The Issue: Unbundling During an Inpatient Hospital Stay
According to billing requirements established by the Centers for Medicare & Medicaid Services (CMS), ambulance services should be billed to inpatient providers. According to claims data reviewed by the RAC program, an issue may exist when a beneficiary during an inpatient stay receives ambulance services that are billed and reimbursed under Medicare Part B. As a result, RACs are initiating automated reviews for overpayments.
While the majority of hospitals do not provide their own ambulance services, it is important for them to review CMS requirements on when ambulance services are to be provided to inpatients and outpatients. To help you better understand these arrangements, we went straight to the following Medicare regulations to see exactly what is needed to prevent improper payments (all of the following CMS online Medicare manuals can be found at the following Web address: http://www.cms.hhs.gov/manuals/)
- Medicare Benefit Policy Manual (Publication 100-02) Chapter 10, Sections 10 and 10.3.3;
- Medicare Processing Manual (Publication 100-04), Chapter 3, Sections 10.4 and 10.5; and .
- Medicare Claims Processing Manual (Publication 100-04), Chapter 15, Sections 10.2 and 30.A.
The Basic Rules
Transportation of a beneficiary from his or her home, an accident scene or any other point of origin is covered under Part B as an ambulance service only to the nearest hospital, critical access hospital (CAH) or skilled nursing facility (SNF) capable of furnishing the required level and type of care for the beneficiary’s illness or injury. This is the rule only if medical necessity and other program coverage criteria are met.
Medicare-covered ambulance services are paid in one of two ways:
- As separately billed services, in which case the entity furnishing the ambulance service bills Part B of the program; or
- As a packaged service, in which case the entity furnishing the ambulance service must seek payment from the provider responsible for the beneficiary’s care.
Patient Origin is Key
If either the origin or the destination of the ambulance transport is the beneficiary’s home, it is paid separately by Medicare Part B. The entity that furnishes the transportation may bill its Medicare carrier or intermediary directly.
If both the origin and destination of the ambulance transport are providers (e.g., a hospital, CAH or SNF), responsibility for payment is determined in accordance with the sequential billing criteria established by CMS. .
Providers must adhere to the following to ensure proper payment:
Note: These three criteria must be applied in sequence as a flow chart, and not independently of one another.
Criterion 1: Provider Numbers
If the Medicare-assigned provider numbers of the two providers are different, the ambulance service may be billed separately to the Medicare program. If the provider number of the providers is the same, then consider criterion 2 – campus – as described below.
Criterion 2: Campus
“Campus” means the physical area immediately adjacent to a provider’s main buildings. It also includes other areas and structures that are not strictly contiguous to the main buildings, but located within 250 yards of them, as well as any of the other areas determined on an individual case basis by the CMS regional office to be part of a provider’s campus.
If the campuses of the two providers sharing the same provider number are the same, the transport may not be billed separately to Medicare. Instead, the provider is responsible for payment. If the campuses of the two providers are different, then criterion 3 must be considered.
Criterion 3: Patient Status
In the case in which the point of origin is not a provider, Part A coverage is not available because at the time the beneficiary is being transported he or she is not an inpatient of any provider paid under Medicare Part A. Ambulance services are excluded from the three-day preadmission payment window.
The transfer or discharge of a beneficiary from one provider with a subsequent admission to another provider is also payable as a Part B ambulance transport. That is, it is paid as long as all program coverage criteria are met. This is because at the time that the beneficiary is in transit, he or she is not a patient of either provider and not subject to either the inpatient preadmission payment window or outpatient payment packaging requirements. This scenario would include an outpatient transfer from a remote off-campus emergency department (ED) to becoming an inpatient or outpatient at the main campus hospital, even if the hospital owns or operates the ED.
Transport after Admission
Once a beneficiary is admitted to a hospital, CAH or SNF, it may be necessary to transport the beneficiary to another hospital or other site temporarily for specialized care while he or she maintains inpatient status with the original provider. This movement of a patient is considered “patient transportation” and is covered as an inpatient hospital or CAH service. It also is covered as a SNF service when it is furnished as such and payment is made under Part A.
Because the service is covered and payable as a beneficiary transportation service under Part A, it cannot be classified and paid for as an ambulance service under Part B. This includes intra-campus transfers between different departments of the same hospital, even if the departments are located in separate buildings. Such intra-campus transfers are not payable separately under the Part B ambulance benefit. Such costs are accounted for in the same manner as the costs of a transfer within a single building.
(Note: If the beneficiary is a resident of a SNF and must be transported by ambulance to receive dialysis or certain other high-end outpatient hospital services, the ambulance transport may be payable separately under Part B.)
About the Author
Randy Wiitala, BS, MT (ASCP) is a senior healthcare consultant with Medical Learning, Inc. (MedLearn in St. Paul, Minn. MedLearn is a nationally recognized expert in healthcare compliance and reimbursement. Founded in 1991, MedLearn delivers actionable answers that equip healthcare organizations with their coding, chargemaster, reimbursement management and RAC solutions.
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If the patient is an inpatient at both providers (i.e., he or she holds inpatient status both at the transportation origin and destination, representing providers sharing the same provider number but located on different campuses), the transport is not separately billable. In this case, the provider is responsible for payment. All other combinations (i.e., outpatient-to-inpatient, inpatient-to-outpatient and outpatient-to-outpatient) are separately billable to Medicare.