Correctly Code Non-Emergent Ambulance Transport

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  • December 10, 2010
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Are you aware that Medicare doesn’t cover ambulance transports to doctors’ offices? According to TrailBlazer Health Services, jurisdiction 4 Medicare administrative contractor (MAC), many coders get tripped up on this sort of claim and inappropriately report non-emergent ambulance transportation services to physician offices.

In a recently issued provider education article, TrailBlazer reminds practices that transports to doctors’ offices, whether for exams, doctor appointments, clinic visits, evaluations, follow-up visits, psychiatric or any other therapeutic service, are not covered under Medicare.

Reporting and Payment Requirements

Report claims for ambulance transportation to a physician’s office, a physician-directed clinic or a physician’s office located within a hospital building or facility with modifier P Physician’s office (including HMO and non-hospital facilities). Do not report these types of claims with modifier H Hospital.
This seems simple enough but, according to the J4 MAC, this sort of inappropriate billing often leads to paid claim errors.

Exception to Every Rule

Perhaps the confusion stems from the one allowed exception to non-coverage of transportation to doctors’ offices. Payment will be made for the entire trip when, and only when, an ambulance stops at a physician’s office because the patient requires emergency treatment, after which the ambulance continues to the hospital.

Claim Scenario

Consider this: A Medicare beneficiary is transported from his home to a hospital-based clinic for a visit with an infectious disease specialist. The infectious disease specialist reports an evaluation and management (E/M) service (office visit) on the same date of service, with his claim indicating a place of service code 11 Physician’s office. No other claims for hospital services are submitted for the beneficiary on the same day.
The modifier pair to report in this case should be R-P Residence-Physician’s office, along with modifier GY Item or service statutorily excluded or does not meet the definition of any Medicare benefit to indicate Medicare non-coverage. The beneficiary is liable for payment for these services even without signing an advance beneficiary notice (ABN).

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