What it Takes to Get Medicare to Pay for Ambulance Transports

Ensuring coverage of ambulance services for your end-stage renal dialysis (ESRD) patients requires diligence. Dialysis facility ambulance transports often do no meet medical necessity criteria, as defined by the Centers for Medicare & Medicaid Services (CMS).

The CMS IOM Pub. 100-02, Medicare Benefit Policy Manual, Chapter 10, Section 10.2.1, “Necessity for the Service” states:

Ambulatory Surgical Center CASCC

Medical necessity is established when the patient’s condition is such that use of any other method of transportation is contraindicated. In any case in which some means of transportation other than an ambulance could be used without endangering the individual’s health, whether or not such other transportation is actually available, no payment may be made for ambulance services. In all cases, the appropriate documentation must be kept on file and, upon request, presented to the carrier/intermediary. It is important to note that the presence (or absence) of a physician’s order for a transport by ambulance does not necessarily prove (or disprove) whether the transport was medically necessary.

Let’s disseminate that statement for a thorough analysis:

“Medical necessity is established when the patient’s condition is such that use of any other method of transportation is contraindicated.”

Translation: Any other transport would be detrimental to the patient’s health.

“In any case in which some means of transportation other than an ambulance could be used without endangering the individual’s health, whether or not such other transportation is actually available, no payment may be made for ambulance services.”

Translation: If emergency transport isn’t essential to the patient’s health, it isn’t covered. “The patient’s car broke down and he needed a way to get to treatment,” would not establish medical necessity.

“In all cases, the appropriate documentation must be kept on file and, upon request, presented to the carrier/intermediary. It is important to note that the presence (or absence) of a physician’s order for a transport by ambulance does not necessarily prove (or disprove) whether the transport was medically necessary.”

Translation: The physician must document in the patient’s record why ambulance services were ordered. The order itself, however, does not establish medical necessity.

To make matters more complicated, “the transport must be to obtain a Medicare covered service, or to return from such a service,” per CMS.

Bottom Line: In billing an ambulance transport for a Medicare patient, verify that documentation stipulates the dire circumstances that provoked the order, and that the purpose of the transport was for the patient to obtain medically necessary ESRD services.

Renee Dustman

Renee Dustman

Executive Editor at AAPC
Renee Dustman, BS, is an executive editor at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. She has more than 20 years experience in print publishing, working in production management and content management. She is also a freelance writer and graphic artist.
Renee Dustman

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Renee Dustman, BS, is an executive editor at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. She has more than 20 years experience in print publishing, working in production management and content management. She is also a freelance writer and graphic artist.

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