Clinical UM Guideline

 

Subject: Ambulance Services: Ground; Emergent
Guideline #:  CG-ANC-05 Publish Date:    02/27/2019
Status: Reviewed Last Review Date:    01/24/2019

Description

This document addresses the use of ground ambulances in emergency situations. An ambulance is a specially equipped vehicle designed and supplied with materials and devices to provide life-saving and supportive treatments or interventions. Wheelchair vans or other such vehicles are not equipped as ambulances and are not addressed in this document.

Note: Please see the following related documents for additional information.

Clinical Indications

Medically Necessary:

The use of emergency ground ambulance services is considered medically necessary when all the following criteria are met:

  1. The ambulance must have the necessary equipment and supplies to address the needs of the individual; and
  2. The individual’s condition must be such that any form of transportation other than by ambulance would be medically contraindicated; and
  3. Either of the following circumstances exists:
    1. Transportation from the scene of a life-threatening accident or emergency to the nearest* hospital or physician’s office with appropriate facilities for treatment of an individual’s illness or injury is required; or
    2. Transportation to or from one hospital or medical facility to another hospital or medical facility, skilled nursing facility, or free-standing dialysis center in order to obtain emergent medically necessary diagnostic or therapeutic services is required (for example magnetic resonance imaging, computed tomography scan, acute interventional cardiology, intensive care unit [ICU] services [including neonatal ICU], Cobalt therapy, etc.) provided such services are unavailable at the facility where the individual initially resides.

*Mileage associated with an emergency ground ambulance service is considered medically necessary up to the distance required for transport to the nearest appropriate facility.

Emergency ground ambulance services for deceased individuals are considered medically necessary when the criteria above are met and when either of the following is present:

  1. The individual was pronounced dead while in route or upon arrival at the hospital or final destination; or
  2. The individual was pronounced dead by a legally authorized individual (physician or medical examiner) after the ambulance call was made, but prior to pick-up. In these circumstances the response to call is considered medically necessary.

Ambulance providers are required to respond to all emergency calls, but occasionally after assessment, transport is declined by the individual. In such cases ambulance services would be considered medically necessary.

Not Medically Necessary:

The use of emergency ground ambulance services is considered not medically necessary when:

  1. The criteria and circumstances above have not been met; or
  2. The services are primarily for the convenience of the individual or the individual’s family or physician; or
  3. The services are for a transfer of a deceased individual to a funeral home, morgue, or hospital, when the individual was pronounced dead at the scene.

Mileage in excess of the distance from the trip origin to the nearest appropriate facility is considered not medically necessary.

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

HCPCS

 

 

A0225

Ambulance service, neonatal transport, base, rate, emergency transport, one way

 

A0380

BLS mileage (per mile)

 

A0390

ALS mileage (per mile)

 

A0425

Ground mileage, per statute mile

 

A0427

Ambulance service, advanced life support, emergency transport, Level 1 (ASL1-Emergency)

 

A0429

Ambulance service, basic life support, emergency transport (BLS-Emergency)

 

A0432

Paramedic intercept (PI), rural area, transport furnished by a volunteer ambulance company which is prohibited by state law from billing third party payers

 

A0433

Advanced life support, Level 2 (ASL2)

 

A0434

Specialty care transport (SCT)

 

A0888

Noncovered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility)

A0998

Ambulance response and treatment, no transport

 

 

ICD-10 Diagnosis

 

 

All diagnoses

Discussion/General Information

An ambulance is a specially equipped vehicle designed and supplied with materials and devices to provide life-saving and supportive treatments or interventions. Ambulance transport services involve the use of specially designed and equipped vehicles to transport ill or injured individuals. Ambulance transport may involve the movement of an individual to the nearest hospital for treatment of an individual’s illness or injury, non-emergency medical transport of an individual to another location to obtain medically necessary specialized diagnostic or treatment services, or non-emergency medical transport to a hospital or to an individual’s home. Although wheelchair vans are specially equipped to accommodate physically challenged individuals, they do not have the proper equipment to qualify as an ambulance. Proper equipment may include ventilation and airway equipment, cardiac equipment (monitoring and defibrillation), immobilization devices, bandages, communication equipment, obstetrical kits, infection control, injury prevention equipment, vascular access equipment, and medications.

An ambulance may be either a ground transportation vehicle, such as a specially equipped truck or van, but may also be a properly equipped aircraft or boat. This document specifically addresses only ground transportation-type ambulances.

In general, an emergency medical condition is defined as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) so that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

Examples of medical emergencies may include illness or injury such as severe chest pains that might indicate a heart attack, slurred speech or weakness that might indicate a stroke, fracture, hemorrhaging, poisoning, major burns, loss of consciousness or respiratory accidents, convulsions, shock and other acute conditions.

In a 2018 prospective cohort study by Lau and colleagues, the authors reported on time delays experienced by participants with stroke who arrived in the emergency department and compared ambulance users and non-ambulance users. Those with stroke are recommended to receive tissue plasminogen activator (TPA) within 4.5 hours after the onset of stroke. Of the 102 participants recruited, 48 (47.1%) of them were brought to the emergency department by ambulance. The proportion participants with stroke who arrived within the therapeutic window was higher in ambulance users (64.6%; 31/48) compared to in non-ambulance users (29.6%; 16/54). In this study, after arrival in the emergency department, the time to medical consultation for ambulance users was 8 minutes and that for non-ambulance users was 15 minutes (P<0.001). The time from onset of stroke to medical consultation in the emergency department for ambulance users was 120 minutes, whereas that for non-ambulance users was 1182 minutes (P<0.001). A total of 34 participants were treated with TPA. While this study has limitations including a small sample size and it was conducted in a single center in Hong Kong, the results showed that more participants who used ambulance services arrived within the therapeutic window for stroke intervention and were seen more quickly by emergency department personnel than those who did not arrive by ambulance.

References

Peer Reviewed Publications:

  1. Galvagno SM Jr, Haut ER, Zafar SN, et al. Association between helicopter vs ground emergency medical services and survival for adults with major trauma. JAMA. 2012; 307(15):1602-1610.
  2. Lau KK, Yu EL, Lee MF, et al. Ambulance use affects timely emergency treatment of acute ischaemic stroke. Hong Kong Med J. 2018; 24(4):335-339.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American College of Emergency Physicians. Policy Statements. Available at: https://www.acep.org/globalassets/new-pdfs/policy-statements/policy-compendium.pdf. Accessed on December 20, 2018.
    • Emergency Medical Services Interfaces with Health Care Systems (February 2018)
  2. American College of Surgeons. Equipment for Ambulances. April 2009. Available at: https://www.facs.org/~/media/files/quality%20programs/trauma/publications/ambulance.ashx. Accessed on December 12, 2018.
  3. First Coast Service Options, Inc. Local Coverage Determination for Emergency and Non-Emergency Ground Ambulance Services (L37697). Revised 09/19/2018. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on December 12, 2018.
  4. Novitas Solutions, Inc. Local Coverage Determination for Ambulance (Ground) Services (L35162). Revised 07/16/2018. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on December 12, 2018.
  5. Palmetto GBA. Local Coverage Determination for Ambulance Services (L34549). Revised 05/31/2018. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on December 12, 2018.
  6. Thomson DP, Thomas SH; 2002-2003 Air Medical Services Committee of the National Association of EMS Physicians. Guidelines for air medical dispatch. Prehosp Emerg Care. 2007; (2):265-271.
Index

Ambulance
Emergency Transport

Document History

Status

Date

Action

Reviewed

01/24/2019

Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Discussion/General Information and References sections.

Revised

02/27/2018

MPTAC review. Clarifications to MN and NMN statements regarding mileage. Updated Description and References section.

Revised

11/02/2017

MPTAC review. Revisions made to NMN statement. Coding section updated. The document header wording updated from “Current Effective Date” to “Publish Date.”

Reviewed

05/04/2017

MPTAC review. Updated Description, Discussion/General Information, and References sections. Updated formatting in Clinical Indications section.

Reviewed

05/05/2016

MPTAC review. Updated References. Removed ICD-9 codes from Coding section.

Reviewed

05/07/2015

MPTAC review. Updated References.

New

05/15/2014

MPTAC review. Initial document development created from CG-ANC-01 Ambulance Services: Ground.