Helpful Questions to Determine Legal CPT Base Rate Codes for Ambulance Billing
One of the first questions to ask is whether the transport is an emergency transport or a non-emergency transport. What is the origin? What is the destination? Many times (but not always) these two questions will guide you in your quest to provide the appropriate code. If the patient was transported from their home to a nearby hospital emergency room, this is probably an emergency. If the patient was transported from a hospital back to that patient's skilled nursing facility, it is more than likely a non-emergency transport.
Was the patient taken to a lower level of care (residence) to a higher level of care (hospital ER)? This may help support an emergency determination.
Was the patient transported from a higher level of care (hospital inpatient) to a lower level of care (nursing home)? This will help support a non-emergent determination.
What about scheduled versus non-scheduled transports? This may sound repetitive after reading that last paragraph, but to those in the ambulance billing community, they will know it is a related issue, but still separate. Was the transport scheduled in advance? If it was, how long ago was it scheduled? According to CMS's definition, a transport must have been scheduled (someone contacting the ambulance service and arranging a time and date for pick up while giving patient-identifying information) at least 24 hours in advance of the transport. This means it can be scheduled for a week in advance, which is seen many times in the case of a hospice respite care transport.
If the ambulance service is contacted on Monday at 10:00 AM and they are notified of a transport on the following day at 11:00 AM, that is a scheduled transport since the transport is 25 hours away. However, if that same phone call schedules a transport for that same Monday afternoon at 3:00, that transport, according to CMS, is a non-scheduled transport since only five hours' notice was provided.
In the case of the scheduled transport, that is a non-emergent transport. If the transport does not meet the requirements for being a scheduled transport, then it is considered to be an emergency when determining the correct CPT base rate.