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Ambulance Billing Guide
- Ambulance Duplicate Claim Denials
- Ambulance Transports Included in SNF Consolidated Billing
- Ambulance Physician Certification Statement Guidelines
- Prior Authorization of Repetitive Scheduled Non-Emergent Ambulance Transport
- New York State Ambulance Services in Rural Areas (for JK providers only)
- Coverage of Rural Air Ambulance Services
- Ambulance Transports Excluded from SNF Consolidated Billing
- Ambulance Medical Necessity Reminder for ESRD Patients
- Related Content
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Related Articles
- Claim Denials for Medically Unnecessary Ambulance Transports: Avoiding Reason Code 55B10
- Ambulance Medical Necessity
- Ambulance Rural ZIP Code Search
- Billing for A0426 or A0428
- Medical Necessity of Ambulance Services
- Proper Claim Submission for Repetitive, Scheduled, Non-Emergent Ambulance Transports
- Responsibility of Providing a Properly Executed Physician Certification Statement/Certificate of Medically Necessity
Ambulance Transports Excluded from SNF Consolidated Billing
When a Medicare beneficiary is a resident in a SNF under a Part A stay, not all ambulance transports are included in the PPS (prospective payment system) payment for a SNF. SNF consolidated billing includes those medically necessary ambulance trips that are furnished during the course of a covered Part A stay except for specific exclusions as indicated in the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 20.3, Other Services Excluded from SNF PPS and Consolidated Billing.
In most cases, ambulance trips are excluded from consolidated billing when resident status has ended. The ambulance company then must bill the MAC (as appropriate) directly for payment. Listed below are specific circumstances under which a beneficiary may receive ambulance services that are covered by Medicare, but excluded from consolidated billing. The following ambulance services may be billed as Part B services to Medicare by the ambulance provider/supplier in the following situations only.
Note: All ambulance transports billed to the MAC for Part B payment must meet medical necessity and CMS ambulance program requirements.
| Transport Description | Ambulance Billing Modifiers |
|---|---|
| Ambulance transport to a SNF for admission | The second character (destination) of any ambulance HCPCS modifier is N (SNF) other than modifier QN, and the date of service is the same as the SNF 21X admission date. |
| The ambulance trip is from the SNF after discharge, to the beneficiary’s home | The first character (origin) of any HCPCS ambulance modifier is N (SNF), the second character (destination) of the HCPCS ambulance modifier is R (Residence), and date of ambulance service is the same date as the SNF through date. * Note: this includes beneficiaries discharged home to receive services from a Medicare-participating home health agency under a plan of care |
| The ambulance trip is to a hospital based or nonhospital based ESRD facility for the purpose of receiving dialysis and related services excluded from consolidated billing | The first character (origin) of the HCPCS ambulance modifier is N (SNF), and the second character (destination) HCPCS ambulance modifier code is G (Hospital-based dialysis facility) or J (Non-hospital based dialysis facility)) for the purpose of receiving dialysis and related services excluded from consolidated billing. |
| The ambulance trip is from the SNF to a Medicare-participating hospital or a CAH for an inpatient admission | The first character (origin) of the HCPCS ambulance modifier is N (SNF), and the second character (destination) of the HCPCS modifier is H |
| The ambulance trip follows a formal discharge or other departure from the SNF to any destination other than another SNF, and the beneficiary does not return to that or any other SNF by midnight of that same day | The first character (origin) of the HCPCS ambulance modifier is- N (SNF) and the second character (destination) of the HCPCS modifier is a Medicare covered destination. |
| An ambulance trip that conveys a beneficiary to a hospital or CAH and back to the SNF for the specific purpose of receiving emergency or other excluded services | Ambulance origin modifier- N (SNF) of H (hospital) Ambulance destination modifier- N (SNF) or H (hospital) |
Reviewed 11/4/2024