When Medicare’s coverage criteria is met, hospital to hospital transport by ground ambulance is a covered service. The program covers both emergent and non-emergent responses at the BLS or ALS level. Providers must demonstrate through their patient care report that all criteria is met for coverage. The following suggestions are based on Medicare guidelines found at the link below.
- PreScreen Tech Note: The patient must be discharged from the initial hospital and admitted to the receiving facility. These hospitals cannot be operating under the same provider number or NPI. Interfacility transfers are not billable under Medicare Part B, the facility is directly responsible for these transfer costs. The same is true when the patient is being taken out of the hospital to receive a service that is not available internally. If the patient is brought back to the original hospital, the facility is responsible for the ambulance transport fees.
- EMT Documentation Tip: The patient care report should state whether the patient was actually discharged from the first hospital and admitted to the second hospital. Or if the patient was being taken out for a procedure and planned to return.
Reason for Transfer
- PreScreen Tech Note: At time of call intake, inquire about patient diagnosis, specialty care needed at destination facility, and ask if that care is available at sending or referring facility. When the transfer is being done for the convenience of the patient, family or preferred physician, Medicare will most likely deny payment. The transport must be reasonable and necessary, based solely on the medical condition and need for specialty care that is not available at the first hospital, before Medicare will pay for it.
- EMT Documentation Tip: Be sure to record the diagnosis that led to the need for the patient’s transfer. Document whether or not the needed specialist service(s) were available at the first hospital and the second.
- 65 Year Old Male patient, admitted to ABC General ER this date at 11:00 hours due to chest pain with syncopal episode. ER staff Dx. Non-STEMI with elevated Troponin levels. Patient is being transferred by ambulance to XYZ Memorial Hospital, Cardiac Care Unit, direct admit, to receive surgical / cardiology consultation and services. Cardio-thoracic surgery services are not available at ABC General Hospital as of this date. See attached PCS signed by ER Physician Smith.
- 39 Year Old Female, admitted to ABC General ER this morning at 04:30 hours for malaise and fever. ER staff diagnosis simple pneumonia. Patient requested transfer to XYZ Memorial ER for further treatment due to nearness of family physician, AMA. Patient & family members on scene were provided with an ABN. See signed copy attached to PCR.
- 46 Year Old Male, admitted to ABC General ER earlier this morning due to dizziness and syncope. ER Staff dx patient with STEMI. Patient requires surgical / cardiology consult that is not available at ABC General. ER Staff was asked to bypass XYZ Memorial Hospital in favor of University Medical Center in Anytown, USA. Patient & family advised that Medicare may not cover the full cost of the transport since we are bypassing XYZ Memorial Hospital. Refusal of Recommended Care and ABN signed and attached.
Skilled Nursing Facilities
- In most cases, the SNF is viewed the same as a hospital. Transfers must be from a facility with greater services than the first. The patient must be discharged from the first SNF and admitted to the second SNF. Additionally, the patient must be discharged from the first facility and admitted to the second.
On Campus Transfers
- CMS recognizes that some hospitals occupy multiple buildings, all doing business as a single provider. These are referred to a campus collectively. Transfers from one building to another, are not usually separately billable to Medicare PArt B. The hospital would be directly responsible for the transport charges. When the buildings are farther apart than 250 yards, and operating under different provider numbers, the transport may be billable to Medicare Part B, but the coverage guidelines are complex. Contact PMC’s billing office for assistance with your in campus, inter facility transfers.
Long Distance Ambulance Transportation to Residence
- We are often asked about long distance transports. The Medicare rules make no allowance for transporting patients beyond the local community for the hospital they are in. This can be an extended distance in rural areas, but locality is limited to “the service area surrounding the institution to which individuals normally travel or are expected to travel to receive hospital or skilled nursing services”. For trips with excessive mileage, use the ABN for all Medicare patients, even if they pay cash at the time of service.
When a patient requires hospital to hospital transport by ground ambulance, the rules can be confusing. Always remember, when in doubt about Medicare’s coverage for a non-emergent ambulance transport, fill out an ABN and have the patient sign it. Be sure that they can see the form and leave them a copy of what they signed. If you fail to obtain an ABN when it was required, the patient can request a refund from the provider, even after receiving the service. If you need more information on the Ambulance ABN form, check out our blog page for the article we wrote on the ambulance ABN.
PMC is a medical billing company that specializes an medical transportation billing. We have been billing emergency and non-emergency ambulance claims for over twenty years. If you found this article helpful, be sure to subscribe to our newsletter for updates.
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