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8.3 Benefits and Limitations
Texas Medicaid reimburses for nonemergency and emergency transports.
Cardiopulmonary resuscitation (CPR) billed as an ambulance service by an ambulance provider will be denied.
The payment rates represent a global payment. It is inappropriate to bill for any supplies or other services related to the transport, unless otherwise specified in this section.
Medical necessity and coverage of ambulance services are not based solely on the presence of a specific diagnosis. Medicaid payment for ambulance transportation may be made only for those clients whose condition at the time of transport is such that ambulance transportation is medically necessary. For example, it is insufficient that a client merely has a diagnosis such as pneumonia, stroke, or fracture to justify ambulance transportation. In each of those instances, the condition of the client must be such that transportation by any other means is medically contraindicated. In the case of ambulance transportation, the condition necessitating transportation is often that an accident or injury has occurred giving rise to a clinical suspicion that a specific condition exists (for instance, fractures may be strongly suspected based on clinical examination and history of a specific injury).
It is the provider's responsibility to supply the contractor with information describing the condition of the client that necessitated ambulance transportation. Medicaid recognizes limitations of usual ambulance personnel for establishing a diagnosis and recognizes therefore, that diagnosis coding of a client's condition using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes when reporting ambulance services may be less specific than for services reported by other professional providers. Providers who submit ICD-9-CM diagnosis codes should choose the code that best describes the client's condition at the time of transport. As a reminder to providers of ambulance services, "rule out" or "suspected" diagnoses should not be reported using specific ICD-9-CM codes. In such instances where a diagnosis is not confirmed, it is more correct to use a symptom, finding, or injury code.
The ambulance provider may be sanctioned, including exclusion from the Medicaid Title XIX programs, for completing or signing a claim form that includes false or misleading representations of the client's condition or the medical necessity of the transport.
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