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2012 Texas Medicaid Provider Procedures Manual

Ambulance Services Handbook : 2. Ambulance Services : 2.2 Services/Benefits, Limitations, and Prior Authorization

2.2 Services/Benefits, Limitations, and Prior Authorization
Texas Medicaid reimburses for nonemergency and emergency transports.
Cardiopulmonary resuscitation (CPR) is included in ambulance transport when needed and is not a separately billable service. Claims for CPR during transport will be denied. If CPR is performed during a nonemergency transport, the advanced life support (ALS) procedure code must be billed.
Reimbursement for disposable supplies is separate from the established global fee for ambulance transports and is limited to one billable code per trip.
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 an accident or injury that 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 the limitations of ambulance personnel in 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 those reported by other professional providers. Providers who submit ICD-9-CM diagnosis codes must 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 must not be reported using specific ICD-9-CM codes. In such instances where a diagnosis is not confirmed, it is correct to use a symptom, finding, or injury code.
The ambulance provider may be sanctioned, including nonparticipation in 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.

Texas Medicaid & Healthcare Partnership
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