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Ambulance Policy Page 1 of 4 UnitedHealthcare Oxford Reimbursement Policy Effective 10/22/2018

1996-2018, Oxford Health Plans, LLC

AMBULANCE POLICY Policy Number: TRANSPORTATION 004.21 T0 Effective Date: October 22, 2018 Table of Contents Page INSTRUCTIONS FOR USE .......................................... 1 APPLICABLE LINES OF BUSINESS/PRODUCTS .............. 1 APPLICATION .......................................................... 1 OVERVIEW .............................................................. 1 REIMBURSEMENT GUIDELINES .................................. 2 DEFINITIONS .......................................................... 3 QUESTIONS AND ANSWERS ...................................... 3 ATTACHMENTS ........................................................ 4 REFERENCES ........................................................... 4 POLICY HISTORY/REVISION INFORMATION ................. 4 INSTRUCTIONS FOR USE The services described in Oxford policies are subject to the terms, conditions and limitations of the member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage members. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required

by Oxford's administrative procedures or applicable state law. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies. Certain policies may not be applicable to Self-Funded members and certain insured products. Refer to the member specific benefit plan document or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the member specific benefit plan document or Certificate of Coverage, the member specific benefit plan document or

Certificate of Coverage will govern. UnitedHealthcare may also use tools developed by third parties, such as the MCG Care Guidelines, to assist us in administering health benefits. The MCG Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.

APPLICABLE LINES OF BUSINESS/PRODUCTS This policy applies to Oxford Commercial plan membership. APPLICATION

This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form (a/k/a CMS-1500) or its electronic equivalent or its successor form. This policy applies to all products and all network and non-network

Ambulance Providers or Suppliers, including, but not limited to, non-network authorized and percent of charge contract Ambulance Providers or Suppliers. OVERVIEW

This policy addresses reimbursement related to services included as part of an ambulance transportation service, ambulance modifier usage, provider specialty reporting ambulance services, and the requirements for reporting Advanced Life Support, Level 2 (ALS2) ambulance transportation. For purposes of this policy, Same Ambulance Provider or Supplier is defined as Ambulance Providers or Suppliers of the same specialty reporting the same Federal Tax Identification number (TIN).

Related Policies

None

UnitedHealthcare Oxford

Reimbursement Policy

Oxford



REIMBURSEMENT GUIDELINES Ambulance Providers and Suppliers

Oxford considers only an Ambulance Provider or Supplier as eligible for reimbursement of ambulance services

reported with Healthcare Common Procedure Coding System (HCPCS) codes A0021 and A0225-A0999.

Other provider specialties, e.g., emergency room physicians, should report the Current Procedural Terminology (CPT) and/or HCPCS codes that specifically and accurately describe the services and procedures outside of the HCPCS code A0021 and A0225-A0999 range. Oxford will not reimburse non-ambulance providers or suppliers for rendering ambulance services. Origin and Destination Modifiers

For ambulance transportation claims, Oxford has adopted the Centers for Medicare and Medicaid Services (CMS) guidelines that require an Ambulance Provider or Supplier to report an origin and destination modifier for each trip

provided. Each ambulance modifier is comprised of a single digit alpha character identifying the origin of the transport in the first position, and a single digit alpha character identifying the destination of the transport in the second position.

Example: RH (residence to hospital). Single digit alpha characters used to designate an origin and destination are listed below: D = Diagnostic or therapeutic site other than P or H when these are used as origin codes

E = Residential, domiciliary, custodial facility (other than 1819 facility) G = Hospital based ESRD facility H = Hospital I = Site of transfer (e.g. airport or helicopter pad) between modes of ambulance transport J = Freestanding ESRD facility N = Skilled nursing facility

P = Physicians office R = Residence S = Scene of accident or acute event X = Intermediate stop at physicians office on way to hospital (destination code only) In alignment with CMS, Oxford will reimburse a code on the Ambulance Transportation Codes List only when reported

with a two-digit ambulance modifier on the Ambulance Modifiers List. Ambulance transportation services reported

without a valid two-digit ambulance modifier will be denied. When X (Intermediate stop at physician's office en route to the hospital) is present within the 2 digit modifier

combination, X must be in the second digit position preceded by a valid origin digit in the first position. If X is the first digit of the two digit modifier combination, the ambulance transportation code will be denied.

Ambulance Transportation Code List Ambulance Modifiers List Services Included in Ambulance Transportation

Per CMS, services including, but not limited to oxygen, drugs, extra attendants, supplies, EKG, and night differential

are not paid separately when reported as part of an ambulance transportation service. In addition, the ambulance must have customary patient care equipment and first aid supplies, including reusable devices and equipment such as backboards, neckboards and inflatable leg and arm splints. These are all considered part of the general ambulance service and payment for them is included in the payment rate for the transport. In alignment with CMS, Oxford will not reimburse codes on the Ambulance Bundled Codes list when provided by the

Same Ambulance Provider or Supplier for the same patient on the same date of service as a code on the Ambulance

Transportation Codes list. This applies to network providers only. Ambulance Transportation Code List Ambulance Bundled Code List Advanced Life Support, Level 2 (ALS2) Ambulance Transportation

There are marked differences in resources necessary to furnish the various levels of ground ambulance services. According to CMS, Basic Life Support (BLS) ambulances must be staffed by at least two people, at least one of whom must be certified as an emergency medical technician (EMT) by the State or local authority where the services are

being furnished and be legally authorized to operate all lifesaving and life-sustaining equipment on board the vehicle. All Advanced Life Support (ALS) vehicles must be staffed by at least two people, at least one of whom must be certified by the State or local authority as an EMT-Intermediate or an EMT-Paramedic. In addition, Advanced Life Support, Level 1 (ALS1) must include the provision of an ALS Assessment or at least one ALS Intervention.



CMS defines Advanced Life Support, Level 2 (ALS2) as transportation by ground ambulance vehicle and the provision of medically necessary supplies and services including (1) at least three separate administrations of one or more medications by intravenous push/bolus or by continuous infusion (excluding crystalloid fluids) or (2) ground

ambulance transport, medically necessary supplies and services, and the provision of at least one of the ALS2 procedures listed below: Manual defibrillation/cardioversion Endotracheal intubation Central venous line Cardiac pacing Chest decompression

Surgical airway or Intraosseous line In alignment with CMS, reimbursement is based on the level of service provided, not on the vehicle used. Refer to the Definitions section for more information on ambulance transport.

DEFINITIONS

Advanced Life Support Assessment: An assessment performed by an ALS crew as part of an emergency response that was necessary because the patient's reported condition at the time of dispatch was such that only an ALS crew was qualified to perform the assessment. An ALS Assessment does not necessarily result in a determination that the patient requires an ALS level of service.

Advanced Life Support Intervention: A procedure that is in accordance with State and local laws, required to be done by an emergency medical technician-intermediate (EMT-Intermediate) or EMT-Paramedic. Advanced Life Support, Level 1 (ALS1): The transportation by ground ambulance vehicle and the provision of medically necessary supplies and services including the provision of an ALS Assessment or at least one ALS Intervention.

Advanced Life Support, Level 2 (ALS2): The transportation by ground ambulance vehicle and the provision of medically necessary supplies and services including (1) at least three separate administrations of one or more medications by intravenous push/bolus or by continuous infusion (excluding crystalloid fluids) or (2) ground

ambulance transport, medically necessary supplies and services, and the provision of at least one of the ALS2 procedures listed below:

Manual defibrillation/cardioversion; Endotracheal intubation; Central venous line; Cardiac pacing; Chest decompression; Surgical airway; or Intraosseous line.

Ambulance Provider or Supplier: A hospital-based or independently owned and/or operated ambulance transportation service. Basic Life Support (BLS): Transportation by ground ambulance vehicle and the provision of medically necessary supplies and services, including BLS ambulance services as defined by the State. The ambulance must be staffed by

an individual who is qualified in accordance with State and local laws as an emergency medical technician-basic (EMT-

Basic). Same Ambulance Provider or Supplier: Ambulance Providers or Suppliers of the same specialty reporting the same Federal Tax Identification number. QUESTIONS AND ANSWERS

1

Q: If a physician rides in the ambulance and provides cardiopulmonary resuscitation (CPR) while en route to the destination, is it appropriate for the physician to report an ambulance service code?

A: No, the physician would report a non-ambulance service code(s) based on the type of service rendered. For example, CPT code 92950 for CPR.



ATTACHMENTS

Ambulance Transportation Code List

A list of codes for emergency and non-emergency ambulance transportation

Amb Transportation Code List

Ambulance Bundled Code List

A list of codes that are not separately reimbursed when reported with an ambulance transportation code

Ambulance Bundled Code List

Ambulance Modifiers List

A list of modifiers to report the origin and destination of an ambulance transportation service

Ambulance Modifiers List

REFERENCES

The foregoing Oxford policy has been adapted from an existing UnitedHealthcare national policy that was researched, developed and approved by UnitedHealthcare Reimbursement Policy Oversight Committee. [2018R0123D]

Centers for Medicare and Medicaid Services, CMS Manual System and other publications and services.

POLICY HISTORY/REVISION INFORMATION

Date Action/Description

10/22/2018

Updated Ambulance Bundled Code List (attachment file listing procedure codes

that are not separately reimbursed when reported with an ambulance transportation code) to reflect quarterly code edits; added HCPCS codes Q5108 and Q5110

Archived previous policy version TRANSPORTATION 004.20 T0
CodesAmbulance Transportation Code ListProprietary Information of UnitedHealthcare. Copyright 2018 United HealthCare Services, Inc.CodeA0021A0225A0380A0390A0425A0426A0427A0428A0429A0430A0431A0432A0433A0434A0435A0436&CProprietary Information of UnitedHealthcare. Copyright 2016 United HealthCare Services, Inc. p. &P of &NCodesAmbulance Bundled Code ListProprietary Information of UnitedHealthcare. Copyright 2018 United HealthCare Services, Inc.Code0298T930009300593010930409304193042A0382A0384A0392A0394A0396A0398A0422A0424A0888A4206A4207A4208A4209A4210A4211A4212A4213A4215A4216A4217A4218A4220A4221A4222A4223A4224A4225A4230A4231A4232A4233A4234A4235A4236A4244A4245A4246A4247A4248A4250A4252A4253A4255A4256A4257A4258A4259A4261A4262A4263A4264A4265A4266A4267A4268A4269A4270A4280A4281A4282A4283A4284A4285A4286A4290A4300A4301A4305A4306A4310A4311A4312A4313A4314A4315A4316A4320A4321A4322A4326A4327A4328A4330A4331A4332A4333A4334A4335A4336A4337A4338A4340A4344A4346A4349A4351A4352A4353A4354A4355A4356A4357A4358A4360A4361A4362A4363A4364A4366A4367A4368A4369A4371A4372A4373A4375A4376A4377A4378A4379A4380A4381A4382A4383A4384A4385A4387A4388A4389A4390A4391A4392A4393A4394A4395A4396A4397A4398A4399A4400A4402A4404A4405A4406A4407A4408A4409A4410A4411A4412A4413A4414A4415A4416A4417A4418A4419A4420A4421A4422A4423A4424A4425A4426A4427A4428A4429A4430A4431A4432A4433A4434A4435A4450A4452A4455A4456A4458A4459A4461A4463A4465A4467A4470A4480A4481A4483A4490A4495A4500A4510A4520A4550A4553A4554A4555A4556A4557A4558A4559A4561A4562A4565A4566A4570A4575A4580A4590A4595A4600A4601A4602A4604A4605A4606A4608A4611A4612A4613A4614A4615A4616A4617A4618A4619A4620A4623A4624A4625A4626A4627A4628A4629A4630A4633A4634A4635A4636A4637A4638A4639A4640A4641A4642A4648A4649A4650A4651A4652A4653A4657A4660A4663A4670A4671A4672A4673A4674A4680A4690A4706A4707A4708A4709A4714A4719A4720A4721A4722A4723A4724A4725A4726A4728A4730A4736A4737A4740A4750A4755A4760A4765A4766A4770A4771A4772A4773A4774A4802A4860A4870A4890A4911A4913A4918A4927A4928A4929A4930A4931A4932A5051A5052A5053A5054A5055A5056A5057A5061A5062A5063A5071A5072A5073A5081A5082A5083A5093A5102A5105A5112A5113A5114A5120A5121A5122A5126A5131A5200A5500A5501A5503A5504A5505A5506A5507A5508A5510A5512A5513A6000A6010A6011A6021A6022A6023A6024A6025A6154A6196A6197A6198A6199A6203A6204A6205A6206A6207A6208A6209A6210A6211A6212A6213A6214A6215A6216A6217A6218A6219A6220A6221A6222A6223A6224A6228A6229A6230A6231A6232A6233A6234A6235A6236A6237A6238A6239A6240A6241A6242A6243A6244A6245A6246A6247A6248A6250A6251A6252A6253A6254A6255A6256A6257A6258A6259A6260A6261A6262A6266A6402A6403A6404A6407A6410A6411A6412A6413A6441A6442A6443A6444A6445A6446A6447A6448A6449A6450A6451A6452A6453A6454A6455A6456A6457A6501A6502A6503A6504A6505A6506A6507A6508A6509A6510A6511A6512A6513A6530A6531A6532A6533A6534A6535A6536A6537A6538A6539A6540A6541A6544A6545A6549A6550A7000A7001A7002A7003A7004A7005A7006A7007A7008A7009A7010A7012A7013A7014A7015A7016A7017A7018A7020A7025A7026A7027A7028A7029A7030A7031A7032A7033A7034A7035A7036A7037A7038A7039A7040A7041A7044A7045A7046A7047A7048A7501A7502A7503A7504A7505A7506A7507A7508A7509A7520A7521A7522A7523A7524A7525A7526A7527A8000A8001A8002A8003A8004A9150A9152A9153A9155A9180A9270A9272A9273A9274A9275A9276A9277A9278A9279A9280A9281A9282A9283A9284A9285A9286A9300A9500A9501A9502A9503A9504A9505A9507A9508A9509A9510A9512A9515A9516A9517A9520A9521A9524A9526A9527A9528A9529A9530A9531A9532A9536A9537A9538A9539A9540A9541A9542A9543A9546A9547A9548A9550A9551A9552A9553A9554A9555A9556A9557A9558A9559A9560A9561A9562A9563A9564A9566A9567A9568A9569A9570A9571A9572A9575A9576A9577A9578A9579A9580A9581A9582A9583A9584A9585A9586A9587A9588A9597A9598A9600A9604A9606A9698A9699A9700A9900A9901A9999E0424E0425E0430E0431E0433E0434E0435E0439E0440E0441E0442E0443E0444E0445E0446E0455E0457E0459E0462E0465E0466E0470E0471E0472E0480E0481E0482E0483E0484E0485E0486E0487E1352E1353E1354E1355E1356E1357E1358E1372E1390E1391E1392E1405E1406G0403G0404G0405J0120J0129J0130J0131J0132J0133J0135J0153J0171J0178J0180J0190J0200J0202J0205J0207J0210J0215J0220J0221J0256J0257J0270J0275J0278J0280J0282J0285J0287J0288J0289J0290J0295J0300J0330J0348J0350J0360J0364J0365J0380J0390J0395J0400J0401J0456J0461J0470J0475J0476J0480J0485J0490J0500J0515J0520J0558J0561J0565J0570J0571J0572J0573J0574J0575J0583J0585J0586J0587J0588J0592J0594J0595J0596J0597J0598J0600J0604J0606J0610J0620J0630J0636J0637J0638J0640J0641J0670J0690J0692J0694J0695J0696J0697J0698J0702J0706J0710J0712J0713J0714J0715J0716J0717J0720J0725J0735J0740J0743J0744J0745J0770J0775J0780J0795J0800J0833J0834J0840J0850J0875J0878J0881J0882J0883J0884J0885J0887J0888J0890J0894J0895J0897J0945J1000J1020J1030J1040J1050J1071J1094J1100J1110J1120J1130J1160J1162J1165J1170J1180J1190J1200J1205J1212J1230J1240J1245J1250J1260J1265J1267J1270J1290J1300J1320J1322J1324J1325J1327J1330J1335J1364J1380J1410J1428J1430J1435J1436J1438J1439J1442J1443J1447J1450J1451J1452J1453J1455J1457J1458J1459J1460J1555J1556J1557J1559J1560J1561J1562J1566J1568J1569J1570J1571J1572J1573J1575J1580J1595J1599J1600J1602J1610J1620J1626J1627J1630J1631J1640J1642J1644J1645J1650J1652J1655J1670J1675J1700J1710J1720J1726J1729J1730J1740J1741J1742J1743J1744J1745J1750J1756J1786J1790J1800J1810J1815J1817J1826J1830J1833J1835J1840J1850J1885J1890J1930J1931J1940J1942J1945J1950J1953J1955J1956J1960J1980J1990J2001J2010J2020J2060J2150J2170J2175J2180J2182J2185J2210J2212J2248J2250J2260J2265J2270J2274J2278J2280J2300J2310J2315J2320J2323J2325J2326J2350J2353J2354J2355J2357J2358J2360J2370J2400J2405J2407J2410J2425J2426J2430J2440J2460J2469J2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Information of UnitedHealthcare. Copyright 2016 United HealthCare Services, Inc. p. &P of &NCodesAmbulance Modifiers ListProprietary Information of UnitedHealthcare. Copyright 2018 United HealthCare Services, Inc.CodeDDDEDGDHDIDJDNDPDRDSDXEDEEEGEHEIEJENEPERESEXGDGEGGGHGIGJGNGPGRGSGXHDHEHGHHHIHJHNHPHRHSHXIDIEIGIHIIIJINIPIRISIXJDJEJGJHJIJJJNJPJRJSJXNDNENGNHNINJNNNPNRNSNXPDPEPGPHPIPJPNPPPRPSPXQLRDRERGRHRIRJRNRPRRRSRXSDSESGSHSISJSNSPSRSSSX&CProprietary Information of UnitedHealthcare. Copyright 2016 United HealthCare Services, Inc. p. &P of &N

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