Emergency transports may be reimbursed for clients with emergency medical condition codes 78001 or 7814. Providers can find a complete list of emergency medical condition codes in the 2009 Texas Medicaid Provider Procedures Manual, section 8.3.1.2 titled “Emergency Transport Billing” on page 8-3.
Procedure codes A0225, A0380, and A0384 are not a benefit of Texas Medicaid.
The origin and destination modifier must be submitted on each procedure code on the ambulance claim.
Extra Attendant
The use of additional attendant(s) must be related to extraordinary circumstances when the basic crew is unable to transport the client safely.
The extra attendant must be certified by the Texas Department of State Health Services (DSHS) to provide emergency medical services.
The use of an extra attendant for air transport is not a benefit of Texas Medicaid.
Situations when an extra attendant may be required beyond the basic crew include, but are not limited to, the following:
· Necessity of additional special medical equipment or treatment in route to destination (Describe what special treatment and equipment is required and why it requires an attendant.)
· Client behavior that may be a danger to self or ambulance crew or that requires or may require restraints
· Extreme obesity of client (Provide weight and clients functional limitations.)
Emergency Transports
Emergency transports that use an extra attendant do not require prior authorization. Modifier ET must be billed with the extra attendant procedure code A0424.
The billing provider’s medical documentation must clearly indicate the services the attendant performed along with rationale for the services to indicate the medical necessity of having the attendant. The billing provider must keep the information that supports medical necessity in the client’s medical record, which will be subject to retrospective review.
When more than one client is transported at the same time in the same vehicle, the use of an extra attendant may be required when each client who is being transported requires medical attention or close monitoring.
Nonemergency Transports
Prior authorization is required when an extra attendant is needed for any nonemergency transport.
The authorization must be updated if an extra attendant is needed for subsequent transports.
To receive prior authorization, the requesting provider must prove medical necessity and identify attendant services that could not be provided by the basic crew. The information supporting medical necessity must be kept in the requesting provider’s medical record and is subject to retrospective review.
Texas Medicaid does not reimburse for an extra attendant based on an ambulance provider’s internal policy.
An extra attendant (procedure code A0424) will be denied if billed with air transports (procedure code A0430 or A0431).
Specialty Care Transport (SCT)
SCT (procedure code A0434) is the interfacility transportation of a critically injured or ill client by a ground ambulance vehicle, including the provision of medically necessary supplies and services, at a level of service beyond the scope of the emergency medical technician (EMT) or paramedic. SCT is necessary when a client’s condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area, for example, emergency or critical care nursing, emergency medicine, respiratory care, cardiovascular care, or a paramedic with additional training.
Ambulance Disposable Supplies
Ambulance disposable supplies are included in the global fee for SCT and must not be billed separately.
Reimbursement for basic life support (BLS) or ALS disposable supplies (procedure code A0382 or A0398) is separate from the established fee for ALS and BLS ambulance transports and is limited to one billable code per transport.
Oxygen
Reimbursement for oxygen (procedure code A0422) is limited to one billable code per transport.
Mileage
All ground ambulance transports must be billed with mileage procedure code A0425.
Prior Authorization Changes
Prior authorization request periods are as follows:
· One-time, nonrepeating requests (1 day) for prior authorization must be submitted on the Non-emergency Ambulance Prior Authorization Request form. The physician's signature is not required for one-time, nonrepeating requests.
· Short-term requests (2 through 60 days) for prior authorization are reserved for those clients whose transportation needs are short-term, i.e., not anticipated to last longer than 60 days.
· Long-term requests (61-180 days) for prior authorization are reserved for those clients whose transportation needs extend beyond 60 days.
Note: Short-term and long-term prior authorization requests must be submitted on the Non-emergency Ambulance Prior Authorization Request form and must be signed. The request must include the physician’s original signature and date signed. Stamped or computerized signatures and dates are not accepted. Without a physician’s signature and date, the form is considered incomplete.
The following authorization forms will be replaced by the new Non-emergency Ambulance Prior Authorization Request form, which may be found in the forms section on this website.
· Physician’s Medical Necessity Certification for Nonemergency Ambulance Transports
· Ambulance Fax Cover Sheet
For more information, call the TMHP Contact Center at 1-800-925-9126.