CMS Pub. 100-04, ch. 6, § 20.3.1

The following ambulance transportation and related ambulance services for residents in a

Part A stay are not included in the Part A PPS payment. Except for specific exclusions,

consolidated billing includes those medically necessary ambulance trips that are

furnished during the course of a covered Part A stay. A/B MACs (A), (B), (HHH), and

DME MACs are responsible for assuring that payment is made only for ambulance

services that meet established coverage criteria.

In most cases, ambulance trips are excluded from consolidated billing when resident

status has ended. The ambulance company then must bill the A/B MAC (A), (B), or

(HHH), or DME MAC (as appropriate) directly for payment. Listed below are a number

of specific circumstances under which a beneficiary may receive ambulance services that

are covered by Medicare, but excluded from consolidated billing.

The following ambulance services may be billed as Part B services by the supplier in the

following situations only.

• The ambulance trip is to the SNF for admission (the second character

(destination) of any ambulance HCPCS modifier is N (SNF) other than modifier

QN, and the date of service is the same as the SNF 21X admission date.);

• The ambulance trip is from the SNF after discharge, to the beneficiary’s home

(the first character (origin) of any HCPCS ambulance modifier is N (SNF), the

second character (destination) of the HCPCS ambulance modifier is R

(Residence), and date of ambulance service is the same date as the SNF through

date). Note: this includes beneficiaries discharged home to receive services from

a Medicare-participating home health agency under a plan of care;

• The ambulance trip is to or from a hospital based or nonhospital based ESRD

facility (the first or second character (origin or destination) of the HCPCS

ambulance modifier is N (SNF), and the other character of the HCPCS ambulance

modifier is G (Hospital-based dialysis facility) or J (Non-hospital based dialysis

facility)) for the purpose of receiving dialysis and related services excluded from

consolidated billing.

• The ambulance trip is from the SNF to a Medicare-participating hospital or a

CAH for an inpatient admission (the first character (origin) of the HCPCS

ambulance modifier is N (SNF), and the second character (destination) of the

HCPCS modifier is H).

• The ambulance trip follows a formal discharge or other departure from the SNF to

any destination other than another SNF, and the beneficiary does not return to that

or any other SNF before the following midnight; and

• An ambulance trip that conveys a beneficiary to a hospital or CAH and back to

the SNF, for the specific purpose of receiving emergency or other excluded

services (see section 20.1.2 above for list of other excluded services). As

discussed in section 20.1.2, the receipt of these exceptionally intensive outpatient

hospital services has the effect of temporarily suspending the beneficiary’s status

as an SNF “resident” for CB purposes with respect to those services; moreover,

once suspended in this manner, the beneficiary’s “resident” status would not

resume until he or she actually arrives back at the SNF. Accordingly, the entire

related ambulance roundtrip, both the outbound (SNF-to-hospital) portion and the

return (hospital-to-SNF) portion, would be excluded from SNF CB and billed

separately under Part B.

The following ambulance services are included in SNF CB and may not be billed as Part

B services to the A/B MAC (A), (B), or (HHH) when the beneficiary is in a Part A stay:

• Transfers Between Two SNFs: Under the regulations at 42 CFR 411.15(p)(3)(iv),

the day of departure from SNF 1 is a covered Part A day (to which consolidated

billing would apply) only if the beneficiary’s admission to SNF 2 occurs before

the following midnight (the first and second character of the ambulance modifier

is N). Patient Status is 03. An ambulance trip that is medically necessary to

effect this type of SNF-to-SNF transfer would be bundled back to SNF 1, as in

this specific situation the beneficiary would continue to be considered a “resident”

of SNF 1 for CB purposes up until the actual point of admission to SNF 2.

However, it should be noted that in addition to the “medical necessity” criterion in

the regulations at 42 CFR 409.27(c) pertaining specifically to ambulance

transports under the SNF benefit (i.e., the patient’s medical condition is such that

transportation by any means other than ambulance would be contraindicated),

coverage in this context also involves the underlying requirement of being

reasonable and necessary for diagnosing or treating the patient’s condition. For

example, a SNF-to-SNF transfer would be considered reasonable and necessary in

a situation where needed care is unavailable at the originating SNF, thus

necessitating a transfer to the receiving SNF in order to obtain that care. By

contrast, a SNF-to-SNF transfer that is prompted by non-medical considerations

(such as the patient’s preference to be placed in the receiving SNF) is not

considered reasonable and necessary for diagnosing or treating the patient’s

condition and, thus, would not be bundled back to the originating SNF.

• Ambulance transports to or from a diagnostic or therapeutic site other than a

hospital or renal dialysis facility (e.g., an independent diagnostic testing facility

(IDTF), cancer treatment center, radiation therapy center, wound care center,

etc.). The ambulance transport is included in the SNF PPS rate if the first or

second character (origin or destination) of any HCPCS code ambulance modifier

is “D” (diagnostic or therapeutic site other than “P” or “H”), and the other

modifier (origin or destination) is “N” (SNF). The first SNF is responsible for

billing the services to the A/B MAC (A).

• An SNF resident’s ambulance roundtrip to a physician’s office (first or second

character (origin or destination) of any HCPCS code ambulance modifier is “P”

(physician’s office), and the other modifier (origin or destination) is “N” (SNF))

is subject to SNF CB and would remain the responsibility of the SNF, because

even though the physician’s services are themselves excluded from SNF CB, this

exclusion does not affect the beneficiary’s overall status as an SNF “resident” for

CB purposes. Further, while a physician’s office is not normally a covered

destination under the separate Part B ambulance benefit, the SNF benefit’s Part

A coverage of ambulance transportation under the regulations at 42 CFR

409.27(c) incorporates only the Part B ambulance benefit’s general medical

necessity requirement at 42 CFR 410.40(e)(1), and not any of the latter benefit’s

more detailed coverage restrictions regarding destinations.

See chapter 15 for additional information on Part B coverage of Ambulance Services.

In contrast to the ambulance coverage described above, Medicare simply does not

provide any coverage at all under Part A or Part B for any non-ambulance forms of

transportation, such as ambulette, wheelchair van, or litter van. Further, as noted

previously, in order for the Part A SNF benefit to cover transportation via ambulance, the

regulations at 42 CFR 409.27(c) specify that the ambulance transportation must be

medically necessary, that is, the patient’s condition is such that transportation by any

means other than ambulance would be medically contraindicated.

This means that in a situation where it is medically feasible to transport an SNF resident

by some means other than an ambulance, for example, via wheelchair van, the wheelchair

van would not be covered (because Medicare does not cover any non-ambulance forms of

transportation), and an ambulance also would not be covered (because the use of an

ambulance in such a situation would not be medically necessary). With respect to

noncovered services for which a resident may be financially liable, the SNF is required

under the regulations at 42 CFR 483.10(g)(18) to “. . . inform each resident before, or at

the time of admission, and periodically during the resident’s stay, of services available in

the facility and of charges for those services, including any charges for services not

covered under Medicare/Medicaid or by the facility’s per diem rate.”