GUIDELINE
Insurance carriers cover ambulance services only if furnished to a patient whose medical condition at the time of transport is such that transportation by other means would endanger the patient’s health or is contraindicated.
EMERGENCY AMBULANCE – CALL 911
Ambulance services are covered only if the services are medically necessary and the patient is transported to the closest appropriate facility. Emergency response means responding immediately at the Basic Life Support BLS or Advanced Life Support 1 (ALS1) level of service to a 911 call or the equivalent.
The patient’s condition must be an emergency that renders the patient unable to go safely to the hospital by other means. Emergency ambulance services are services provided after the sudden onset of a medical condition and there are acute signs/symptoms of sufficient severity that manifest the emergency medical condition such that the absence of immediate medical attention could reasonably be expected to result in one or more of the following:
- Place the patient’s health in serious jeopardy.
- Cause serious impairment to bodily functions.
- Cause serious dysfunction of any body organ or part.
NON-EMERGENCY AMBULANCE TRANSPORTS Non-emergency ambulance services may be those that are scheduled in advance- scheduled services being either repetitive or non-repeating.
For conditions that do not fit the definitions given above for emergency ambulance services, Insurance carriers cover Non-emergency ambulance transportation if the patient is bed- confined or if the patient’s medical condition at the time of transport is such that transportation by ambulance is medically required whether or not he/she is bed confined.
Medical necessity is established for non-emergency ambulance services when the patient’s condition at the time of transport is such that the use of any other method of transportation (such as taxi, private car, wheelchair van or other type of vehicle) is contraindicated.
“Carrousel MTS is committed to unequivocally adhere to the guidelines set forth by Medicare, Medicaid, and other Insurance Carriers in regards to qualification for Non-emergency medical Transportation Services.”
Examples of such medical conditions are as follows:
- AIRWAY MANAGEMENT— 02 ADMINISTRATION, SUCTION REQUIRED OR AIRWAY CONTROL/POSITION REQUIRED EN ROUTE.
- POSITIONING REQUIRES SPECIALIZED HANDLING- DUCUBITUS ULCERS / CONTRACTURES
- PATIENT IS A FALL RISK DUE TO WEAKNESS AND DISORIENTATION
- PATIENT IS A DANGER TO SELF OR OTHERS- CONSTANT MONITORING OR IN RESTRAINTS
The standards for which patients may qualify for non-emergency transport have become much more critical and strict. As of October 2015 all patients MEDICAL NECESSITY for non-emergency transports will be determined by their qualifications of both a primary and secondary diagnosis code. The primary diagnosis code can be any ICD-10 code that is available under local coverage guidelines and must accurately describe the patient’s medical condition AT THE TIME OF TRANSPORT.
The secondary mandatory diagnosis code must be chosen out of the four options made available to providers that “most accurately describes WHY non-emergency transport is reasonable and necessary”. The 4 secondary available options are as listed below:
- Z74.01-BED CONFINEMENT STATU
- Z74.3-NEED FOR CONTINUOUS SUPERVISION
- Z78.1-PHYSICAL RESTRAINTS STATUS
- Z99.89-DEPENDENCE ON OTHER ENABLING MACHINES OR DEVICES