Analysis of Medi-Cal Ground Ambulance Reimbursement January 2011 Table of Contents Page Analysis of Medi-Cal Ground Ambulance Reimbursement 1 California Ambulance Statistics 2 Medi-Cal Ambulance Rate History 3 Medi-Cal Ambulance Utilization History 4 Medi-Cal Ambulance Utilization Report 5 Medicare Ambulance Utilization History 6 Ambulance Service Coverage Under Medicare 7
Analysis of Med-Cal Ground Ambulance Reimbursement 2009 Medi-Cal Fee-for-Service Data (1) Abbreviations 2011 Assumptions Original Rates After 1.9% Reduction (Estimated) E / NE Emergency / Non-emergency (2) $ 209.44 National Medicare Conv. Factor (2011) $ 107.16 $ 102.73 Non-emergency Base Rate BLS-NE Basic Life Support-Non-emergency (3) $ 6.73 Medicare Mileage Rate (2011) $ 118.20 $ 116.05 Emergency Base Rate BLS-E Basic Life Support-Emergency (4) 1.18 CA Ave Geographic Adjustment (2011) $ 3.55 $ 3.55 Medi-Cal Mileage Rate (NE + E) ALS-NE Advanced Life Support-Non-emergency (5) $ 235.83 Conversion Factor (CA Medicare-2011) 8.71 Ave Medi-Cal Miles/Trans ALS-E Advanced Life Support-Emergency (6) $ 245.26 Conversion Factor (GAO-2011) $ 30.92 Ave Mileage Payment/Trans (NE + E) ALS-2 Advanced Life Support-Level 2 (7) $ 282.05 Conversion Factor (HO-2011) $ 2.37 Ave Add-ons/Trans NE SCT Specialty Care Transport $ 4.55 Ave Add-ons/Trans E FFS Fee-for-service 10.2% Percent of total transports Non-emergency RVU Relative Value Unit where the 1.0 value equals the BLS-NE base rate 89.8% Percent of total transports Emergency HCPCS Healthcare Common Procedure Coding System codes required by federal regulations Current Medi-Cal Rates (FFS & HMO) Proposed Medi-Cal Rates (FFS & HMO, Cost-based) Ave Ave Total (11) Ave Total (12) Current Current Add-ons Mlg Ave (8) (9) Proposed Mlg Ave Estimated Medi-Cal Service Base Per Per Payment % Total Total HCPCS Service (10) M-Cal Per Payment % Total Total Codes Levels Rates Trans Trans Per Trans Trans Trans Payments Codes Levels RVUs Rates Trans Per Trans Trans Trans Payments X0032+X0400 NE $ 102.73 $ 2.37 $ 30.92 $ 136.03 10.2% 47,160 $ 6,415,205 A0428 BLS-NE 1.00 $ 245.26 $ 58.63 $ 303.89 9.2% 42,618 $ 12,951,182 X0030 E $ 116.05 $ 4.55 $ 30.92 $ 151.53 89.8% 416,080 $ 63,048,100 A0429 BLS-E 1.60 $ 392.42 $ 58.63 $ 451.05 15.7% 72,729 $ 32,804,063 -- -- -- -- -- -- A0426 ALS-NE 1.20 $ 294.32 $ 58.63 $ 352.94 1.0% 4,632 $ 1,634,968 -- -- -- -- -- -- A0427 ALS-E 1.90 $ 466.00 $ 58.63 $ 524.63 70.0% 324,268 $ 170,119,424 -- -- -- -- -- -- A0433 ALS-2 2.75 $ 674.47 $ 58.63 $ 733.10 2.0% 9,265 $ 6,792,020 X0402 NE Mileage $ 3.55 -- A0434 SCT 3.25 $ 797.10 $ 58.63 $ 855.73 2.1% 9,728 $ 8,324,585 X0034 E Mileage $ 3.55 -- A0425 Mileage $ 6.73 100.0% 463,241 $ 69,463,305 463,241 $ 232,626,242 Totals from 2009 Medi-Cal Report: 291,919 $ 43,774,378 Totals from 2009 Medi-Cal Report: 291,919 $ 69,463,305 Difference: $ (25,688,927) Medi-Cal Funding Shortfall: $ 163,162,937 Notes: 1 Hewlett Packard Enterprise Services (HP), "Medi-Cal Ambulance Utilization Report," Sacramento, CA: State of California, Dept of Health Services for fee-for-service (FFS) claims filed for dates of service (DOS) from 1/01/09-12/31/09. HMO transports are estimated, see attached calculation. NE = 10.2% 2 Centers for Medicare and Medicaid Services (CMS), Medicare Ambulance Fee Schedule, 2011 national conversion factor (CF), which equals the base rate of BLS-NE at relative value unit (RVU) 1.0. Go to CMS' Ambulance Services Center, www.cms.gov/center/ambulance.asp for more information. 3 CMS, Medicare Ambulance Fee Schedule. The 2011 mileage rate would apply to all urban and rural transports. GPCI does not apply to mileage, however, annual inflation update does apply to mileage. 4 The weighted average geographic update used by Medicare (i.e., the geographic practice cost index known as GPCI) for all of Calif is 1.18 or 18% (see page 6). 5 The national Medicare conversion factor is increased by the weighted average geographic adjustment for Calif according to CMS formula: [(RVU*(.3+(.7*GPCI)))*CF]. 6 U.S. Government Accountability Office (GAO), "Ambulance Providers: Costs and Expected Medicare Margins Vary Greatly," Report to Congressional Committees, GAO-07-383, May 2007. The Calif Medicare conversion factor is increased by 4% reflecting federal GAO report that Medicare payments are 6% below cost, minus 2% as a result of Congressional action. 7 Hobbs, Ong & Associates, Inc., "Industry Performance Survey," California Ambulance Association, September 2006, page 5. The GAO conversion factor is increased by 15% reflecting cost per transport in Calif according to the Hobbs, Ong Industry Performance Survey. 8 CMS, Medicare Ambulance Fee Schedule. Federal regulations require Medi-Cal to adopt the HCPCS (Healthcare Common Procedure Coding System) codes which were implemented by Medicare on April 1, 2002. 9 CMS, Medicare Ambulance Fee Schedule. Ambulance service levels are based upon the medical condition of the patient at time of transport (see page 7 for abreviations and definitions). 10 CMS, Medicare Ambulance Fee Schedule. Relative value units (RVUs) establish the base rates for all six ambulance transport service levels; the 1.0 value equals the BLS-NE base rate. 11 Proposed Medi-Cal rates are in compliance with state statutes, federal regulations and case law using the federal US GAO (GAO-07-383) ambulance cost study as the evidentiary base. All previous add-on charges would be bundled into base rates with the exception of mileage. These requirements are laid out under Title XIX of the Social Security Act for the State of California (State Medi-Cal Plan, Attachment 4.19-B, page 1). 12 Transport volumes are estimates based upon Medi-Cal utilization and Medicare service levels and definitions. Assumes required adoption of HCPCS codes including Medicare service levels, definitions and recognition of ALS. Analysis Prepared by California Ambulance Association 1 January 2011
California Ambulance Statistics California Ambulance Statistics 3,600 Number of Licensed Ambulances (74% are private) 166 Number of Licensed Ambulance Providers 17,000 Number of Licensed Paramedics 715 Number of Ambulance Providers Billing Medi-Cal 70,000 Number of Licensed EMTs 549 Number of Fire Department Ambulance Providers (est.) Sources: California EMS Authority, 2009 and Hewlett Packard Enterprise Services, 2009 Calculation of Statewide Ambulance Transports 36,961,664 California Population 8.3% Est. % Population Transported Annually 3,067,818 Est. # Annual Calif. Ambulance Transports Sources: U.S. Census Bureau, 2009 Population Estimates, Census 2000, 1990 Census; CDC, National Hospital Ambulatory Medical Care Survey, 2006. CDC reports that per capita ambulance transports to emergency department's is 6.2%. Calculation assumes mix of total transports is 75% emergency / 25% non-emergency. Therefore, if the per capita emergency ambulance transports is 6.2% (75% of total trans), then per capita non-emergency transports is 2.1% (25% of total trans), Calculation of Ambulance Charity Care 3,067,818 California Ambulance Transports (E & NE) 18% 18% Private Pay/Uninsured 552,207 Private Pay/Uninsured Transports $ 680 CA Cost/Transport (HO) $ 375,500,937 Cost of Care to Private Pay/Uninsured 15% 15% Collection Rate (est.) $ 56,325,141 Total Collections from Private Pay/Uninsured $ 319,175,796 Total Charity Care to Uninsured Calculation of Medi-Cal HMO Transports Total FFS HMO 15.1% 9.5% 5.6% Medi-Cal Transports 463,241 291,919 171,322 Medi-Cal Payments $ 69,464,702 $ 43,774,378 $ 25,690,324 Source: Hewlett Packard Enterprise Services, "Medi-Cal Ambulance Utilization Report," fee-for-service (FFS) claims filed from 1/01/09-12/31/09. If total Medi-Cal transports Medi-Cal FFS are 15.1% of transports and total state-wide transports are 9.5% of total state-wide transports, then Med-Cal HMO transports are 5.6% of total state-wide transports. This estimation methodology would be replaced with actual data when available. Average Payer Mix Ave Net Revenue % of Transports Payer Type Per Trans by Payer Type Medicare $ 426 34.9% Medi-Cal $ 150 21.0% Private Pay $ 201 17.9% Comm Insurance $ 1,100 17.7% Facilities $ 723 8.2% Other $ 342 0.2% Sources: Hobbs, Ong & Associates, Inc., "Industry Performance Survey," California Ambulance Association, September 2006, page 5; Hewlett Packard Enterprise Services, "Medi-Cal Ambulance Utilization Report," fee-for-service claims filed from 1/01/09-12/31/09; CMS, "Medicare Physician/Supplier Procedure Summary Master File, 2009. Analysis Prepared by California Ambulance Association 2 January 2011
Medi-Cal Ambulance Rate History 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 (1) Amb Inflation Factor 3.0% 2.3% 2.1% 3.0% 3.7% 2.5% 1.1% 2.1% 3.3% 4.3% 3.0% 2.7% 5.0% 0.0% 1.1% Ambulance Cost Per Transport (2) HCFA (98) $ 411.67 (3) Project Hope (98) $ 373.00 (4) GAO (04) $ 489.70 $ 592.00 (5) Hobbs,Ong (05) $ 562.00 Medi-Cal Base Rates Per Transport (6) Non-Emergency $ 61.71 $ 95.94 $ 107.16 $ 107.16 $ 107.16 $ 107.16 $ 107.16 $ 107.16 $ 107.16 $ 107.16 $ 107.16 $ 102.73 $ 102.73 $ 102.73 $ 92.46 Emergency $ 71.59 $ 105.82 $ 118.20 $ 118.20 $ 118.20 $ 118.20 $ 118.20 $ 118.20 $ 118.20 $ 118.20 $ 118.20 $ 116.05 $ 116.05 $ 116.05 $ 104.45 Mileage $ 3.55 $ 3.55 $ 3.55 $ 3.55 $ 3.55 $ 3.55 $ 3.55 $ 3.55 $ 3.55 $ 3.51 $ 3.51 $ 3.51 $ 3.16 1.9% Rate Increase/Decrease 47.8% 11.7% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -1.9% 0.0% 0.0% -10.0% Medi-Cal Ave. Payment Per Transport (6) n/a n/a n/a n/a n/a n/a $ 153.88 $ 154.00 $ 144.47 $ 149.95 n/a $ 134.96 Medicare Ave. Payment Per Transport (7) n/a n/a n/a n/a n/a n/a n/a n/a $ 408.04 $ 426.23 $ 383.61 $ 383.22 Medi-Cal Below Cost 33% 37% 23% Since Last Medi-Cal Increase (1999-2011) Costs and inflation increased by: 33.9% Medi-Cal rates decreased by: 13.2% Sources 1 U.S. Dept of Labor, Bureau of Labor Statistics, "Consumer Price Index-Urban," at www.bls.gov/cpi. Actual ambulance inflation update varies slightly from published CPI-U due to Congressional action. 2 Health Care Financing Administration (HCFA), Hospital-based Ground Ambulance Costs, September 2000, Federal Register, Vol. 65, No. 177, September 12, 2000, page 55085. 3 Project Hope, Findings from the 1999 National Survey of Ambulance Providers, March 2000, page 25. 4 U.S. Government Accountability Office (GAO), "Ambulance Providers: Costs and Expected Medicare Margins Vary Greatly," Report to Congressional Committees, GAO-07-383, May 2007. 5 Hobbs, Ong & Associates, Inc. (HO), "Industry Performance Survey," California Ambulance Association, September 2006. 6 Electronic Data Systems (EDS), "Medi-Cal Ambulance Utilization Report," fee-for-service claims for 2006, 2007, 2008 and 2009, includes proposed 10% rate cut in 2011. 7 Centers for Medicare and Medicaid Services (CMS), "Medicare Physician/Supplier Procedure Summary Master File, 2009. Amount for 2010 estimated based upon 10% rate reduction due to final phase-in of national Medicare ambulance fee schedule, 2011 estimated based upon 2011 ambulance inflation factor. Analysis Prepared by California Ambulance Association 3 January 2011
Medi-Cal Ambulance Utilization History Ground Ambulance Transportation Services Change Change 05-06 06-07 CY 08 CY 09 08-09 06-09 Total Payments Emergency $ 35,395,213 82% $ 34,757,799 83% $ 37,255,153 90% $ 39,731,607 91% 7% 12% Non-emergency $ 7,569,272 18% $ 7,203,879 17% $ 4,232,394 10% $ 4,042,771 9% -4% -47% Total Payments $ 42,964,485 100% $ 41,961,678 100% $ 41,487,547 100% $ 43,774,378 100% 6% 2% Total Transports Emergency 219,445 79% 217,887 80% 252,224 88% 262,200 90% 4% 19% Non-emergency 59,769 21% 54,593 20% 34,949 12% 29,719 10% -15% -50% Total Transports 279,214 100% 272,480 100% 287,173 100% 291,919 100% 2% 5% Ave Payment/Trans - Emerg $ 161.29 $ 159.52 $ 147.71 $ 151.53 3% -6% Ave Payment/Trans - Non-Emerg $ 126.64 $ 131.96 $ 121.10 $ 136.03 12% 7% Ave Payment/Trans - Total $ 153.88 $ 154.00 $ 144.47 $ 149.95 4% -3% Total Medical Transportation Change 05-06 06-07 CY 08 CY 09 06-09 Payments Wheel Chair/Litter Van $ 81,187,578 60% $ 89,375,719 62% $ 93,623,036 64% $ 105,155,296 65% 12% 30% Ground $ 42,964,485 32% $ 41,961,678 29% $ 41,487,547 28% $ 43,774,378 27% 6% 2% Air $ 10,369,629 8% $ 11,797,982 8% $ 11,735,559 8% $ 13,614,251 8% 16% 31% Total Payments $ 134,521,692 100% $ 143,135,379 100% $ 146,846,142 100% $ 162,543,925 100% 11% 21% Transports Wheel Chair/Litter Van 1,142,270 1,269,125 1,467,403 1,703,864 16% 49% Ground 279,214 272,480 287,173 291,919 2% 5% Air 3,840 4,153 4,269 4,854 14% 26% Source: Electronic Data Systems (EDS)/Hewlett Packard Enterprise Services (HP), "Medi-Cal Ambulance Utilization Report," Sacramento, CA: State of California, Dept of Health Services. Report of fee-for-service claims filed from 8/01/05-7/31/06, 7/01/06-7/31/07, 1/01/08-12/31/08 and 1/01/09-12/31/09. Does not include HMO transports. Analysis Prepared by California Ambulance Association 4 January 2011
2009 Medi-Cal Ambulance Utilization Report Ambulance Services: A0800; A0999; X0002-X0036; DOS: 01/01/09-12/31/09 Paid Claims Procedure Per Unit Number of Ave Per Paid Weighted Ave Procedure Name Paid Amt Code Value* Claim Lines Claim Per Trans A0800 AMB TRANS 7PM-7AM Not valid 0 $0.00 $ - A0999 UNLISTED (MEDICAL TRANSPORTATION) Manual Price 238 $73.75 $ 0.31 X0002 MED TRANS AMB 2 PATIENTS,EACH PATIENT $ 37.02 939 $32,960.05 $ 35.10 X0004 MED TRANS S AMB NIGHT CALL 7 PM TO 7 AM $ 9.88 0 $0.00 $ - Still need payment data for night charge X0006 MED TRANS S AMB EMERGENCY RUN $ 9.88 113 $1,044.24 $ 9.24 $ 0.0040 X0008 NEONATAL INTENSIVE CARE INCUBATOR $ 51.49 250 $12,141.46 $ 48.57 $ 2.22 X0014 = X0010 MED TRANS S AMB WAIT TIME OV 15 MIN E 15 $ 9.88 6,145 $124,969.09 $ 20.34 $ 4.21 SCT Trans: X0012 COMPRESSED AIR FOR INFANT RESPIRATORS $ 10.23 399 $3,922.08 $ 9.83 $ 0.72 5,469 X0014 EXTRA ATTENDANT- RN FIRST HOUR $ 16.44 5,469 $91,860.88 $ 16.80 $ 16.80 SCT % of X0016 EXTRA ATTENDANT-RN 2ND-3RD HOURS EACH $ 11.51 313 $4,447.90 $ 14.21 $ 0.81 Ttl Trans: X0018 EXTRA ATTENDANT-RN EACH ADDITIONAL HOUR $ 5.25 38 $256.21 $ 6.74 $ 0.05 2.1% X0020 COST OF IV FLUIDS Manual Price 0 $0.00 $ - X0022 ECG IN AMBULANCE Not valid 0 $0.00 $ - Still need payment data for "93041" X0030 AMBULANCE SERVICE, BASIC LIFE SUPPORT $ 118.20 262,200 $30,429,071.36 $ 116.05 $ 116.05 X0032 MED TRAN S AMB 1 PATIENT $ 107.16 4,349 $480,347.06 $ 110.45 $ 102.73 X0034 MED TRANS S AMB MIL ONE WAY PER MI $ 3.55 264,507 $8,239,421.92 $ 31.15 $ 30.92 E Oxygen: X0036 MED TRAN S AMB OXYGEN PER TANK $ 9.88 97,217 $922,381.57 $ 9.49 $ - $ 3.11 Ambulance Totals: 642,177 $40,342,897.57 NE Oxygen: $ 0.35 Non-Emergency Transfer Services: X0400 - X0416; DOS: 01/01/09-12/31/09 Procedure Per Unit Number of Ave Per Paid Weighted Ave Procedure Name Paid Amt Code Value* Claim Lines Claim Per Trans X0400 RESP TO CALL AMBUL AC/LTC TRANS ONLY $ 107.16 25,370 $2,572,804.87 $ 101.41 $ 102.73 X0402 AMB MIL,ONE WAY PER MI AC/LTC TRANS ONLY $ 3.55 25,004 $788,110.33 $ 31.52 $ 30.92 X0404 RES CA,LIT PAT/LIT VAN AC/LTC TRANS ONLY $ 26.29 6,072 $146,813.33 $ 24.18 X0406 RE TO CALL NON/LIT PAT AC/LTC TRANS ONLY $ 17.65 5,365 $86,927.51 $ 16.20 X0408 LITTLE/WHEELVAN MI ONE WAY PER MI AC/LTC $ 1.30 11,340 $96,838.12 $ 8.54 X0410 WHEELCHAIR USE AC/LTC TRANS ONLY $ 0.89 2,204 $1,842.59 $ 0.84 X0412 OXYGEN, PER TANK AC/LTC TRANS ONLY $ 11.86 3,935 $45,061.50 $ 11.45 $ 1.52 X0414 ATTENDANT AC/LTC TRANS ONLY $ 5.52 4,996 $25,504.02 $ 5.10 $ 0.86 X0416 UNLISTED AC/LTC TRANS ONLY Manual Price 0 $0.00 $ - Ambulance Totals: 59,305 $ 3,431,480.72 $ 43,774,378 SUMMARY Trans Pymts P/T EMERGENCY + SCT Base Rates 262,200 $ 30,429,071.36 $ 116.05 Total Payments for X0030 / Total E Base Rates (X0030) Mileage - $ 8,108,478.57 $ 30.92 Total Mileage Payments (X0034 + X0402) / Total Base Rates (X0030 + X0032 + X0400) Add-Ons - $ 1,194,057.23 $ 4.55 Total Payments (A0999 + X0002-X0018 + X0036) / Total E Base Rates (X0030) E TOTAL 262,200 $ 39,731,607.16 $ 151.53 $ 151.53 89.8% NONEMERGENCY Base Rates 29,719 $ 3,053,151.93 $ 102.73 Total Payments (X0032 + X0400) / Total Base Rates (X0032 + X0400) Mileage - $ 919,053.68 $ 30.92 Total Mileage Payments (X0034 + X0402) / Total Base Rates (X0030 + X0032 + X0400) Add-Ons - $ 70,565.52 $ 2.37 Total Payments (X0412 + X0414) / Total Base Rates (X0032 + X0400) NE TOTAL 29,719 $ 4,042,771.13 $ 136.03 $ 136.03 10.2% GRAND TOTAL 291,919 $ 43,774,378 $ 149.95 100.0% MILEAGE SUMMARY Total Total Mlg Total Mlg Ave Miles Mileage Rate Trans Pymts Pymts/Trans Per Trans Per Trans 291,919 $ 9,027,532 $ 30.92 8.71 $ 3.55 (Mileage - Number of Claim Lines) 289,511 Source: Hewlett Packard Enterprise Services (HP), "Medi-Cal Ambulance Utilization Report," Sacramento, CA: State of California, Dept of Health Services. Report of fee-for-service claims filed from dates of service (DOS) 1/01/09-12/31/09. Does not include HMO transports. Analysis Prepared by California Ambulance Association 5 January 2011
Medicare Ambulance Utilization History Change Allowed Charges 2008 % 2009 % 08-09 A0428 BLS-NE $129,275,242 28.2% $158,130,791 31.0% 22% A0429 BLS-E $64,978,039 14.2% $68,034,477 13.3% 5% A0426 ALS-NE $3,231,682 0.7% $4,113,357 0.8% 27% A0427 ALS-E $193,245,881 42.1% $204,451,334 40.0% 6% A0433 ALS-2 $6,033,181 1.3% $5,944,120 1.2% -1% A0434 SCT $10,304,366 2.2% $11,719,621 2.3% 14% A0425 Mileage $51,806,772 11.3% $58,387,079 11.4% Total Allowed Charges $ 458,875,163 100.0% $ 510,780,779 100.0% 11% Allowed Transports A0428 BLS-NE 516,150 45.9% 590,490 49.3% 14% A0429 BLS-E 162,777 14.5% 159,917 13.3% -2% A0426 ALS-NE 11,147 1.0% 13,190 1.1% 18% A0427 ALS-E 412,933 36.7% 412,717 34.4% 0% A0433 ALS-2 8,823 0.8% 8,246 0.7% -7% A0434 SCT 12,742 1.1% 13,799 1.2% 8% A0425 Mileage 7,613,334 8,204,747 Total Allowed Transports 1,124,572 100% 1,198,359 100% 7% Allowed Charges/Transport $ 408.04 $ 426.23 4% Miles/Transport 6.8 6.8 Geographic Practice Cost Index (GPCI) Uncompensated Medicare Services Locality Locality Name PE GPCI Transports 26 Anaheim/Santa Ana, CA 1.271 79,763 Medicare Rates are 4% below cost: 18 Los Angeles, CA 1.220 364,696 $ 20,431,231 03 Marin/Napa/Solano, CA 1.272 18,070 07 Oakland/Berkley, CA 1.286 70,899 05 San Francisco, CA 1.422 21,475 06 San Mateo, CA 1.418 10,630 09 Santa Clara, CA 1.310 29,031 17 Ventura, CA 1.251 18,500 99 Rest of California* 1.078 287,206 99 Rest of California* 1.078 96,610 Weighted Average 1.18 996,880 Sources: Medicare physician/supplier procedure summary master file, 2008 and 2009, allowed amounts include beneficiary deductibles and coinsurance. 2010 Practice Expense GPCI found at: www.palmettogba.com/palmetto/providers.nsf/docscat/jurisdiction%201%20part%20b~publications~fee%20schedules. CMS physician/supplier procedure summary master file, 2006, for transport counts by locality. Prepared by Chris Hogan, Direct Research, McLean, VA. Analysis Prepared by California Ambulance Association 6 January 2011
Ambulance Service Coverage Under Medicare Note: The summary below is intended to be a brief overview of the ambulance services covered by Medicare. For more information, please go to: http://www.cms.hhs.gov/center/ambulance.asp. Levels of Ground Ambulance Transport -- Medicare has specific definitions that set forth the various levels of service and the medical necessity criteria for ambulance services payable by Medicare based on CMS Manual, Pub. 100-02, Chapter 10, Section 30.1.1: A0428 1.00 BLS-NE Basic Life Support Non-Emergency A0429 1.60 BLS-E Basic Life Support Emergency A0426 1.20 ALS-NE Advanced Life Support Non-Emergency A0427 1.90 ALS-E Advanced Life Support Emergency A0433 2.75 ALS-2 Advanced Life Support 2 A0434 3.25 SCT Specialty Care Transport A0425 Mileage Emergency Response -- The definition of an emergency response is set forth in 42 C.F.R. 414.605, which provides that an emergency response means responding immediately at the BLS or ALS-1 level of services to a 911 call or the equivalent. An immediate response is one in which the ambulance entity begins as quickly as possible to take the steps necessary to respond to the call. The definition does not include ALS-2 or SCT, because these levels of service do not have separate codes for emergency and non-emergency. Basic Life Support (BLS) -- Basic Life Support (BLS) is transportation by ground ambulance and the provision of medically necessary supplies and services, including BLS ambulance services as defined by the State. The vehicle must be staffed by at least one individual qualified as an EMT-Basic under state and local laws. Advanced Life Support (ALS) -- Advanced Life Support (ALS) is transportation by ground ambulance and the provision of medically necessary supplies and services, including the provision of either an ALS assessment (emergency responses only) or at least one ALS intervention. An "ALS intervention is a procedure that, under state and local law, cannot be done by an EMT-Basic, i.e., requires at least a paramedic or EMT-Intermediate. ALS Assessment -- ALS Assessment is an assessment performed by an ALS crew as part of an emergency response that was necessary because the patient s reported condition at the time of dispatch was such that only an ALS crew was qualified to perform the assessment. An ALS assessment does not necessarily result in a determination that the patient requires an ALS level of service. Advanced Life Support 2 (ALS-2) -- Advanced Life Support 2 (ALS-2) is transportation by ground ambulance and the provision of medically necessary supplies and services, including either: (1) the separate administration of three or more medications by intravenous push/bolus or by continuous infusion or (2) the provision of at least one ALS-2 procedure. Specialty Care Transport (SCT) -- Specialty Care Transport (SCT) is the interfacility transportation of a critically ill or injured beneficiary by ground ambulance and the provision of medically necessary supplies and services, at a level of service beyond the scope of a paramedic. This is necessary when the patients condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty care area, e.g., nursing, emergency medicine, respiratory care, cardiovascular care, or a paramedic with additional training. Source: Werfel, D., Medicare Reference Manual, 2009, American Ambulance Association, page 45-48. Analysis Prepared by California Ambulance Association 7 January 2011