Monday, August 17, 2015

CPT code A0427 - Reason for denial

Common payment errors for ambulance emergency transport HCPCS code A0427 

One of the top contributors to First Coast Service Options’ (First Coast’s) claims payment error rate, as measured by the Comprehensive Error Rate Testing (CERT) program, is improper billing of Healthcare Common Procedure Coding System (HCPCS) code A0427. HCPCS code A0427 is defined as an ambulance service, advanced life support (ALS), emergency transport, level 1.

Recent CERT error findings demonstrate the beneficiary did not meet coverage guidelines for the following reasons:

• Insufficient documentation to support medical necessity of the service or the level of service billed;

• Documentation did not include the beneficiary's signature (or the signature of his or her authorized representative).

Ambulance suppliers are encouraged to review the following article regarding Medicare’s ambulance benefit and ensure that they meet documentation requirements for services that are medically reasonable and necessary.

Medical necessity

One common CERT error for HCPCS code A0427 is the clinical documentation submitted for review did not support the level of emergency ambulance transport billed. For example, submitted documentation for one claim indicated that the beneficiary was “weak, having nausea/vomiting, and severe back pain from surgery. Beneficiary was able to walk to stretcher for transportation.”

To be covered, ambulance services must be medically necessary and reasonable. According to  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. The manual also states that the reasons for the ambulance transport must be medically necessary. That is, the transport must be to obtain a Medicare covered service, or to return from such a service.

Furthermore, Section 10.2.2 Reasonableness of the Ambulance Trip external pdf file states that under the fee schedule (FS), payment is made according to the level of medically necessary services actually furnished. That is, payment is based on the level of service furnished (provided they were medically necessary), not simply on the vehicle used. Even if a local government requires an ALS response for all calls, payment under the FS is made only for the level of service furnished, and then only when the service is medically necessary.

Other common CERT errors is that although an ICD-9 code(s) was submitted on the claim, the clinical documentation submitted regarding the beneficiary’s condition was either insufficient or missing. According to CMS Publication 100-04, Chapter 15 Ambulance, Section 40 Medical Conditions and Instructions external pdf file, Medicare contractors will rely on medical record documentation to justify coverage, not simply the HCPCS code or the condition code by themselves.


In all cases, the appropriate documentation must be kept on file and, upon request, presented to the carrier/intermediary. Appropriate documentation includes:

• Dispatch instructions;

• Patient's condition;

• Other on-scene information; and

• Details of the transport (e.g., medications administered, changes in the patient's condition, and miles traveled)

• Proper and legible signatures

Missing signatures 

Another common CERT error for HCPCS code A0427 is the documentation submitted did not include the beneficiary’s signature or the signature of his or her authorized representative. As outlined in CMS Publication , Medicare requires the signature of the beneficiary, or that of his or her representative, for both the purpose of accepting assignment and submitting a claim to Medicare.

If the beneficiary is unable to sign because of a mental or physical condition, the following individuals may sign the claim form on behalf of the beneficiary:

• The beneficiary’s legal guardian.

• A relative or other person who receives Social Security or other governmental benefits on behalf of the beneficiary.

• A relative or other person who arranges for the beneficiary’s treatment or exercises other responsibility for his or her affairs.

• A representative of an agency or institution that did not furnish the services for which payment is claimed, but furnished other care, services, or assistance to the beneficiary.

• A representative of the provider or of the nonparticipating hospital claiming payment for services it has furnished, if the provider or nonparticipating hospital is unable to have the claim signed in accordance with 42 CFR 424.36(b) (1-4)

• A representative of the ambulance provider or supplier who is present during an emergency and/or nonemergency transport, provided that the ambulance provider or supplier maintains certain documentation in its records for at least four years from the date of service. A provider/supplier (or his/her employee) cannot request payment for services furnished except under circumstances fully documented to show that the beneficiary is unable to sign and that there is no other person who could sign.

Medicare does not require that the signature to authorize claim submission be obtained at the time of transport for the purpose of accepting assignment of Medicare payment for ambulance benefits. When a provider/supplier is unable to obtain the signature of the beneficiary, or that of his or her representative, at the time of transport, it may obtain this signature any time prior to submitting the claim to Medicare for payment.

Proper use of ambulance services (HCPCS A0427 and A0428)

Ambulance services reviewed by Part B comprehensive error rate testing (CERT) for First Coast Service Options Inc. (First Coast) continue to have a high error rate. First Coast conducted two post payment widespread probe (WSP) reviews for dates of service February 1, 2016, to July 31, 2016, in response to data analysis for aberrancies to Healthcare Common Procedure Coding System (HCPCS) codes A0427 (advanced life support, level 1 emergency [ALS 1]) with RH modifier (residence to hospital); and, A0428 (basic life support, non-emergency, [BLS]) with modifier HN (hospital to extended care facility [ECF] or skilled nursing facility [SNF]).
The widespread probe results were as follows:

• HCPCS code A0427-RH (ALS) and A0425-RH- overall error rate was 15.64 percent
• HCPCS code A0428-HN (BLS) and A0425-HN- overall error rate was 33.61 percent
• HCPCS code A0425- ground mileage, per statute mile.

Services were denied for the following reasons outlined in the Centers for Medicare & Medicaid Services (CMS) internet only manual (IOM) 100-02 Medicare Benefit Policy Manual Chapter 10- Ambulance Services external pdf file:

• The documentation submitted in the medical record did not support the patient’s condition was such that use of other means of transportation was contraindicated.
• Insufficient documentation (such as the signature form was not submitted; the physician certification statement [PCS] was not submitted or was incomplete; and/or the medical record included conflicting information).
• The medical record did not include documentation to support the service was rendered.

First Coast actions

In response to the high percentage of error rates and the continual risks of improper payments associated with ambulance services billed, First Coast will provide an educational webcast on July 11, 2017. Following the webcast, a prepayment medical review audit for HCPCS codes A0428 and A0425 with the HN modifier will be implemented for claims processed on or after August 1, 2017, in Florida. The new audit will be based on a threshold of claims submitted for payment in an effort to reduce the error rates for this ambulance service.

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