From the Medicare Learning Network
Increased Ambulance Payment Reduction for Non-Emergency Basic Life Support (BLS) Transports to and from Renal Dialysis Facilities
- MLN Matters Number: MM10549
- Related CR Release Date: April 6, 2018
- Related CR Transmittal Number: R4017CP
- Related Change Request (CR) Number: 10549
Effective Date: October 1, 2018
Implementation Date: October 1, 2018
PROVIDER TYPES AFFECTED
This MLN Matters Article is intended for providers and suppliers billing Medicare Administrative Contractors (MACs) for ambulance transport services provided to Medicare beneficiaries.
PROVIDER ACTION NEEDED
Change Request (CR) 10549 provides instructions regarding Section 53108 of the Bipartisan Budget Act of 2018. This section reduces the ambulance payment by 23 percent for non-emergency Basic Life Support (BLS) transports of individuals with End-Stage Renal Disease (ESRD), to and from renal dialysis treatment (at both hospital-based and freestanding renal dialysis treatment facilities). Please make sure your billing staffs are aware of these changes.
Payment for ambulance transports (including items and services furnished in association with such transports) are based on the Ambulance Fee Schedule (AFS) and include a base rate payment plus a separate payment for mileage. This raised payment reduction for non-emergency BLS transports to and from renal dialysis treatment applies to both the base rate and the mileage reimbursement.
CR8269, issued May 10, 2013, implemented Section 637 of the American Taxpayer Relief Act of 2012, which, for transports occurring on and after October 1, 2013; required a 10-percent reduction in fee schedule payments for non-emergency (BLS transports of beneficiaries with ESRD); to and from both hospital-based and freestanding renal dialysis treatment facilities, for non-emergent dialysis services. The MLN Matters article associated with this CR is available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8269.pdf.
MLN Matters MM10549 Related CR 10549
CR10549 provides instructions regarding Section 53108 of the Bipartisan Budget Act of 2018, (signed into law on February 9, 2018), which requires that, effective October 1, 2018, the reduction of fee schedule payments for BLS transports to and from renal dialysis treatments be increased to 23 percent.
Non-emergency BLS ground transports are identified by Healthcare Common Procedure Coding System (HCPCS) code A0428 (Ambulance service, basic life support, non-emergency transport, (bls)). Ambulance transports to and from renal dialysis treatment are further identified by origin/destination modifier codes “G” (hospital-based ESRD) and “J” (freestanding ESRD facility), in either the origin or destination position of an ambulance modifier.
Effective for claims with dates of service on and after October 1, 2018, payment for non-emergency BLS transports to and from renal dialysis treatment facilities will be reduced by 23 percent. The reduced rate will be calculated after the normal payment rate (including any applicable add-on payments) is calculated, and will be applied to the base rate for non-emergency BLS transports (identified by HCPCS code A0428 when billed with the indicated modifier codes) and the associated, separate mileage payment (identified by HCPCS code A0425).
- Payment for emergency transports and non-emergency BLS transports to other destinations (rural and urban) will remain unchanged. The AFS will also remain unchanged.
- For ambulance services, suppliers and hospital-based ambulance providers must report an accurate origin and destination modifier for each ambulance trip provided. Origin and destination modifiers used for ambulance services are created by combining two alpha characters. Each alpha character, with the exception of “X”, represents an origin code or a destination code. The pair of alpha codes creates a modifier. The first position alpha code equals origin; the second position alpha code equals destination.
- The reduction will be applied on claim lines containing HCPCS code A0428 with modifier code “G” or “J”, in either the first position (origin code) or second position (destination code) within the two-digit ambulance modifier code and HCPCS code A0425.
- MACs will keep in place all existing edits and logic (implemented previously via CMS CR 8269) that currently apply to the reduced AFS payment rates; however, effective for claims with dates of service on or after October 1, 2018, will increase the reduction from 10 percent to 23 percent. Additionally, they will continue to use the claim adjustment reason code, group code and Medicare Summary Notice messages that are currently used for the reduced AFS payment methodology
Note: This 23-percent reduction applies to beneficiaries with ESRD that are receiving a non-emergency BLS transport to and from renal dialysis treatment. While it is possible that a beneficiary who is not diagnosed with ESRD will require routine transport to and from renal dialysis treatment, it is highly unlikely. However, MACs have the discretion to override or reverse the reduction on appeal if they deem it appropriate based on supporting documentation.
MLN Matters MM10549 Related CR 10549
The official instruction, CR10549, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4017CP.pdf.
If you have any questions, please contact your MAC at their toll-free number. That number is available at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/.
Date of Change Description
April 6, 2018
Initial article released.
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