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Emergency Triage, Treat, and Transport Benefits for Ambulance Services Effective September 1, 2022

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, precertification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client’s specific MCO for details.

Effective for dates of service on or after September 1, 2022, emergency triage, treat, and transport (ET3) services for ambulance providers will become a benefit of Texas Medicaid.

Emergency Ambulance Transport

Emergency ambulance transport may be reimbursed in emergent situations when specially equipped ambulance transportation is required to safely manage the client’s medical condition. Emergency transportation may be initiated by an emergency response system 9-1-1 call or by a call to a fire department, the police, or another locally established system for medical emergency calls. At the time of the call, emergency teams are required to respond; however, upon arrival on the scene, the services required at that time (based on field evaluation by the emergency team) may be determined to be:

  • Emergent.
  • Nonemergent but medically necessary.

Emergency Triage, Treat, and Transport (ET3)

ET3 services allow greater flexibility for Medicaid-enrolled ambulance providers to address clients’ health care needs when responding to a 9-1-1 call or a call to a fire department, the police, or another locally established system for emergency calls.

ET3 permits emergency transportation (ground ambulance) providers to:

  • Transport a client to an alternative destination other than an emergency department.
  • Initiate and facilitate appropriate treatment in place (TIP) at the scene.
  • Initiate and facilitate appropriate TIP through telemedicine or telehealth services.

Transport to an Alternative Destination

An ambulance provider may transport a client to an alternative destination, such as an urgent care clinic, mental health center, physician’s office, or federally qualified health clinic (FQHC) when the following requirements apply:

  • The client’s condition is determined to be nonemergent, but the client requires medical attention.
  • An alternative destination will meet the client’s level of care more appropriately than an emergency department.
  • There is no other appropriate transportation available.

The alternative destination must be within or near the responding emergency transportation provider’s service area.

Before initiating ET3 transport to an alternative destination, the provider must have preestablished arrangements with alternative destination partners within their region and have knowledge of the alternative destination’s:

  • Hours of operation.
  • Clinical staff available.
  • Services provided.

The Texas Health and Human Services Commission (HHSC) expects ambulance providers to use best practices and exercise their normal standard of care to determine the nearest, most appropriate alternative destination for a client.

Treatment in Place (TIP)

If the emergency response team evaluates the client and determines that the services required at the time are medically necessary but not emergent, the emergency transportation provider may provide treatment to the client in accordance with the provider’s scope of practice, their emergency transport service’s medical direction, and established protocols.

The treatment on scene may also be performed, when medically necessary, through a telemedicine or telehealth visit performed in accordance with telemedicine and telehealth service requirements that will be published in the September 2022 Texas Medicaid Provider Procedures Manual, Telecommunication Services Handbook.

ET3 Alternative Destinations and TIP

The following modifiers must be submitted on the claim in the destination position of the origin/destination modifier combination for alternative destinations or TIP:

Modifier

Transport Type

C

Community mental health center (including substance use disorder center)

F

FQHC

O

Physician’s office

U

Urgent care facility

W

TIP (in person or through telemedicine or telehealth)

Emergency Triage Services

To bill for ET3 services, a provider must:

  • Be enrolled in Texas Medicaid as an ambulance provider.
  • Be responding to a call initiated by an emergency response system, such as a 9-1-1 call or a call to a fire department, the police, or another locally established system for medical emergency calls.
  • Evaluate the client and determine whether the client’s needs are nonemergent but require medical attention.

Billing for Transport to an Alternative Destination

For transport to an alternative destination reimbursement, providers must bill using the most clinically appropriate emergency transport code (procedure code A0427 or A0429), the ET modifier, and one of the destination modifiers listed above to indicate ET3 services.

Providers may also include the mileage code (procedure code A0425) on the claim as appropriate.

Note: If an emergency transportation provider transports a client to an alternative destination and determines at the time that the alternative site is closed or unable to provide the needed level of care, then the emergency transportation provider may transport the client to the nearest emergency department. In these cases, the provider may not bill for two transports.

Billing for TIP

TIP is classified as an emergency transportation service and must be billed using the most clinically appropriate emergency transport code (procedure code A0427 or A0429), the ET modifier, and the W destination modifier, which indicates TIP.

Claims must include TIP destination modifier W in the destination position of the origin/destination modifier combination. TIP claims that do not have modifier W in the emergency indicator field will be denied.

Supplies (procedure codes A0382 and A0398) and oxygen (procedure code A0422) may be reimbursed, but mileage (procedure code A0425) and other ambulance transportation services are not reimbursed for TIP services. Claims billed with nonpayable ambulance TIP services will be denied.

The following modifier combinations are valid for TIP ambulance claims:

Origin and Destination Modifier

Description

DW

Diagnostic or therapeutic site/freestanding facility (e.g., radiation therapy center) other than the H or P modifier

EW

Residential, domiciliary, or custodial facility (unskilled facility)

JW

Nonhospital-based dialysis facility

PW

Physician’s office

RW

Residence (client’s home or any residence)

SW

Scene of accident or acute event

If a client being treated in place has a real-time deterioration in the clinical condition that necessitates immediate transport to an emergency department, the ambulance provider must not bill for both the TIP ambulance service and the transport to the emergency department. In this case, the ambulance provider must bill only for the emergency department transport.

Ambulance providers that meet ET3 requirements may include the informational-only procedure code G2022 on claims for ambulance transportation to an emergency department, when the client refused TIP or transportation to an alternative destination.

When billing for TIP through telemedicine or telehealth, providers must bill using the most clinically appropriate emergency transportation code (procedure code A0427 or A0429), the ET modifier, the W destination modifier to indicate TIP, and procedure code Q3014. Procedure code Q3014 is informational-only to identify TIP through telemedicine or telehealth services.

Multiple TIP and transport claims rendered on the same date of service for the same recipient will be suspended for review.

Mileage

Emergency ground ambulance transports (procedure codes A0427 and A0429) may be billed without the mileage code A0425 for ET3 TIP services. Ambulance providers must include the TIP destination W modifier in the destination position of the origin/destination modifier combination.

For more information, call the TMHP Contact Center at 800-925-9126.