Ambulance Transports: HCPCS Codes A0426 or A0428

This Electronic Comparative Billing Report (eCBR) focuses on providers who submit claims for ambulance transport using HCPCS codes A0426 and/or A0428.

Table 1: HCPCS Codes and Descriptions of Ambulance Services

An overview of the Billing for HCPCS codes A0246 and A0248 services is shown below for your review for clarification purposes.

Medical necessity for an ambulance service is established when the patient's condition is such that use of any other method of transportation is contraindicated. Medically necessary non-emergent transportation by an ambulance is appropriate if a patient is either: 

• Bed-confined, with documentation that the patient’s condition (at the time of transport) is such that other methods of transportation are contraindicated, 

or

• The patient’s medical condition, regardless of bed confinement, is such that transportation by ambulance is medically required

For a patient to meet bed-confinement requirements, a patient must be unable to either:

• Get up from bed without assistance
• Ambulate
• Sit in a chair or wheelchair

When means of transportation other than by ambulance can be used without endangering the individual's health, whether such other transportation is available, other forms of transportation should be used rather than ambulance transport.

Medicare’s benefit for ambulance services is a “transport” benefit — without a transport to a Medicare-covered destination, there is no Medicare billable service. Mileage for these transports is calculated per actual loaded (patient onboard) miles and is expressed in statute miles (not nautical miles) and may be paid only for ambulance transport to an approved destination.

Prior Authorization (PA) Option for RSNAT Services
The RRB SMAC is participating in CMS’s Repetitive, Scheduled Non-Emergent Ambulance Transports (RSNAT) — PA program. This PA option assists in making sure services are provided in compliance with Medicare’s guidelines for Coverage, Coding, and Payment. The option allows providers/suppliers to:

• Submit documentation to Medicare for review before services are rendered and before claims are submitted for payment to prevent performing costly services that Medicare will not cover
• Address issues with claims prior to rendering services and submitting claims for payment

Providers are not required to participate in the RSNAT PA program. Medicare regulations require, providers who submit claims for repetitive services will have to submit documentation for every claim from the fourth service forward. Provider participation, therefore, is encouraged. 

The PA option for RSNAT changes claims submissions by first requiring submission 

• Medical necessity requirements for transport
• Level of care guidelines for transport; ALS and BLS standards remain the same as before 
• Medicare coverage and payment requirements, including requirements relating to the origin and destination of the transportation, vehicle and staff, and billing and reporting
• Ambulance medical documentation requirements

The major change is requiring submission of PA request with supporting documentation before a transport becomes repetitive.

For additional information on this program, please visit CMS’s Prior Authorization and Pre-Claim Review Initiatives web page. 

¹ CMS: Medicare Benefit Policy Manual, Chapter 10 - Ambulance Services, Sections 10.2.1 — 10.2.4 (PDF), accessed on June 16, 2023.

² Palmetto GBA: Railroad Providers, Ambulance Prior Authorization accessed on May 16, 2023.

Documentation Requirements for Ambulance Services

The patient medical record must include justification for transport by ambulance. The documentation should include elements like:

• Run sheet for the transport billed
• Documentation supporting bed-confinement
• Signed and dated Provider Certification Statement (PCS)
• Documentation supporting reason alternate transport is contraindicated
• Relevant history to support medical necessity
• Crew signatures and credentials
• Signature attestation (if applicable)
• Beneficiary signature
• Signature of accepting facility representative 
• Abbreviation key (if applicable)
• Advance Beneficiary Notice (ABN) (if applicable)

Methods and Results

The metrics reviewed in this eCBR are the proportion of billing for the ambulance transports services with comparisons to peers within the nationwide Railroad Retirement Board Specialty Medicare Administrative Contractor (RRB SMAC) jurisdiction. This report is an analysis of Medicare Part B claims extracted from the Palmetto GBA data warehouse. The analysis shows the percentage of your claims for HCPCS codes A0426 and A0428 at levels compared to your peers in the RRB SMAC jurisdiction.

Example of eCBR Results from eServices

eCBR Lookup


 
Please be aware that the information contained within this eCBR is not intended to be punitive or an indication of fraud. Rather, it is intended to be proactive communication that will assist you in identifying potential billing issues and help you with performing a self-audit of your conformity with Medicare guidelines.

For more information about this or other eCBRs, please call our Provider Contact Center at 888–355–9165. Customer service representatives are available Monday through Friday, from 8:30 a.m. to 4:30 p.m. in all time zones with the exception of Pacific Time. This service is available from 8:30 a.m. to 4 p.m. PT.

Educational Resources

CMS Resources at www.CMS.gov

• CMS Ambulances Services Center 
• IOM Publication 100-02 Medicare Benefit Policy Manual, Chapter 10 — Ambulance Services (PDF)
• IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 15 — Ambulance (PDF)
• CMS’s Prior Authorization and Pre-Claim Review Initiatives web page 
• MLN Provider Compliance Products
  • Complying with Medicare Signature Requirements
  • Complying with Medical Record Documentation Requirements
  • Provider Compliance Tips for Ambulance Services   

Railroad Medicare Resources at www.PalmettoGBA.com/RR

• Ambulance web page
• RRB SMAC Medical Review Checklists  
• Railroad Providers — Ambulance Prior Authorization