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October 11, 2021

Targeted Probe and Education Program to Focus on Ambulance Claims

The CGS Targeted Probe and Education program will begin review of claims associated with ambulance services. Guidance for ambulance service provision and documentation may be found in the Ambulance Fact SheetPDF located at the Part B Fact Sheets Web page.

All ground and air ambulance transportation services must meet all requirements regarding medical reasonableness and necessity as outlined in the applicable statute, regulations, and manual provisions.

Medical necessity is established when the patient's condition is such that use of any other method of transportation is contraindicated.  In any case in which some means of transportation other than an ambulance could be used without endangering the individual's health, whether or not such other transportation is actually available, no payment may be made for ambulance services.  In all cases, the appropriate documentation must be kept on file and, upon request.  It is important to note that the presence (or absence) of a physician’s order for a transport by ambulance does not necessarily prove (or disprove) whether the transport was medically necessary.  The ambulance service must meet all program coverage criteria in order for payment to be made.

In addition, the reason for the ambulance transport must be medically necessary.  That is, the transport must be to obtain a Medicare covered service, or to return from such a service.

We expect the documentation submitted to include a copy of the following legible and signed documentation from each patient's medical record:

  • Beneficiary's name
  • Date of service
  • Physician Certification Statement (PCS) signed with credentials and dated or documentation of signed receipt for unsigned PCS request from the U.S. Postal Service or other similar services
  • Transport note with documentation as to why patient needs to be transported by ambulance. (paint a picture such as patient unable to sit upright due to contractures)
  • Mileage noted to support transport to the nearest facility or documentation to support why transport was not to the nearest facility.
  • Documentation to show illness or injury that supports other means of transportation is contraindicated.
  • Relevant history, condition and/or level of function
  • Hospital to Hospital transports - Documentation to support services not available at originating hospital or higher level of services needed.
  • Documentation supporting level of transport being billed.
  • Transport note with signature and credentials of the crew member providing care of the beneficiary.
  • Appropriate signatures

For additional documentation requirements, please reference:

CPT codes under review will include:

  • A0428- Ambulance service, basic life support, non-emergency transport
  • A0429-Ambulance service, basic life support, emergency transport
  • A0425-Ground mileage, per statute mile

For more information on Targeted Probe and Education, please see the following links:

Consider using the myCGS Portal for claim review status and submission of documentation. For more information, please access myCGS

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