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October 23, 2014 - Updated 01.12.16

Progressive Corrective Action (PCA) Review: Ambulance

The J15 Part B Medical Review Department performed Progressive Corrective Action (PCA) reviews on ambulance services throughout the year. The results of PCA reviews occurring over 2015 are as follows:

A0425

  • Mileage was denied:
    • Not documented
    • The transport was denied, therefore, the associated mileage was denied as well.
  • Mileage was reduced:
    • Inaccurately reported, likely due to miscalculations.
    • Mileage reduced to allow to the nearest facility.

A0427

  • Documentation requirements to support the medical necessity of the transport were not met.
    • Patient could have traveled another way.
  • Documentation did not support the code billed. The services were reduced to non-emergency ALS1 (HCPCS code A0426), or BLS (HCPCS code A0428) or emergency BLS (HCPCS code A0429) based on the documentation provided.
  • Documentation indicated no transport occurred.
  • Inappropriate use of CPT modifier 25.

A0428

  • Documentation requirements to support the medical necessity of the transport were not met.
    • Patient could have traveled another way.
    • Incomplete or missing Certificates of Medical Necessity (CMN) and Physician Certification Statements (PCS)
  • No documentation was received for the review.
  • Invalid Advance Beneficiary Notice of Non-Coverage (ABN)

A0429

  • Documentation requirements to support the medical necessity of the transport were not met.
    • Patient could have traveled another way.
  • Documentation did not support the code billed. The services were reduced to non-emergency BLS (HCPCS code A0428) based on the documentation provided.

A0433

  • The documentation indicated the patient was a hospice patient and should be covered under hospice.
  • Illegible documentation.
  • Documentation did not support the code billed. The services were reduced to non-emergency ALS1 (HCPCS code A0426) or BLS (HCPCS code A0428), or emergency ALS1 (HCPCS code A0427) based on the documentation provided.

A0434

  • The documentation submitted did not support a specialty care transport. There was no indication of critical care services noted in the documentation.
  • Documentation did not support the code billed. The services were reduced to non-emergency ALS1 (HCPCS code A0426), emergency ALS1 (HCPCS code A0427) or ALS2 (HCPCS code A0433) based on the documentation provided.

For more information on Medicare guidelines for ambulance services, including documentation required to process a claim, please refer to:

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