Billing & Payment Policies for Healthcare Services provided to Injured Workers and Crime Victims

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Effective July 1, 2012

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Table of contents

Definitions

Payment policies:
All ambulance services
Arrival of multiple providers
Emergency air ambulance transport
Multiple patient transportation
Nonemergency transport
Proper facilities

More info:
Related topics

Definitions

Bed confined criteria:

The worker is:

• Unable to get up from bed without assistance, and
• Unable to ambulate, and
• Unable to sit in a chair or wheelchair.

Destination:

Nearest place of proper treatment.

HCPCS code modifier mentioned in this chapter:

–GM  Multiple patients on one ambulance trip

Loaded miles:

Miles traveled from the pickup of the worker(s) to their arrival at the destination.

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  Payment policy: All ambulance services

(See definitions of loaded miles and destination in “Definitions” at the beginning of this chapter.)

When these services are paid

Ambulance services are paid when the injury to the worker is so serious that use of any other method of transportation is contraindicated.

Payment is based on the level of medically necessary services provided, not only on the vehicle used.

How mileage is paid

The insurer pays for mileage (ground and/or air) based only on loaded miles, which are the miles traveled from the pickup of the worker(s) to their arrival at the destination.

Note: The destination is defined as the nearest place of proper treatment.

Vehicle and crew requirements

To be eligible to be paid for ambulance services for workers, the provider must meet the criteria for vehicles and crews established in WAC 246-976 “Emergency Medical Services and Trauma Care Systems” and other requirements as established by the Washington State Department of Health for emergency medical services.

Links: Key sections of this WAC are:

• General: WAC 246-976-260 Licenses required,
• Ground ambulance vehicle requirements:
  • WAC 246-976-290 Ground ambulance vehicle standards,
  • WAC 246-976-300 Ground ambulance and aid vehicles—Equipment,
  • WAC 246-976-310 Ground ambulance and aid vehicles--Communications equipment,
  • WAC 246-976-390 Verification of trauma care services,
• Air ambulance services: WAC 246-976-320 Air ambulance services,
• Personnel:
  • WAC 246-976-182 Authorized care,
  • Washington State Department of Health, Office of Emergency Medical Services Certification Requirements Guidelines.

Services that can be billed

HCPCS code	Description	Fee schedule
A0425	Ground mileage, per statute mile	$12.91 per mile
A0426	Ambulance service, advanced life support, nonemergency transport, level 1 (ALS 1)	$638.90
A0427	Ambulance service, advanced life support, level 1 (ALS 1-emergency)	$663.13
A0428	Ambulance service, basic life support, nonemergency transport (BLS)	$349.01
A0429	Ambulance service, basic life support, emergency transport (BLS – emergency)	$558.43
A0430	Ambulance service, conventional air services, transport, one way (fixed wing)	$5,698.13
A0431	Ambulance service, conventional air services, transport, one way (rotary wing)	$6,624.90
A0433	Advanced Life Support, Level 2 (ALS 2)	$959.80
A0434	Specialty care transport (SCT)	$1,134.31
A0435	Fixed wing air mileage, per statute mile	$31.72 per mile
A0436	Rotary wing air mileage, per statute mile	$73.69 per mile
A0999	Unlisted ambulance service	By report restrictions: (1) Reviewed to determine if a more appropriate billing code is available, and (2) Reviewed to determine if medically necessary.

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 Payment policy: Arrival of multiple providers

Payment limits

When multiple providers respond to a call for services:

• Only the provider that furnishes the transport of the worker(s) is eligible to be paid for the services provided, and
• No payment is made to the other provider(s).

Payment policy: Emergency air ambulance transport

Payment limits

Air ambulance transportation services, either by helicopter or fixed wing aircraft, will be paid only if:

• The worker’s medical condition requires immediate and rapid ambulance transportation that couldn’t have been provided by ground ambulance, or
• The point of pickup is inaccessible by ground vehicle, or
• Great distances or other obstacles are involved in getting the worker to the nearest place of proper treatment.

  Payment policy: Multiple patient transportation

How these services are paid

The insurer pays the appropriate base rate for each worker transported by the same ambulance.

When multiple workers are transported in the same ambulance, the mileage will be prorated equally among all the workers transported.

Requirements for billing

The provider is responsible for prorating mileage billing codes based on the number of workers transported on the single ambulance trip.

The provider must use HCPCS code modifier –GM (Multiple patients on one ambulance trip) for the appropriate mileage billing codes. 

Payment policy: Nonemergency transport

Who may arrange for these services

Only medical providers may arrange for nonemergency ambulance transportation.

Note: Workers may not arrange nonemergency ambulance transportation.

Medical necessity requirements

Nonemergency transportation by ambulance is appropriate if:

• The worker is bed confined (see bed confined criteria, below), and it is documented that the worker’s accepted medical condition is such that other methods of transportation are contraindicated, or
• If the worker’s accepted medical condition, regardless of bed confinement, is such that transportation by ambulance is medically required.
  
  
  Note: Bed confined criteria are that the worker is:
  • Unable to get up from bed without assistance, and
  • Unable to ambulate, and
  • Unable to sit in a chair or wheelchair.

Nonemergency transportation may be provided on a scheduled (repetitive or nonrepetitive) or unscheduled basis:

• Scheduled, nonemergency transportation may be repetitive (for example, services regularly provided for diagnosis or treatment of the worker’s accepted medical condition) or nonrepetitive (for example, single time need).
• Unscheduled services generally pertain to nonemergency transportation for medically necessary services.
  
  Note: The insurer reserves the right to perform a post audit on any nonemergency ambulance transportation billing to ensure medical necessity requirements are met.
  

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Payment policy: Proper facilities

What makes a facility a place of proper treatment

To be a place of proper treatment, the facility must be generally equipped to provide the needed medical care for the worker.

A facility isn’t considered a place of proper treatment if no bed is available when inpatient medical services are required.

Payment limits

The insurer pays the provider for ambulance services to the nearest place of proper treatment.

Links: Related topics

If you’re looking for more information about…	Then go here:
Administrative rules for ambulance services	Washington Administrative Code (WAC) 246-796: http://apps.leg.wa.gov/wac/default.aspx?cite=246-976
Becoming an L&I provider	L&I’s website: www.Lni.wa.gov/ClaimsIns/Providers/Becoming/default.asp
Billing instructions and forms	Chapter 2: Information for All Providers
Fee schedules for all healthcare professional services (including ambulance services)	L&I’s website: http://feeschedules.Lni.wa.gov

Need more help?  Call L&I’s Provider Hotline at 1-800-848-0811.

CPT® codes and descriptions only are © 2011 American Medical Association