[Federal Register Volume 65, Number 177 (Tuesday, September 12, 2000)]
[Proposed Rules]
[Pages 55078-55100]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 00-23195]



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Part II





Department of Health and Human Services





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Health Care Financing Administration



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42 CFR Parts 410 and 414



Medicare Program; Payment of Ambulance Services, Fee Schedule; and 
Revision to Physician Certification Requirements for Coverage of 
Nonemergency Ambulance Services; Proposed Rule

  Federal Register / Vol. 65, No. 177 / Tuesday, September 12, 2000 / 
Proposed Rules  

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration

42 CFR Parts 410 and 414

[HCFA-1002-P]
RIN 0938-AK07


Medicare Program; Fee Schedule for Payment of Ambulance Services 
and Revisions to the Physician Certification Requirements for Coverage 
of Nonemergency Ambulance Services

AGENCY: Health Care Financing Administration (HCFA), HHS.

ACTION: Proposed rule.

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SUMMARY: This proposed rule would establish a fee schedule for the 
payment of ambulance services under the Medicare program, implementing 
section 1834(l) of the Social Security Act. As required by that 
section, this proposed fee schedule for ambulance services was the 
product of a negotiated rulemaking process that was carried out 
consistent with the Federal Advisory Committee Act. The fee schedule 
described in this proposed rule would replace the current retrospective 
reasonable cost reimbursement system for providers and the reasonable 
charge system for suppliers of ambulance services. In addition, this 
proposed rule would require that payment for ambulance services would 
be made only on an assignment related basis; establish new codes to be 
reported on claims for ambulance services; establish increased payment 
for ambulance services furnished in rural areas based on the location 
of the beneficiary at the time the patient is placed on board the 
ambulance; and revise the physician certification requirements for 
coverage of nonemergency ambulance services.

DATES: We will consider comments if we receive them at the appropriate 
address, as provided below, no later than 5 p.m. on November 13, 2000.

ADDRESSES: Mail written comments (one original and three copies) to the 
following address ONLY: Health Care Financing Administration, 
Department of Health and Human Services, Attn: HCFA-1002-P, P.O. Box 
8013, Baltimore, MD 21244-8013.
    Since comments must be received by the date specified above, please 
allow sufficient time for mailed comments to be received timely in the 
event of delivery delays. If you prefer, you may deliver your written 
comments (one original and three copies) by courier to one of the 
following addresses:

Room 443-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW, 
Washington, DC 20201, or
C5-15-03, Central Building, 7500 Security Boulevard, Baltimore, MD 
21244-1850.

    Comments mailed to the two above addresses may be delayed and 
received too late to be considered.
    Because of staffing and resource limitations, we cannot accept 
comments by facsimile (FAX) transmission. In commenting, please refer 
to file code HCFA-1002-P.
    Comments received timely will be available for public inspection as 
they are received, generally beginning approximately 3 weeks after 
publication of a document, in Room 443-G of the Department's offices at 
200 Independence Avenue, SW, Washington, DC 20201, on Monday through 
Friday of each week from 8:30 a.m. to 5 p.m. (phone: (202) 690-7890).

FOR FURTHER INFORMATION CONTACT: Margot Blige, (410) 786-4642, for 
coverage issues. Glenn McGuirk, (410) 786-5723, for payment issues.

SUPPLEMENTARY INFORMATION:

I. Background

A. Current Payment System

    The Medicare program pays for ambulance services on a reasonable 
cost basis when furnished by a provider and on a reasonable charge 
basis when furnished by a supplier. (For purposes of this discussion, 
the term ``provider'' means all Medicare-participating institutional 
providers that submit claims for Medicare ambulance services (hospitals 
(including critical access hospitals), skilled nursing facilities 
(SNFs), and home health agencies (HHAs)). The term ``supplier'' means 
an entity that is independent of any provider.) The reasonable charge 
methodology which is the basis of payment for ambulance services 
furnished by ambulance suppliers is determined by the lowest of the 
customary, prevailing, actual, or inflation indexed charge (IIC).
    The following describes the current billing methods for ambulance 
services:
     Method 1 is a single, all-inclusive charge reflecting all 
services, supplies, and mileage.
     Method 2 is one charge reflecting all services and 
supplies (base rate) with a separate charge for mileage.
     Method 3 is one charge for all services and mileage, with 
a separate charge for supplies.
     Method 4 is separate charges for services, mileage, and 
supplies.
    Over the past 20 years, the Congress has been moving towards fee 
schedules and prospective payment systems for Medicare payment. In the 
case of ambulance services, the reasonable charge methodology has 
resulted in a wide variation of payment rates for the same service 
depending on location. In addition, this payment methodology is 
administratively burdensome, requiring substantial recordkeeping for 
historical charge data. The Congress, under the Balanced Budget Act of 
1997 (BBA), (Pub. L. 105-33), mandated the establishment of a fee 
schedule for payment of ambulance services.

B. Recent Legislation

1. Balanced Budget Act of 1997
    Section 4531(b)(2) of the BBA added a new section 1834(l) to the 
Social Security Act (the Act). Section 1834(l) of the Act requires that 
we establish a national fee schedule for payment of ambulance services 
furnished under Medicare Part B. This section also requires that in 
establishing the ambulance fee schedule, we will--
     Establish mechanisms to control increases in expenditures 
for ambulance services under Part B of the Medicare program;
     Establish definitions for ambulance services that link 
payments to the type of services furnished;
     Consider appropriate regional and operational differences;
     Consider adjustments to payment rates to account for 
inflation and other relevant factors;
     Phase in the fee schedule in an efficient and fair manner; 
and,
     Require payment for ambulance services be made only on an 
assignment related basis.
    In addition, the BBA requires that ambulance services covered under 
Medicare be paid based on the lower of the actual billed charge or the 
ambulance fee schedule amount. The BBA also requires that total 
payments under the ambulance fee schedule may be no more than what 
would have been paid if the ambulance fee schedule were not in effect. 
As discussed below, we intended to incorporate $65 million in program 
savings in the 1998 base year data upon which the ambulance fee 
schedule is calculated consistent with the statutory requirement that, 
in the aggregate, we pay no more than would have been paid in the 
absence of the fee schedule for CY 2001. This amount correlates to 
$67.3 million when updated for the effects of inflation.
2. Balanced Budget Refinement Act of 1999
    Section 412 of the Medicare, Medicaid, and the State Child Health

[[Page 55079]]

Insurance Program Balanced Budget Refinement Act of 1999 (BBRA) 
provided a new definition for the term ``rural'' in the context of the 
Medicare coverage provision for paramedic advanced life support (ALS) 
intercept services. The BBRA states that, effective for services 
furnished on or after January 1, 2000:

    An area shall be treated as a rural area if it is designated as 
a rural area by any law or regulation of the State or if it is 
located in a rural census tract of a metropolitan statistical area 
(as determined under the most recent Goldsmith modification, 
originally published in the Federal Register on February 27, 1992 
(57 Fed. Reg. 6725)).

    This definition applies only to the Medicare paramedic ALS 
intercept benefit implemented at 42 CFR 410.40(c). This is a very 
limited benefit and to date we know of only one State (New York) with 
areas that meet the statutory requirements. (See the March 15, 2000 
final rule (65 FR 13911).) For all other ambulance services, the 
definition of ``rural'' specified in this proposed rule would apply.

C. Components of Ambulance Fee Schedule Payment Amounts

    In general, the payment amount for each air ambulance service paid 
under the ambulance fee schedule would be the product of two primary 
factors: (1) A nationally uniform unadjusted base rate; and (2) a 
geographic adjustment factor for an ambulance fee schedule area. A 
detailed description of these factors is discussed in this proposed 
rule.
    In general, the payment amount for each ground ambulance service 
paid under the ambulance fee schedule would be the product of three 
primary factors: (1) A nationally uniform relative value for the 
service; (2) a geographic adjustment factor for an ambulance fee 
schedule area; and (3) a nationally uniform conversion factor (CF) for 
the service. A detailed description of these factors is discussed in 
this proposed rule.
    Relative value units (RVUs) measure the value of ambulance services 
relative to the value of a base level ambulance service. Thus, if the 
value of the resources necessary to furnish service B are twice the 
value of the resources needed to furnish service A, service B will have 
RVUs that are twice the value of the RVUs for service A. RVUs are 
multiplied by a CF expressed as a dollar value to produce a payment 
amount. The RVUs represent, on average, the relative resources 
associated with the various levels of ambulance services.
    Because the fee schedule is based on the relative values of 
different levels of ground ambulance services relative to a basic life 
support ground ambulance service, a factor is needed in order to 
convert the relative value to a dollar amount equal to the national 
base payment rate. In order to determine the conversion factor (CF), 
the general approach is first to determine the total amount of money 
available and divide that total by the total number of relative value 
units. As we describe in more detail below, we used 1998 Medicare 
ambulance claims data to determine the total RVUs in this calculation. 
The total dollars is equal to the total allowed charges for all 
ambulance services billed to Medicare in 1998, less the $65 million 
adjustment for those basic life support (BLS) services that had been 
paid at the advanced life support (ALS) services payment rate, as 
described in Section 1834(l)(3) of the Act. This section states that, 
in establishing the ambulance fee schedule, the Secretary must ensure 
that the aggregate amount of payment made for ambulance services in 
calendar year (CY) 2000 does not exceed the aggregate amount of payment 
that would have been made absent the fee schedule. In the January 22, 
1999 notice concerning the negotiated rule meetings, we stated that, 
although we were postponing final agency action on the proposal to 
define BLS and ALS services because of the BBA requirement that this 
issue be subject to negotiated rulemaking, we believe that the savings 
that would have been realized through implementation of that policy 
should not be lost to the Medicare program. We determined that $65 
million in program savings would have been realized in the base year 
1998 data if the final rule had been in effect. The total RVUs are 
equal to the sum of the total number of allowed services that were 
billed in 1998 for each of the categories (levels) of ambulance 
services established by the negotiated rulemaking committee multiplied 
by the respective relative value of each of the new levels of service.
    Section 4531(b)(3) of the BBA provides that the fee schedule was to 
be effective for ambulance services furnished on or after January 1, 
2000. However, because of other statutory obligations and the scope of 
systems changes required to implement the ambulance fee schedule, we 
could not meet this statutory deadline while assuming that our 
respective systems were compliant with the Year 2000 requirements. 
Therefore, because we were unable to implement the ambulance fee 
schedule on January 1, 2000, we delayed implementation of the fee 
schedule for ambulance services until January 1, 2001. This action is 
in keeping with our objective to have the ambulance fee schedule become 
effective as soon as possible after the January 1, 2000 statutory date, 
given our Year 2000 activities and our other statutory obligations to 
implement various revised payment systems in calendar year 2000.

D. Negotiated Rulemaking Process

    Section 1834(l)(1) of the Act provided that the ambulance fee 
schedule be established through the negotiated rulemaking process 
described in the Negotiated Rulemaking Act of 1990 (Pub. L. 101-648, 5 
U.S.C. 561-570). Prior to using negotiated rulemaking under the 
Negotiated Rulemaking Act, the head of an agency must generally 
consider whether the following conditions exist:

 There is a need for a rule.
 There are a number of identifiable interests that will be 
significantly affected by the rule.
 There is a reasonable likelihood that a committee can be 
convened with a balanced representation of persons who--
    + Can adequately represent the interests identified; and,
    +  Are willing to negotiate in good faith to reach a consensus on 
the proposed rule.
 There is a reasonable likelihood that a committee will reach a 
consensus on the proposed rule within a fixed time frame.
 The negotiated rulemaking procedure will not unreasonably 
delay the notice of proposed rulemaking and the issuance of a final 
rule.
 The agency has adequate resources and is willing to commit its 
resources, including technical assistance, to the committee.
 The agency, to the maximum extent possible consistent with the 
legal obligations of the agency, will use the consensus of the 
committee as the basis for the rule proposed by the agency for notice 
and comment.

    Negotiations were conducted by a committee chartered under the 
Federal Advisory Committee Act (FACA) (5 U.S.C. App. 2). We used the 
services of an impartial convener to help identify interests that would 
be significantly affected by the proposed rule (including residents of 
rural areas) and the names of persons who were willing and qualified to 
represent those interests. The Negotiated Rulemaking Committee on the 
Medicare Ambulance Services Fee Schedule (that is, ``the Committee'') 
consisted of national representatives of interests that were likely to 
be

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significantly affected by the fee schedule. (Additional information 
about the negotiations can be found in the January 22, 1999 notice or 
may be accessed at our Internet website at http://www.hcfa.gov/medicare/ambmain.htm.)
    To the extent that this proposed rule accurately reflects the 
Committee Statement as signed on February 14, 2000, each member to the 
Committee has agreed not to comment on those issues on which consensus 
was reached.

E. Interaction With the Proposed Rule Published on June 17, 1997

    On June 17, 1997, we published a proposed rule (62 FR 32715) in the 
Federal Register to revise and update the Medicare ambulance services 
regulations at 42 CFR 410.40. Specifically, we proposed: to base 
Medicare payment on the level of ambulance service required to treat 
the beneficiary's condition; to clarify and revise the policy on 
coverage of nonemergency ambulance services; and to set national 
vehicle, staff, billing, and reporting requirements. As noted above, 
section 1834(l)(2) of the Act provides, in part, that in establishing 
the ambulance fee schedule, the Secretary will establish definitions 
for ambulance services that link payments to the types of services 
furnished. One of the provisions of the June 17, 1997 proposed rule 
would have defined ambulance services as either BLS or ALS and linked 
Medicare payment to the type of service required by the beneficiary's 
condition. We received a large number of comments on this issue, and, 
in general, commenters were very concerned about our proposal. In light 
of that concern and because defining ambulance services is a required 
element of this negotiated rulemaking (under section 1834(l) of the 
Act), we decided not to proceed with a final rule on the definition of 
BLS and ALS services. Instead, we included this issue as a matter for 
the Committee. We did, however, proceed with a final rule on all other 
issues of the June 17, 1997 proposed rule. That rule was published on 
January 25, 1999 (64 FR 3637).
    Section 1834(l)(3) of the Act provides that, in establishing the 
ambulance fee schedule, the Secretary must ensure that the aggregate 
amount of payment made for ambulance services in calendar year (CY) 
2000 does not exceed the aggregate amount of payment that would have 
been made absent the fee schedule. In the January 22, 1999 notice 
concerning the negotiated rule meetings, we stated that, although we 
were postponing final agency action on the proposal to define BLS and 
ALS services because of the BBA requirement that this issue be subject 
to negotiated rulemaking, we believe that the Medicare program should 
not lose the savings that would have been realized through 
implementation of that policy. We determined that $65 million in 
program savings would have been realized in the base year 1998 data if 
the final rule had been in effect. After adjusting for inflation, 
program savings for CY 2001 have been estimated at $67.6 million. 
Therefore, in the January 22, 1999 notice (64 FR 3474), we stated that 
we intended to incorporate these savings in the base amount upon which 
the fee schedule is calculated consistent with the statutory 
requirement that in the aggregate we pay no more than would have been 
paid in the absence of the fee schedule.

II. Provisions of the Proposed Rule

A. Proposed Changes Based on Negotiated Rulemaking

    In accordance with the negotiated rulemaking procedures described 
above, we propose the following additions to Part 414 based on the 
recommendations of the Committee.
    1. Definitions and levels of services. In Part 414, we propose to 
add Subpart H, Sec. 414.605 that would define several levels of ground 
ambulance services ranging from BLS to specialty care transport. (Note 
that the term ``ground'' refers to both land and water transportation. 
The definitions and RVUs for each of the levels of service are 
described in Sec. 414.605, ``Definitions.'') Also, the rate per ground 
mile for all ground ambulance services would be the same for each level 
of service.
    During 1990, the development of a training blueprint and the 
evaluation of current levels of prehospital provider training and 
certification were identified as priority needs for national emergency 
medical services (EMS). As a result, the National EMS Training 
Blueprint Project was formed.
    In May 1993, representatives of EMS organizations adopted the 
National EMS Education and Practice Blueprint (Blueprint) consensus 
document. This consensus document is used as the basis for defining the 
levels of service. As stated in the National EMS Education and Practice 
Blueprint, Executive Summary, printed September 1993, ``The Blueprint 
divides the major areas of prehospital instruction and/or core 
performance into 16 'core elements'.'' For each core element, the 
Blueprint recommends that there be four levels of prehospital EMS 
providers ``corresponding to various knowledge and skills in each of 
the core elements.'' At the First Responder level, personnel use a 
limited amount of equipment to perform initial assessments and 
interventions. The EMT--Basic has the knowledge and skill of the First 
Responder, but is also qualified to function as the minimum staff for 
an ambulance. EMT--Intermediate personnel has the knowledge and skills 
identified at the First Responder and EMT--Basic levels, but is also 
qualified to perform essential advanced techniques and to administer a 
limited number of medications. The EMT--Paramedic, in addition to 
having the competencies of an EMT--Intermediate, has enhanced skills 
and can administer additional interventions and medications.
    Since the release of the Blueprint, a consensus panel of EMS 
educators has recommended that the Department of Transportation, 
National Highway Traffic and Safety Administration (DOT/NHTSA) revise 
the document. DOT/NHTSA has accepted the recommendation of the panel 
and expects to release a revised Blueprint or an equivalent document in 
the near future.
    To request a copy of the National Emergency Medical Services 
Education and Practice Blueprint, please fax your request to: NHTSA/EMS 
Division, (202) 366-7721. Please include your name and address. Because 
of staffing and resource limitations NHTSA will forward the requested 
document via regular mail.
    There would be two levels of air ambulance services to distinguish 
fixed wing from rotary wing (helicopter) aircraft. In addition, to 
recognize the operational cost differences of the two types of 
aircraft, there would be two distinct payment amounts for air ambulance 
mileage. The air ambulance services mileage rate would be calculated 
per actual loaded (patient onboard) miles flown, expressed in statute 
miles (that is, ground, not nautical, miles.)
    We are proposing the following seven levels of ambulance services.
    a. Basic Life Support (BLS)--When medically necessary, the 
provision of basic life support (BLS) services as defined in the 
National Emergency Medicine Services (EMS) Education and Practice 
Blueprint for the Emergency Medical Technician-Basic (EMT-Basic) 
including the establishment of a peripheral intravenous (IV) line.
    b. Advanced Life Support, Level 1 (ALS1)--When medically necessary, 
this is the provision of an assessment by an advanced life support 
(ALS) ambulance provider or supplier and the

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furnishing of one or more ALS interventions. An ALS assessment is 
performed by an ALS crew and results in the determination that the 
patient's condition requires an ALS level of care, even if no other ALS 
intervention is performed. An ALS provider or supplier is defined as a 
provider trained to the level of the EMT-Intermediate or Paramedic as 
defined in the National EMS Education and Practice Blueprint. An ALS 
intervention is defined as a procedure beyond the scope of an EMT-Basic 
as defined in the National EMS Education and Practice Blueprint.
    c. Advanced Life Support, Level 2 (ALS2)--When medically necessary, 
the administration of at least three different medications or the 
provision of one or more of the following ALS procedures:
     Manual defibrillation/cardioversion.
     Endotracheal intubation.
     Central venous line.
     Cardiac pacing.
     Chest decompression.
     Surgical airway.
     Intraosseous line.
    d. Specialty Care Transport (SCT)--When medically necessary, for a 
critically injured or ill beneficiary, a level of interhospital service 
furnished beyond the scope of the paramedic as defined in the National 
EMS Education and Practice Blueprint. This is necessary when a 
beneficiary's condition requires ongoing care that must be furnished by 
one or more health professionals in an appropriate specialty area (for 
example, nursing, emergency medicine, respiratory care, cardiovascular 
care, or a paramedic with additional training).
    e. Paramedic ALS Intercept (PI)--These services are defined in 
Sec. 410.40(c) ``Paramedic ALS Intercept Services''. These are ALS 
services furnished by an entity that does not provide the ambulance 
transport. Under limited circumstances, Medicare payment may be made 
for these services. (To obtain additional information about paramedic 
ALS intercept services, please refer to the March 15, 2000 final rule 
(65 FR 13911)).
    f. Fixed Wing Air Ambulance (FW)--Fixed wing air ambulance services 
are covered when the point from which the beneficiary is transported to 
the nearest hospital with appropriate facilities is inaccessible by 
land vehicle, or great distances or other obstacles (for example, heavy 
traffic) and the beneficiary's medical condition is not appropriate for 
transport by either BLS or ALS ground ambulance.
    g. Rotary Wing Air Ambulance (RW)--Rotary wing (helicopter) air 
ambulance services are covered when the point from which the 
beneficiary is transported to the nearest hospital with appropriate 
facilities is inaccessible by ground vehicle, or great distances or 
other obstacles (for example, heavy traffic) and the beneficiary's 
medical condition is not appropriate for transport by either BLS or ALS 
ground ambulance.
2. Emergency Response Adjustment Factor
    We are proposing to add Sec. 414.610, ``Basis of Payment,'' 
paragraph (c)(1), to state that for the BLS and ALS1 levels of service, 
an ambulance service that qualifies as an emergency response service 
would be assigned higher RVUs to recognize the additional costs 
incurred in responding immediately to an emergency medical condition. 
An immediate response is one in which the ambulance supplier begins as 
quickly as possible to take the steps necessary to respond to the call. 
No emergency response adjustment factor applies to PI, ALS2, SCT, FW, 
or RW.
3. Operational Variations
    We are proposing to add Sec. 414.610(a) which would state that the 
ambulance fee schedule applies to all entities that furnish ambulance 
services, regardless of type. For example, all public or private, for 
profit or not-for-profit, volunteer, government-affiliated, 
institutionally-affiliated or owned, or wholly independent supplier 
ambulance companies, however organized, would be paid according to this 
ambulance fee schedule.
4. Regional Variations
    a. Cost of living differences:
    The payment for ambulance services would be adjusted to reflect the 
varying costs of conducting business in different regions of the 
country. We would adjust the payment by the geographic adjustment 
factor (GAF), equal to the practice expense (PE) portion of the 
geographic practice cost index (GPCI) for the Medicare physician fee 
schedule. (For purposes of this document, we use the abbreviation 
``GPCI'' to mean the PE portion of the GPCI.) The GPCI is an index that 
reflects the relative costs of certain components of a physician's 
costs of doing business (for example, employee salaries, rent, and 
miscellaneous expenses) in one area of the country versus another. The 
geographic areas would be the same as those used for the physician fee 
schedule. (A detailed discussion of the physician fee schedule areas 
can be found in the July 2, 1996 proposed rule (61 FR 34615) and the 
November 22, 1996 final rule (61 FR 59494).)
    The GPCI would be applied to 70 percent of the base payment rate 
for ground ambulance services; this percentage approximates the portion 
of ground ambulance service costs that are represented by salaries. 
Similarly, the GPCI would be applied to 50 percent of the base payment 
rate for air ambulance services. The GPCI would not be applied to the 
mileage payment rate. In addition, the applicable GPCI would be based 
on the geographic location at which the beneficiary is placed on board 
the ambulance.
    We would use the most recent GPCI; the physician fee schedule law 
requires that the GPCI be updated every 3 years. The next revision will 
be effective January 1, 2001. We anticipate using the updated data, 
which was proposed in the July 17, 2000 proposed rule on the physician 
fee schedule (65 FR 44176).
    b. Services furnished in rural areas:
    We are proposing to add Sec. 414.610(c)(1)(v) which would state 
that an adjustment would be made to increase the base payment rate for 
ambulance services furnished in rural areas. This adjustment would be 
made because of the additional cost per ambulance trip of isolated, 
essential ambulance suppliers (that is, when there is only one 
ambulance service in a given geographic area) for which there are not 
many trips furnished over the course of a typical month because of a 
small rural population. While we recognize the inadequacy of the 
methodology to completely compensate for these costs (that is, not 
every rural ambulance supplier is isolated, essential, low-volume, and 
the definition of rural we are proposing is not as precise as other 
alternatives), we propose an additional adjustment to increase the 
mileage rate if the location at which the beneficiary is placed on 
board the ambulance is located in a rural area. The definition of a 
rural area would be an area outside a Metropolitan Statistical Area 
(MSA) or a New England County Metropolitan Area, or an area within an 
MSA identified as rural, using the Goldsmith modification.
    The Goldsmith modification evolved from an outreach grant program 
sponsored by the Office of Rural Health Policy of the Health Resources 
and Services Administration (HRSA) of the Department of Health and 
Human Services. This program was created to establish an operational 
definition of rural populations lacking easy geographic access to 
health services in large counties with metropolitan cities. Using 1980 
census data, Dr. Harold F. Goldsmith and his associates created a 
methodology for identifying rural census tracts located within a large

[[Page 55082]]

metropolitan county of at least 1,225 square miles. However, these 
census tracts are so isolated by distance or physical features that 
they are more rural than urban in character. Additional information 
regarding the Goldsmith modification can be found on the Internet at 
http://www.nal.usda.gov/orhp/Goldsmith.htm.
    We could not easily adopt and implement, within the timeframe 
necessary to implement the fee schedule by January 1, 2001, a 
methodology for recognizing geographic population density disparities 
other than MSA/non-MSA. However, we will consider alternative 
methodologies that may more appropriately address payment to isolated, 
low-volume rural ambulance suppliers. Thus, the rural adjustment in 
this rule is a temporary proxy to recognize the higher costs of certain 
low-volume rural supplies.
    In the process of evaluating the operation of the regulations 
developed through the negotiated rulemaking process, there are several 
difficult issues that will need to be resolved. Examples of such issues 
include: (1) Appropriately identifying an ambulance supplier as rural; 
(2) identifying the supplier's total ambulance volume (since Medicare 
only has a record of its Medicare services); and (3) identifying 
whether the supplier is isolated, given that some suppliers might not 
furnish services for Medicare (that is, Medicare would have no record 
of their existence) and one of these suppliers may be located near an 
otherwise ``isolated'' supplier. Addressing these issues in some cases 
will require the collection of data that is currently unavailable. We 
intend to work with the industry to identify and collect all pertinent 
data as soon as possible, and we encourage comments regarding the type 
and source of data that could be used for this purpose.
    The application of the rural adjustment would be determined by the 
geographic location at which the beneficiary is placed on board the 
ambulance. The rural adjustment would be made using the following 
methodology:
     Ground--A 50 percent add-on applied to only the mileage 
payment rate for the first 17 loaded miles.
     Air--A 50 percent add-on applied to the base rate and to 
all of the loaded mileage.
5. Mileage
    We are proposing to add Sec. 414.610(c)(1) that would state that 
mileage would be paid separately from the base rate. The payment for 
mileage reflects the costs attributable to the use of the ambulance 
vehicle (for example, maintenance and depreciation), which increase as 
the vehicle's mileage increases. Based on the Committee's agreement, 
the mileage rate for 2001 is as follows: $5 for ground ambulance, $6 
for fixed wing ambulance, and $16 for rotary wing ambulance. Payment 
for some mileage in rural areas is made at a higher rate and is 
discussed in detail later in this proposed rule.
6. Structure of the Fee Schedule for Ambulance Services
    We are proposing in Sec. 414.610(a) that the fee schedule payment 
for ambulance services would equal a base rate payment plus payments 
for mileage and applicable adjustment factors. (See Table 1 for a 
description of the structure of the ambulance fee schedule.)
7. Ambulance Inflation Factor
    We are proposing to add Sec. 414.615, ``Transition methodology for 
implementing the ambulance fee schedule,'' which would state that the 
ambulance fee schedule would include the ambulance inflation factor 
specified in section 1834(l)(3) of the Act and discussed below.
8. Phase-in Methodology
    We are proposing to add Sec. 414.615 that would provide for a 4-
year transition period. (The phase-in schedule is described in section 
IV.)

B. Proposed Changes Not Based on Negotiated Rulemaking

    We are proposing changes to certain policies that were not within 
the scope of the negotiated rulemaking process. These proposed changes 
are as follows:
1. Coverage of Ambulance Services
    In Sec. 410.40(b), we are proposing to revise the introductory 
language to provide a cross reference to Sec. 414.605 for a description 
of the specific levels of services. We are proposing to revise 
paragraph Sec. 410.40(d)(1) to state that transportation includes fixed 
wing and rotary wing ambulances. Also, we are proposing to revise 
Sec. 410.40(d)(3) by adding two options to document medical necessity.
2. Physician Certification Requirements
    On January 25, 1999, we published a final rule (64 FR 3637) that 
updated Medicare coverage policy concerning ambulance services. That 
final rule provided the documentation requirements for coverage of 
nonemergency ambulance services for Medicare beneficiaries. The rule 
requires ambulance suppliers to obtain, from the beneficiary's 
attending physician, a written order certifying the medical necessity 
of nonemergency scheduled and unscheduled ambulance transports. The 
final rule became effective February 24, 1999.
    Our present regulations (at Secs. 410.40(d)(2) and 410.40(d)(3)) 
set forth the requirements for scheduled and unscheduled nonemergency 
ambulance transports. The regulations require ambulance suppliers to 
obtain, from the beneficiary's attending physician, a written physician 
statement certifying the medical necessity of requested ambulance 
transports.
    Section 410.40(d)(3)(i) specifies that, in cases when a beneficiary 
living in a facility and under the direct care of a physician requires 
nonemergency, unscheduled transport, the physician's certification can 
be obtained up to 48 hours after transport. After publication of this 
rule, we were made aware of instances in which ambulance suppliers, 
despite having provided ambulance transports, were experiencing 
difficulty in obtaining the necessary physician certification 
statements within the required 48-hour timeframe.
    While we still believe that the 48-hour timeframe is the 
appropriate standard, we recognize that there may be instances when, 
not through fault of their own, it may not be possible for the 
ambulance suppliers to meet the requirement. Therefore, we have 
determined that there is a need to revise and clarify this requirement 
(as described in Sec. 410.40, ``Coverage of ambulance services,'' 
paragraph (d)(3)).
    Before submitting a claim, the ambulance supplier must obtain: (1) 
A signed physician certification statement from the attending 
physician; (2) if the ambulance supplier is unable to obtain a signed 
physician certification statement from the attending physician, a 
signed physician certification must be obtained from either the 
physician, physician assistant, nurse practitioner, clinical nurse 
specialist, registered nurse, or discharge planner who is employed by 
the hospital or facility where the beneficiary is being treated and who 
has personal knowledge of the beneficiary's condition at the time the 
transport is ordered or the service was furnished (the term physician 
certification statement will also be applicable to statements signed by 
other authorized individuals); or (3) if the supplier is unable to 
obtain the required statement as described in 1 and 2 above within 21 
calendar days following the date of service, the ambulance supplier 
must document its attempts to obtain the physician certification 
statement and may then submit the claim.

[[Page 55083]]

Acceptable documentation must include a signed return receipt from the 
U.S. Postal Service or similar delivery service. A signed return 
receipt will serve as proof that the ambulance supplier attempted to 
obtain the required physician certification statement from the 
beneficiary's attending physician.
    In all cases, the appropriate documentation must be kept on file 
and, upon request, presented to the carrier or intermediary. It is 
important to note that neither the presence nor absence of the signed 
physician certification statement necessarily proves (or disproves) 
whether the transport was medically necessary. The ambulance supplier 
must meet all coverage criteria in order for payment to be made.
3. Payment During the First Year
    As explained below in more detail, we would use the universe of 
claims paid in 1998 (reduced by the $65 million savings that would have 
been realized through implementation of the BLS and ALS definitions 
proposed in the June 17, 1997 proposed rule (62 FR 32718)) to establish 
the CF and would index the 1998 dollars to 2001 dollars using the 
compounded inflation factors provided by section 1834(l)(3) of the Act. 
(The transition and the inflation factors are described in proposed 
Sec. 414.615.)
4. Billing Method
    In Sec. 414.610, we would state that after the transition period, 
we would bundle into the base rate payment all items and services 
furnished within the ambulance service benefit. This would eliminate 
billing on an itemized basis for any items and services related to the 
ambulance service (for example, oxygen, drugs, extra attendants, and 
EKG testing). In addition, only the base rate code and the mileage code 
would be used to bill Medicare. (This decision was made, in accordance 
with section 1834(l)(7) of the Act, which gives us the authority to 
specify a uniform coding system.) During the transition period, 
suppliers who currently use billing methods 3 or 4 may continue to bill 
for supplies separately.
5. Local or State Ordinances
    In Sec. 414.610, we would state that, regardless of any local or 
State ordinances that contain provisions on ambulance staffing or 
furnishing of all ambulance services by ALS suppliers, we would pay the 
appropriate ambulance fee schedule rate for the services that are 
actually required by the condition of the beneficiary. This policy 
derives from the Medicare statutory requirement (see section 1834 
(1)(2)(C) of the Act) to link payments to the types of services 
furnished.
6. Mandatory Assignment
    In Sec. 414.610, we would state that effective January 1, 2001, all 
payments for ambulance services must be made on an assignment-related 
basis. Ambulance suppliers must accept the Medicare allowed charge as 
payment in full and not bill the beneficiary any amount other than 
unmet Part B deductible or coinsurance amounts. There is no 
transitional period for mandatory assignment.
7. Miscellaneous Payment Policies
    Although not included in the proposed regulations, we are 
clarifying the following payment policies.
    a. Multiple patients--Occasionally, an ambulance will transport 
more than one patient at a time. (For example, this may happen at the 
scene of a traffic accident.) In this case, we propose to prorate the 
payment as determined by the ambulance fee schedule among all of the 
patients in the ambulance. For example, if two patients were 
transported at one time, and one was a Medicare beneficiary and the 
other was not, we would make payment based on one-half of the ambulance 
fee schedule amount for the level of medically appropriate service 
furnished to the Medicare patient. The Medicare Part B coinsurance, 
deductible, and assignment rules would apply to this prorated payment.
    Similarly, if both patients were Medicare beneficiaries, payment 
for each beneficiary would be made based on half of the ambulance fee 
schedule amount for the level of medically appropriate services 
furnished to each patient. The Medicare Part B coinsurance, deductible, 
and assignment rules would apply to these prorated amounts.
    b. Pronouncement of death--There are three rules that apply to 
ambulance services and the pronouncement of death. First, if the 
beneficiary was pronounced dead by an individual who is licensed to 
pronounce death in that State prior to the time that the ambulance is 
called, no payment would be made. Second, if the beneficiary is 
pronounced dead after the ambulance is called but before the ambulance 
arrives at the scene, payment for an ambulance trip would be made at 
the BLS rate, but no mileage would be paid. Third, if the beneficiary 
is pronounced dead after being loaded into the ambulance, payment would 
be made following the usual rules (that is, the same level of payment 
would be made as if the beneficiary had not died).
    c. Multiple Arrivals--When multiple units respond to a call for 
services, we would pay the entity that provides the transportation for 
the beneficiary. The transporting entity would bill for all services 
furnished, as stated in current policy. For example, if BLS and ALS 
entities respond to a call and the BLS entity furnishes the 
transportation after an ALS assessment is furnished, the BLS entity 
would bill using the ALS1 rate. We would pay the BLS entity at the ALS1 
rate. The BLS entity and the ALS entity would have to negotiate payment 
for the ALS assessment.
    d. BLS Services in an ALS Vehicle--Effective January 1, 2001, 
claims will be paid at the BLS level where an ALS vehicle was used but 
no ALS level of service was furnished. Claims must be filed using the 
appropriate BLS code. There is no transitional period for claims paid 
at the BLS level for non-ALS services rendered in an ALS vehicle.

III. Methodology for Determining the Conversion Factor

    Our approach to determining the CF would be to: (1) Use the most 
recent complete year of ambulance claims; (2) translate those claims 
into the format that would have been used under the fee schedule; and 
(3) calculate the CF to be applied to the RVUs of the different levels 
of service that would result in the same total program payment for 
those claims less $65 million. We would then inflate this CF in 
accordance with the inflation factor prescribed in the statute. (See 
section 1834(1)(3) of the Act.) We used 1998 as the base year because 
this was the most recent complete year for which claims data were 
available. For claims processed by carriers (that is, claims from 
independent ambulance suppliers), we used allowed charges. For claims 
processed by fiscal intermediaries (FIs) from provider-based ambulance 
services, we used the submitted charges on the Medicare claims 
multiplied by the cost-to-charge ratio applicable to the ambulance 
costs for that provider.
    We decided that choosing the most common number of miles on 
existing claims would be the best estimate as to those claims that did 
not report mileage. The research indicated that the mode for urban 
claims was 1, and the mode for rural claims was also 1.
    We modified the claims data in several ways to calculate the 
proposed fee schedule and its impact. First, we separated all claims 
into two groups:
     Carrier processed claims for ambulance services (8 million 
in 1998).

[[Page 55084]]

     FI processed claims for ambulance services (900,000 in 
1998).

A. Carrier Processed Claims

    Not all of the 1998 claims were directly usable for purposes of the 
proposed ambulance fee schedule. Some of the claims did not show 
mileage and, because mileage would be required for each ambulance 
service under the fee schedule, an adjustment had to be made for the 
missing miles. In other cases, the billing codes under the old system 
did not translate directly into services that would be paid under the 
proposed fee schedule. Below is a more detailed explanation of the 
adjustments that were made to the 1998 base year data in order to 
accommodate missing data.
1. Mileage
    Approximately 1.1 million claims for ground ambulance services did 
not show any mileage. The proposed fee schedule for ambulance services 
would provide a payment for the trip and a payment per statute mile for 
the loaded mileage traveled. Therefore, in calculating the proposed CF, 
we added mileage to those claims that did not report mileage. We did so 
by assigning the mode value (that is, the number of miles billed most 
often) per trip in urban areas (1.0 miles) and the mode value or 
mileage per trip in rural areas (1.0 miles).
    Current billing instructions provide that only one ambulance trip 
may be billed per line on a claim. Therefore, we did not count multiple 
trips billed on the same line of a claim. This reduced the total trip 
count processed by carriers by approximately 1 percent. Billing rules 
prohibit more than one trip to be reported on a line; therefore, we 
assumed any number greater than one was an error. Because the allowed 
charges on these claims represented the amounts paid, there was a 
corresponding increase by the same percentage of the average charge per 
trip.
2. Billing Codes
    We determined that the billing codes that represent items and 
services included under the ambulance fee schedule are all billing 
codes submitted by ambulance suppliers in the range of HCFA Common 
Procedure Coding System (HCPCS) A0030 through A0999 (excluding HCPCS 
code A0888, which is not covered by Medicare) and Common Procedural 
Terminology-4 (CPT-4) \1\ codes 93005 and 93041. HCPCS billing codes 
A0030 through A0999 represent ambulance services, supplies, and 
equipment that are covered by the ambulance fee schedule, and CPT codes 
93005 and 93041 represent electrocardiogram (EKG) services that may be 
billed by ambulance suppliers. In addition, we included all HCPCS 
billing codes in the range of A4000 through Z9999; these services may 
only be paid by a carrier to an ambulance supplier if they represent 
items and services covered under the Medicare ambulance benefit. We 
excluded all other CPT billing codes in the range of 00001 through 
99999 (except the two EKG codes listed above) because they represent 
services not covered by the ambulance fee schedule.
---------------------------------------------------------------------------

    \1\ CPT codes and descriptions only are copyright 2000 American 
Medical Association. All Rights Reserved. Applicable FARS/DFARS 
Apply.
---------------------------------------------------------------------------

    Next, we adjusted all billing codes that represented an ALS vehicle 
when no ALS service was furnished. We removed the actual allowed 
charges on these claims and replaced them with the charges that would 
have been allowed by the carrier for the corresponding BLS level of 
service (that is, emergency for emergency and nonemergency for 
nonemergency). As described in this preamble, this adjustment reduced 
the Medicare portion of the total allowed charges for ambulance 
services by $65 million.
3. Crosswalking the Old Billing Codes to the New Billing Codes
    We converted the old billing codes in the base year data to the new 
billing codes as they would be under the proposed fee schedule. The old 
BLS codes convert directly to the proposed BLS codes. The old air 
ambulance codes (fixed wing and helicopter) convert to the proposed air 
ambulance codes. The old water ambulance code converts to the proposed 
BLS-Emergency code. The old mileage codes distinguished ALS miles from 
BLS miles; both of these old codes would convert to the single proposed 
mileage code. Codes used to report air mileage would convert to the 
proposed codes for fixed and rotary wing mileage respectively. All air 
miles would be reported in statute miles. As mentioned earlier, we 
converted the codes for an ALS vehicle when no ALS services were 
furnished to the corresponding BLS codes. The conversion of the 
remaining old ALS codes (for example, when ALS services were furnished) 
to proposed ALS codes is less straightforward because there are more 
levels of ALS service under the proposed fee schedule than currently 
exist. All nonemergency ALS codes convert to the proposed ALS1 
(nonemergency) code. Based on advice from various negotiating committee 
members, we propose converting the old emergency ALS codes according to 
the following formulas:
     For claims on which both the origin and destination was a 
hospital: 33 percent would convert to specialty care transport (SCT), 5 
percent to advanced life support, level two (ALS2), and the remainder 
to ALS1--Emergency.
     For all other claims: 8.3 percent would convert to ALS2, 
and the remainder to ALS1--Emergency.

B. FI Processed Claims

    Since all FI claims contained mileage, we did not make any 
adjustment for mileage. We determined the codes that represented items 
and services included under the ambulance fee schedule. In the case of 
hospital-based claims, the same claim is used to report services 
furnished in the emergency room and other outpatient departments of the 
hospital as is used to report the ambulance service. Therefore, it is 
impossible to know exactly where any of the nonambulance services were 
furnished. Because most of these nonambulance services were of the kind 
that would likely have been furnished in the hospital's emergency room, 
we did not include them in data for the proposed ambulance fee 
schedule. Therefore, we determined the billing codes that would be 
covered by the ambulance fee schedule were all billing codes 
representing ambulance services (for example, in the range of HCPCS 
codes A0030 through A0999 (excluding HCPCS code A0888, which is not 
covered by Medicare)) submitted by hospitals.
    Codes that represented the use of an ALS vehicle, but when no ALS 
level of service was furnished, were converted to the corresponding BLS 
BILLING CODE. However, in this case, no adjustment was made for payment 
because payment for these claims would have been corrected to the 
proper amount at cost settlement.

C. Air Ambulance

    To establish a consistent system of RVUs that could be applied to 
ground and air ambulance services, we would have been required to know 
the cost per service in each setting. Unfortunately, these data do not 
exist. The air ambulance representative to the Committee presented data 
and stated that the data, when combined with an analysis by an 
economist, demonstrated that the total costs in 1998 for air ambulance 
services were between a minimum of $134.8 million and a maximum of $168 
million. This amount exceeded the billed charges for air ambulance 
services. The representative also stated that RVUs should be based

[[Page 55085]]

on cost and that there were no verifiable cost data on the ground 
ambulance services side against which to compare the cost of air 
ambulance services. In addition, other Committee members were unsure of 
the accuracy of the air ambulance services cost data, stating that the 
air ambulance services costs were not based on an audited statistical 
sample and that the data had not been subject to independent scrutiny. 
Based on recommendations from the Committee, we would set the amount of 
the base year expenditures to be used in determining the payment levels 
for air ambulance services between $134.8 million and $158 million.
    We considered several approaches in an attempt to accurately 
estimate the appropriate amount for air ambulance services within the 
range prescribed by the Committee.
    We considered using cost data from a ground ambulance services 
survey acquired by an independent source that was hired by a member of 
the Committee. We tried to compare the results of this survey to cost 
data from our estimate. Because the study was only a self-reporting 
survey and did not report audited costs and because the results varied 
widely and were substantially different from our estimate, we could not 
establish a consistent relationship between the survey that resulted in 
any estimates within the range prescribed by the Committee.
    We converted old billing codes to the proposed billing codes in the 
same way as discussed above for the carrier-rocessed claims. Using the 
billed charge adjusted by the supplier's cost-to-charge ratio, we are 
able to estimate the supplier's Medicare-allowable cost for all 
ambulance services. However, we are unable to estimate with any 
certainty the split of air ambulance services costs and ground 
ambulance services costs from the same supplier. This is because the 
Medicare cost-apportioning rules do not furnish data in this detail. 
Originally, we assumed that the same cost-to-charge ratio applies to 
both air and ground ambulance services charges. However, because this 
assumption may not be correct and because it results in an amount below 
the range specified by the Committee, we did not pursue this 
methodology.
    Next, we considered using the billed charges for ambulance 
services. Over 80 percent of ground ambulance services are furnished by 
independent (not provider-based) ambulance services suppliers. However, 
the average adjusted charge (that is, the charge adjusted by the 
provider's cost-to-charge ratio) for ALS and basic life support (BLS) 
ground ambulance services, excluding mileage, furnished by provider-
based ambulance services is more than 60 percent greater than the 
average charge for independent ambulance services suppliers ($342 vs. 
$206 per trip). Assuming the appropriate payment for ground ambulance 
services is the average allowed charge for the independent suppliers, 
the amount of money misallocated to provider-based ground ambulance 
services substantially exceeds the amount that would result in a total 
payment for air ambulance services at the maximum authorized by the 
Committee ($158 million). Considering this large discrepancy between 
the payment rates for provider-based and independent supplier ground 
ambulance services and the fact that suppliers are able to furnish 
services at the lower rate, we believe that the appropriate payment for 
ground ambulance services is closer to the independent supplier charge. 
Consequently, we have chosen the maximum air ambulance total amount 
designated by the Committee, that is, $158 million.

D. Calculation of the CF

    Following this process, we determined the total number of ambulance 
trips and loaded miles and the total amount of charges allowed by 
Medicare for ambulance services in the base year of 1998 (less the 
adjustment for those cases where an ALS vehicle was used, but no ALS 
services were furnished, described above). To calculate the CF for 
ground ambulance services, we followed these steps--
     Multiplied the volume of services for each level of ground 
ambulance service by the respective RVUs recommended by the Committee 
(including application of the practice expense of the GPCI and rural 
payment rate as described above);
     Summed those products to arrive at the total number of 
RVUs;
     Subtracted the total allowed amount for air ambulance 
services ($158 million as discussed above) from the total charges 
allowed by Medicare for ambulance services, which results in the total 
amount of charges allowed by Medicare for ground ambulance services;
     Subtracted the total amount of RVUs for ground mileage 
from this total charge amount;
     Divided the remaining charge amount by the total number of 
RVUs for ground services and applied the ambulance inflation factor for 
2001, which results in a CF for ground ambulance trips of $157.52.
    We would follow a similar procedure to determine the fee schedule 
amount for air ambulance services. Because there are only two kinds of 
air ambulance--fixed wing and rotary--we would not calculate RVUs and a 
CF, but would calculate the actual fee schedule amounts directly. 
Namely, we divided the total number of billed air ambulance services 
into the total amount of payment available for these services ($158 
million). The amounts in the base year (1998) are $2,115.00 and 
$2,459.00 for fixed wing and rotary trips, respectively. Then these 
numbers would also be inflated by the inflation factor provided in 
section 1834(l) of the Act. (Additional information regarding the 
inflation factor is discussed below.)
    We would monitor payment data and evaluate whether projections used 
to establish the original CF (for example, the ratio of the volume of 
BLS services to ALS services) is accurate. If the actual proportions 
among the different levels of service are different from the projected 
amounts, we would adjust the conversion factor accordingly and apply 
this adjusted conversion factor prospectively.

IV. Implementation Methodology

    Currently, payment of ambulance services follows one of two 
methodologies, depending on the type of ambulance biller. Claims from 
ambulance service suppliers are paid based on a reasonable charge 
methodology, whereas claims from providers are paid based on the 
provider's interim rate (which is a percentage based on the provider's 
historical cost-to-charge ratio multiplied by the submitted charge) and 
then cost-settled at the end of the provider's fiscal year.
    The proposed ambulance fee schedule would be phased in over a 4-
year period. The transition would begin on January 1, 2001 and the fee 
schedule would be phased in on a CY basis. Therefore, for dates of 
service (DOS) beginning January 1, 2001, suppliers/providers would be 
paid based on 80 percent of the respective current payment allowance 
(as described in Program Memorandum AB-99-73) applicable to 2001 plus 
20 percent of the ambulance fee schedule amount. (See Sec. 414.615 for 
additional information.)
    Based on the Committee's consensus recommendation, we would 
implement the ambulance fee schedule as follows:

[[Page 55086]]



------------------------------------------------------------------------
                                                    Former        Fee
                                                    payment    schedule
                                                  percentage  percentage
------------------------------------------------------------------------
Year One (CY 2001)..............................          80          20
Year Two (CY 2002)..............................          50          50
Year Three (CY 2003)............................          20          80
Year Four (CY 2004).............................           0         100
------------------------------------------------------------------------

A. Revisions and Additions to HCPCS Codes

    Claims would be processed using the proposed billing codes created 
for the ambulance fee schedule. From these proposed codes, the amount 
for the portion of the payment based on the current system (80 percent 
in 2001) would be derived using the HCPCS crosswalks as shown below.
    We would change current ambulance HCPCS codes in order to implement 
the ambulance fee schedule. The proposed HCPCS codes would have to be 
effective January 1, 2001. The existing HCPCS codes are not billable 
effective January 1, 2001, except for those HCPCS codes related to 
items and services for which a Method 3 or Method 4 biller may bill for 
supplies separately during the transition period.
    National HCPCS codes and descriptions of services created for 
ambulance services were presented to the HCFA Alpha-Numeric group. The 
following chart shows how the existing codes would crosswalk to the 
proposed new codes under the ambulance fee schedule. We would establish 
the codes before implementation of the ambulance fee schedule on 
January 1, 2001. Additionally, the chart shows current HCPCS codes that 
would not have a corresponding code under the proposed ambulance fee 
schedule. The items and services represented by these codes would be 
bundled into the base rate services.

Codes Not Valid Under the New Fee Schedule (Codes Terminate Effective 
01/01/04):
    A0382, A0384, A0392, A0396, A0398, A0420, A0422, A0424, A0999

                                               HCPCS Code Changes
----------------------------------------------------------------------------------------------------------------
       Current HCPCS Code(s)                  New HCPCS Code               Descriptions of proposed new codes
----------------------------------------------------------------------------------------------------------------
A0380, A0390......................  A0425                               Ground mileage (per statute mile).
A0306, A0326, A0346, A0366........  A0426                               Ambulance service, advanced life
                                                                         support, non-emergency transport, level
                                                                         1 (ALS1).
A0310, A0330, A0350, A0370........  A0427                               Ambulance service, advanced life
                                                                         support, emergency transport, level 1
                                                                         (ALS1-Emergency).
A0300, A0304, A0320, A0324, A0340,  A0428                               Ambulance service, basic life support,
 A0344, A0360, A0364.                                                    non-emergency transport (BLS).
A0050, A0302, A0308, A0322, A0328,  A0429                               Ambulance service, basic life support,
 A0342, A0348, A0362, A0368.                                             emergency transport (BLS-Emergency).
A0030.............................  A0430                               Ambulance service, conventional air
                                                                         services, transport, one way (fixed
                                                                         wing).
A0040.............................  A0431                               Ambulance service, conventional air
                                                                         services, transport, one way (rotary
                                                                         nwing).
Q0186.............................  A0432                               Paramedic ALS intercept (PI), rural
                                                                         area, transport furnished by a
                                                                         volunteer ambulance company which is
                                                                         prohibited by state law from billing
                                                                         third party payers.
                                    A0433                               Advanced life support, Level 2 (ALS2).
                                                                         The administration of at least three
                                                                         different medications and/or the
                                                                         provision of one or more of the
                                                                         following ALS procedures: Manual
                                                                         defibrillation/cardioversion,
                                                                         endotracheal intubation, central venous
                                                                         line, cardiac pacing, chest
                                                                         decompression, surgical airway,
                                                                         intraosseous line.
                                    A0435                               Air mileage; fixed wing (per statute
                                                                         mile).
                                    A0436                               Air mileage; rotary wing (per statute
                                                                         mile).
                                    A0434                               Specialty Care Transport (SCT). In a
                                                                         critically injured or ill patient, a
                                                                         level of inter-facility service
                                                                         provided beyond the scope of the
                                                                         Paramedic. This service is necessary
                                                                         when a patient's condition requires
                                                                         ongoing care that must be provided by
                                                                         one or more health professionals in an
                                                                         appropriate specialty area (for
                                                                         example, nursing, emergency medicine,
                                                                         respiratory care, cardiovascular care,
                                                                         or a paramedic with additional
                                                                         training).
----------------------------------------------------------------------------------------------------------------

    New suppliers that have not billed Medicare in the past would be 
subject to the transition period rules. They would be assigned an 
allowed charge under the current reasonable charge rules (50th 
percentile charges) and would follow the same blended transition 
payments as other ambulance suppliers. In all cases, the resulting 
transitional payment would be subject to the Part B coinsurance and 
deductible requirements.
    Currently, provider claims are paid based on the provider's interim 
rate (the provider's submitted charge multiplied by the provider's past 
year's cost to charge ratio) which is cost settled at the end of the 
provider's fiscal year and limited by the statutory inflation factor 
applied to the provider's cost per ambulance trip. The fee schedule 
transition would begin on January 1, 2001 and would phase in the fee 
schedule on a CY basis. Therefore, for providers that file cost reports 
on other than a CY basis, for cost reporting periods beginning after 
January 1, 2001, two different blended rates would apply. Effective for 
services furnished during CY 2001, the proposed blended amount for 
provider claims would equal the sum of 80 percent of the current 
payment system amount and 20 percent of the ambulance fee schedule 
amount. The intent of our implementing payment under the fee schedule 
at only 20 percent in the first year is to give ambulance providers a 
period of time to adjust to the new payment amounts, because some 
providers may receive substantially lower payments that at present. For 
DOS in CY 2002, the blended amount would equal the sum of 50 percent of 
the current payment system amount and 50 percent of the ambulance fee 
schedule amount. For DOS in CY 2003, the blended amount would equal the 
sum of 20 percent of the current payment system amount and 80 percent 
of the ambulance fee schedule amount. For DOS in CY 2004 and beyond, 
the payment amount would equal the ambulance fee schedule amount. The 
program's payment in all cases would be subject to the Part B 
coinsurance and deductible requirements.

[[Page 55087]]

    To assure that the providers receive the correct payment amount 
during the transition period, all submitted charges attributable to 
ambulance services furnished during a cost-reporting period would be 
aggregated and treated separately from the submitted charges 
attributable to all other services furnished in the hospital. Also, the 
necessary statistics would be maintained for the provider's Provider 
Statistics and Reimbursement report; this would ensure that the 
ambulance fee schedule portion of the blended transition payment would 
not be cost settled at cost settlement time.
    New providers would not have a cost per trip from the prior year. 
Therefore, there would be no cost per trip inflation limit applied to 
new providers in their first year of furnishing ambulance services.
    New suppliers would use the customary charge established for new 
suppliers in accordance with standard program procedures from the year 
2000, adjusted for each year of the transition period by the ambulance 
inflation factor that we published.
    Section 1834(1) of the Act also requires that all payments made for 
ambulance services under the proposed fee schedule be made on an 
assignment-related basis. As stated in section 1842(b)(18) of the Act, 
referenced in section 1834(l)(6), ambulance suppliers would have to 
accept the Medicare allowed charge as payment in full and not bill or 
collect from the beneficiary any amount other than the unmet Part B 
deductible and Part B coinsurance amounts. Violations of this 
requirement may subject the supplier to sanctions. The law provides 
that mandatory assignment provisions apply as soon as payment is made 
under the fee schedule; therefore, there would be no transitional 
period for mandatory assignment of claims. Also, the rule that claims 
would be paid at the BLS level if an ALS vehicle was used but no ALS 
level of service was furnished would be effective on January 1, 2001 
and would not be subject to transition. These claims would have to be 
filed using the appropriate BLS code.

V. Mechanisms To Control Expenditures for Ambulance Services

A. Number of Services

    We do not anticipate that the number of ambulance services 
furnished will increase to offset the effects of lower payments per 
service. Therefore, the Committee has not suggested mechanisms to 
control expenditures. However, we will monitor payment data and 
evaluate whether projections used to set the original CF (for example, 
the ratio of the volume of BLS services to ALS services) are accurate. 
If the actual proportions of the various levels of service are 
different (too high or too low) from the projected ones, we will adjust 
the CF accordingly.

B. Low Billers

    A concern was raised about low billers of ambulance services. Low 
billers are suppliers who currently bill less than the maximum charge 
allowed by Medicare. There are several reasons low billers exist. For 
example, low billers may be municipal or volunteer suppliers of 
services, regulated by local ordinances, limited by an inflation-
indexed charge that is part of the Medicare program's current 
reasonable charge policy, or restricted for other reasons.
    Because the total ambulance service payment amount is based on the 
actual allowed charges from the base year (1998), the CF will reflect 
the lower than maximum charges. At the same time, if low billers of 
ambulance services continue to charge less than the ambulance fee 
schedule amount, we will pay less than if all suppliers charged the 
ambulance fee schedule amount. Therefore, some members of the ambulance 
industry have urged us to increase the fee schedule CF anticipating 
that otherwise savings would result from billers who continue to charge 
less than the fee schedule amount. We have estimated that in the base 
year 1998 the difference between actual charges and the maximum charges 
allowed by Medicare is approximately $150 million. Approximately half 
of this amount is attributable to charges that are 70 percent of the 
maximum allowed charges or greater. Assuming that a low biller is 
someone whose charge is less than 70 percent of the maximum allowed 
charge, approximately $75 million can be attributed to low billing.
    We have neither a means to estimate the extent to which low billing 
will continue after the fee schedule is implemented and the inflation-
indexed charge limit no longer applies, nor a means to estimate the 
extent to which volunteer and municipal ambulances will choose not to 
file Medicare claims at the fee schedule amounts to which they could be 
entitled. The Congress has provided that ``the amounts paid shall be 80 
percent of the lesser of the actual charge for the services or the 
amount determined by a fee schedule * * *'' (section 1833(a)(1)(R) of 
the Act). Moreover, the Congress did not require that payment under the 
ambulance fee schedule be budget neutral to the current reasonable 
charge system, but rather specified only that the aggregate amount of 
payments for ambulance services not exceed the amount that would have 
been paid absent the fee schedule.
    Given the law and the uncertainty of suppliers' future behavior, we 
propose not to attempt to adjust the CF on the assumption that low 
billing will or will not continue. However, as mentioned above, we will 
monitor payment and billing data and recalculate the CF as appropriate.

VI. Adjustments to Account for Inflation and Other Factors

    In setting the CF for 2001, we would adjust the base year data from 
1998 for inflation. Section 4531 of the Balanced Budget Act of 1997 
prescribes the inflation factor to be used in determining the payment 
allowances for ambulance services paid under Medicare under the current 
payment system. The inflation factor is equal to the projected consumer 
price index for all urban consumers (U.S. city average) (CPI-U) minus 1 
percentage point from March-to-March for claims paid under cost 
reimbursement (providers) and from June-to-June for claims paid under 
reasonable charges (carrier processed claims). The base year for our 
data is 1998. The inflation factors in percent are:

------------------------------------------------------------------------
                                                   March-to-   June-to-
                                                     March       June
                                                   (provider   (carrier
                                                    claims)     claims)
------------------------------------------------------------------------
1999/1998.......................................       0.9         1.1
2000/1999.......................................       2.4         2.0
2001/2000.......................................       1.3         1.4
Compounded inflation factor (in percent)........       4.665       4.566
------------------------------------------------------------------------

    We would use the most recently available estimate of inflation from 
2000 to 2001 at the time of the writing of the final rule.
    In addition, the Committee acknowledged that the statutory 
provisions in section 1834(l)(3)(B) of the Act, regarding annual 
updates to the fee schedule, would be used to make adjustments to 
account for inflation. That section of the Act provides for an annual 
update to the ambulance fee schedule based on the percentage increase 
in the CPI-U for the 12-month period ending with June of the previous 
year. For 2001 and 2002, the increase in the CPI-U is reduced by 1.0 
percentage point for each year.
    We would monitor payment data and evaluate whether projections used 
to establish the original CF (for example,

[[Page 55088]]

the ratio of the volume of BLS services to ALS services) is accurate. 
If the actual proportions among the different levels of service are 
different from the projected amounts, we would adjust the CF 
accordingly.

VII. Medical Conditions Lists

    When the Congress mandated that the ambulance fee schedule be 
developed through the negotiated rulemaking process, we deferred final 
action on our proposal to base Medicare payment on the level of 
ambulance service required to treat the beneficiary's condition. That 
proposal would have used International Classification of Diseases, 9th 
revision, Clinical Modification (ICD-9-CM) diagnostic codes that would 
have described the nature of the beneficiary's medical condition. Use 
of the ICD-9-CM codes would also have assisted ambulance suppliers to 
bill the medically necessary level of ambulance service.
    While we are not establishing a formal proposal in this proposed 
rule, as a first step, we reopened the discussion of developing a 
medical condition listing during the negotiated rulemaking process. The 
goal of the discussion was to develop a list of medical conditions, not 
diagnoses, that generally require ambulance services and the 
appropriate level of care. The identified condition(s) would describe 
the beneficiary's medical condition that would necessitate the 
ambulance services.
    The medical conditions listed in Addendum A of this proposed rule 
would enable the ambulance supplier to identify the level of service at 
which a claim may be paid. The list identifies nonemergency conditions; 
emergency medical conditions--traumatic and nontraumatic; and emergency 
and nonemergency conditions that warrant interfacility transport 
services. This listing would also aid Medicare contractors in their 
efforts to assure that claims for ambulance services are paid 
appropriately and that providers and suppliers of ambulance services 
are educated as to the documentation that would best support a claim. 
Use of an identified condition, however, would not make the claim 
payable if the beneficiary could have been served by other means. We 
recognize that unusual circumstances exist that warrant the use of 
ambulance services. In these circumstances, the publication of the list 
would not preclude the contractor from accepting other relevant medical 
information (for example, ICD-10-CM codes or other relevant on-the-
scene information) to describe a medical condition that is not included 
on the list. Therefore, the medical condition list is not all-
inclusive.
    Since the negotiated rulemaking committee concluded its work, we 
have received positive feedback on the medical conditions list in 
Addendum A. While we maintain the final decision-making authority 
regarding required use of the above referenced medical condition list 
or a similar type of list, we are soliciting information from 
interested parties on the need for such a listing and the development 
of codes used in association with such a list that would best support 
the processing of claims.

VIII. Collection of Information Requirements

    Under the Paperwork Reduction Act of 1995 (PRA), we are required to 
provide 60-day notice in the Federal Register and solicit public 
comment before a collection of information requirement is submitted to 
the Office of Management and Budget (OMB) for review and approval. In 
order to fairly evaluate whether an information collection should be 
approved by OMB, section 3506(c)(2)(A) of the PRA requires that we 
solicit comment on the following issues:
     The need for the information collection and its usefulness 
in carrying out the proper functions of our agency.
     The accuracy of our estimate of the information collection 
burden.
     The quality, utility, and clarity of the information to be 
collected.
     Recommendations to minimize the information collection 
burden on the affected public, including automated collection 
techniques.
    We are soliciting public comment on each of these issues for the 
following sections of this document that contain information collection 
requirements:

Section 410.40  Coverage of Ambulance Services.

    (d)(3)(iii) If the ambulance supplier is unable to obtain the 
signed physician certification statement from the beneficiary's 
attending physician, a signed physician certification statement must be 
obtained from either the physician, physician assistant (PA), nurse 
practitioner (NP), clinical nurse specialist (CNS), registered nurse 
(RN), or discharge planner, who is employed by the hospital or facility 
where the beneficiary is being treated, and who has personal knowledge 
of the beneficiary's condition at the time the ambulance transport is 
ordered or the ambulance service was furnished.
    The burden associated with this requirement is the time and effort 
necessary for the required hospital employee to provide the 
certification. We estimate that, there will be 5,000 certifications on 
an annual basis at an estimated 5 minutes per certification. Therefore, 
the annual national burden associated with this requirement is 417 
hours.
    (d)(3)(iv) If the ambulance supplier is unable to obtain the 
required physician certification statement within 21 calendar days 
following the date of the service, the ambulance supplier must document 
its attempts to obtain the requested physician certification statement 
and may then submit the claim. Acceptable documentation must include a 
signed return receipt from a U.S. Postal Service or other similar 
service. This documentation will serve as proof that the ambulance 
supplier attempted to obtain the required signature from the attending 
physician.
    The burden associated with this requirement is the time and effort 
necessary for the ambulance supplier to document its attempts to obtain 
the requested physician certification statement. We estimate that 5,000 
providers will be required to submit a receipt instead of certification 
for an average of 12 instances on an annual basis, at an estimated 5 
minutes per instance. Therefore, the annual national burden associated 
with this requirement is 5,000 hours.

Section 414.610  Basis of Payment.

    (d) The zip code of the point of pick-up must be reported on each 
claim for ambulance services, so that the correct GAF and RAF may be 
applied, as appropriate.
    The burden associated with this requirement is the time and effort 
necessary for the ambulance supplier to note the required zip code for 
each claim of service. We estimate that of the 9,000 (potential) 
providers, 5000 providers will be required to provide the 
documentation, for an estimated 550,000 (5% of total claims volume of 
11M) instances on an annual basis. Per provider (5,000), we estimate 1 
minute per instance to meet this requirement, for a burden of 2 hours 
per provider on an annual basis. Therefore, the annual national burden 
associated with this requirement is 10,000 hours.
    If you comment on these information collection and recordkeeping 
requirements, please mail copies directly to the following:

Health Care Financing Administration, Office of Information Services, 
Information Technology Investment Management Group, Attn: John Burke, 
Room N2-14-26,7500 Security Boulevard, Baltimore, MD 21244-1850.

[[Page 55089]]

Office of Information and Regulatory Affairs, Office of Management and 
Budget, Room 10235, New Executive Office Building, Washington, DC 
20503, Attn: Allison Herron Eydt, HCFA Desk Officer.

IX. Regulatory Impact Analysis

A. Overall Impact

    We have examined the impacts of this rule as required by Executive 
Order 12866 and the Regulatory Flexibility Act (RFA) (Public Law 96-
354). Executive Order 12866 directs agencies to assess all costs and 
benefits of available regulatory alternatives and, if regulation is 
necessary, to select regulatory approaches that maximize net benefits 
(including potential economic, environmental, public health and safety 
effects, distributive impacts, and equity). A regulatory impact 
analysis (RIA) must be prepared for major rules with economically 
significant effects ($100 million or more annually). We have determined 
that this is not a major rule. It would result in spending for the 
first year at approximately $67.6 million less than would have been 
paid if the fee schedule were not implemented. The total impact would 
be $84.5 million in reduced revenue for ambulance providers and 
suppliers ($67.6 million plus $16.9 million in reduced Part B 
coinsurance). In addition, approximately $19 million in total revenue 
(due to Medicare Part B coinsurance and deductible requirements of 
approximately 80 percent that would be program expenditures) would be 
redistributed among entities that furnish ambulance services according 
to the data presented in this section.
    The RFA requires agencies to analyze options for regulatory relief 
of small businesses. For purposes of the RFA, small entities include 
small businesses, nonprofit organizations, and government agencies. 
Most hospitals and most other providers and suppliers are small 
entities, either by nonprofit status or by having revenues of $5 
million or less annually. For purposes of the RFA, most ambulance 
providers and most ambulance suppliers are considered to be small 
entities. Individuals and States are not included in the definition of 
a small entity.
    In addition, section 1102(b) of the Act requires us to prepare an 
RIA if a rule may have a significant impact on the operations of a 
substantial number of small rural hospitals. This analysis must conform 
to the provisions of section 603 of the RFA. For purposes of section 
1102(b) of the Act, we define a small rural hospital as a hospital that 
is located outside of a Metropolitan Statistical Area and has fewer 
than 50 beds. In the aggregate, in 2001, $17 million in total revenue 
would be redistributed from urban to rural entities. It is also true 
that some rural entities would be paid less than their current rate. 
While we do not have specific data on the number of small rural 
hospitals that furnish ambulance services, we recognize that the rural 
adjustment factor incorporated in this proposal may not completely 
offset the higher costs of low-volume suppliers. As stated earlier, we 
recognize that this rural adjustment is a temporary proxy to 
acknowledge the higher costs of certain low-volume isolated and 
essential suppliers. We will consider alternative methodologies that 
would more appropriately address payment to isolated, low-volume rural 
ambulance suppliers. Therefore, we solicit public comment on the 
number, location, and characteristics of the rural entities that are 
affected by this proposal.
    Section 202 of the Unfunded Mandates Reform Act of 1995 also 
requires that agencies assess anticipated costs and benefits before 
issuing any rule that may result in an expenditure in any one year by 
State, local, or tribal governments, in the aggregate, or by the 
private sector, of $100 million. The proposed rule would not have any 
unfunded mandates.
    Executive Order 13132 establishes certain requirements that an 
agency must meet when it promulgates a proposed rule (and subsequent 
final rule) that imposes substantial direct compliance costs on State 
and local governments, preempts State law, or otherwise has Federalism 
implications. The proposed rule would not impose compliance costs on 
the governments mentioned.
    Although we view the anticipated results of this proposed 
regulation as beneficial to the Medicare program and to Medicare 
beneficiaries, we recognize that not all of the potential effects of 
this proposed rule can be anticipated.
    The foregoing analysis concludes that this regulation may have a 
financial impact on a number of small entities. This analysis, in 
combination with the rest of the preamble, is consistent with the 
standards for analysis set forth by the RFA.

B. Anticipated Effects

1. Effect on Ambulance Providers and Suppliers
    Section 1834(l)(3)(A) of the Act requires that the aggregate amount 
paid under the ambulance fee schedule not exceed the aggregate amount 
that would have been paid absent the fee schedule. One of the 
characteristics of the present payment system is that widely varying 
amounts are paid for the same type of service depending upon the 
location of the service. In effect, the proposed ambulance fee schedule 
would lower payments in areas of high current levels of payment and 
raise payments in areas of low current levels of payment. When 
examining the impact of the proposed ambulance fee schedule, a given 
area could have a large reduction in payment only because such an area 
had historically been paid at a rate higher than average for the type 
of service. Also, as previously described, we are taking into account a 
$67.6 million program savings that would have resulted from a coverage 
change that was proposed in 1997. Implementation of that proposed rule 
was delayed until the ambulance fee schedule was established.
    Implementation of the proposed ambulance fee schedule would have 
several general effects. One effect would be that in 2001, $19 million 
in total revenue would be redistributed from providers to ambulance 
suppliers because providers have been paid, on average, more for the 
same service furnished by a supplier.
2. Effects on Urban, Rural, and Air Ambulance Services
    Payment could be redistributed from urban ambulance services to 
rural ambulance services for two reasons: (1) urban ambulance services 
have been paid, on average, more than for the same services furnished 
in rural areas; and (2) the proposed ambulance fee schedule would pay 
more for the same services furnished in a rural area because of the 
rural adjustment factor (RAF). Payment would also be redistributed from 
urban air ambulance services to rural air ambulance services because of 
the RAF for air services. Finally, there would be a redistribution of 
payment from ground ambulance services to air ambulance services. This 
effect is explained in greater detail in the discussion of the CF.
    Currently, providers are paid on average 66 percent more than 
independent suppliers for the same type of ambulance service. This is 
because providers are currently paid based on reasonable cost and 
suppliers are paid based on reasonable charges capped by the inflation 
indexed charge (IIC). The IIC has limited the growth of suppliers' 
payments over the years, whereas, until enactment of the BBA in 1997, 
there had not been a limit on the growth of providers' reimbursable 
cost for ambulance services.

[[Page 55090]]

    There are offsetting factors that affect payment in urban versus 
rural areas. While payment rates in rural areas would generally be 
lowered by the proposed GPCI (since the GPCI is generally lower in 
rural areas than it is in urban areas), rural payment rates would 
increase because of the rural mileage add-on. As a result, in 2001, $17 
million in total revenue would be redistributed from providers and 
suppliers in urban areas to providers and suppliers in rural areas.
    Furthermore, in 2001, $7 million in total revenue would be 
redistributed from providers and suppliers of ground ambulance services 
to providers and suppliers of air ambulance services.
    The following chart summarizes these findings for 2001:

------------------------------------------------------------------------
              From                       To                Revenue
------------------------------------------------------------------------
Providers......................  Suppliers.........  $19 million.
Urban..........................  Rural.............  $17 million.
Ground.........................  Air...............  $7 million.
------------------------------------------------------------------------

These amounts represent total revenue, that is, the 80 percent Medicare 
portion plus the 20 percent beneficiary coinsurance liability.
3. Effect on the Medicare Program
    We estimate that the proposed rule would produce a calendar year 
net savings to the Medicare program of $67.6 million because of the 
delayed implementation of the coverage policy proposed in the June 17, 
1997 rule. The following chart shows the estimated fiscal year annual 
savings that the Medicare program would realize over the next 5 years 
as a result of our proposal to implement the policy proposed in 1997 of 
paying for an ALS ambulance vehicle at the BLS payment rate when no ALS 
service is furnished to the beneficiary. This change would be 
implemented as part of the ambulance fee schedule.

------------------------------------------------------------------------
                                                            Savings  ($
                       Fiscal year                           Million)
------------------------------------------------------------------------
2001....................................................              40
2002....................................................              70
2003....................................................              70
2004....................................................              70
2005....................................................              80
------------------------------------------------------------------------

    Under this proposed rule, we anticipate savings for beneficiaries 
in terms of reduced coinsurance and savings due to mandatory assignment 
of benefits.
    The table below represents the proposed fee schedule amounts for CY 
2001 under this rule:

                                              Table 1.--2001 Fee Schedule for Payment of Ambulance Services
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                              Amount
                                                                            Unadjusted     adjusted  by     Amount  not       Loaded       Rural  ground
              Service level                    RVUs             CF          base  rate     GPCI  (70% of  adjusted  (30%      mileage        mileage*
                                                                           (UBR)       UBR)           of URB)
--------------------------------------------------------------------------------------------------------------------------------------------------------
BLS.....................................            1.00          157.52         $157.52         $110.26          $47.26           $5.00           $7.50
BLS--Emergency..........................            1.60          157.52          252.03          176.42           75.61            5.00            7.50
ALS1....................................            1.20          157.52          189.02          132.31           56.71            5.00            7.50
ALS1--Emergency.........................            1.90          157.52          299.29          209.50           89.79            5.00            7.50
ALS2....................................            2.75          157.52          433.18          303.23          129.95            5.00            7.50
SCT.....................................            3.25          157.52          511.94          358.36          153.58            5.00            7.50
PI......................................            1.75          157.52          275.66          192.96           82.70        (1) No Mileage Rate
--------------------------------------------------------------------------------------------------------------------------------------------------------


 
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                              Amount
                                                            Unadjusted     adjusted  by     Amount  not       Loaded         Rural Air       Rural air
                      Service Level                          base rate     GPCI  (50% of  adjusted  (50%      mileage       mileage **     base rate ***
                                                           (UBR)       UBR)           of UBR)
--------------------------------------------------------------------------------------------------------------------------------------------------------
FW......................................................       $2,213.00       $1,106.50       $1,106.50           $6.00           $9.00       $3,319.50
RW......................................................        2,573.00        1,286.50        1,286.50           16.00           24.00       3,859.50
--------------------------------------------------------------------------------------------------------------------------------------------------------
* A 50 percent add-on to the mileage rate (that is, a rate of $7.50 per mile) for each of the first 17 miles identified as rural. The regular mileage
  allowance applies for every mile over 17 miles.
** A 50 percent add-on to the air mileage rate is applied to every mile identified as rural.
*** A 50 percent add-on to the air base rate is applied to air trips identified as rural.
The payment rate for rural air ambulance (rural air mileage rate and rural air base rate) is 50 percent more than the corresponding payment rate for
  urban services (that is, the sum of the base rate adjusted by the geographic adjustment factor and the mileage).
 This column illustrates the payment rates without adjustment by the GPCI. The conversion factor (CF) has been inflated for 2001.

Legend for Table 1

ALS1--Advanced Life Support, Level 1
ALS2--Advanced Life Support, Level 2
BLS--Basic Life Support
CF--Conversion Factor
FW--Fixed Wing
GPCI--Practice Expense Portion of the Geographic Practice Cost x 
from the Physician Fee Schedule
PI--Paramedic ALS intercept
RVUs--Relative Value Units
RW--Rotary Wing
SCT--Specialty Care Transport
UBR--Unadjusted Base Rate

    Formulas--The amounts in the above chart are used in the 
following formulas to determine the fee schedule payments--

Ground:
    Ground--Urban:
    Payment Rate=[(RVU* (0.3+(0.7*GPCI)))*CF]+[MGR*#MILES]
    Ground--Rural:
    Payment Rate=[(RVU* (0.3+(0.7*GPCI)))*CF]+ 
[(((1+RG)*MGR)*#MILES17)+ (MGR*#MILES17)]

Air:
    Air--Urban:
    Payment Rate = [(((RVU* 0.5)+((RVU*0.5)*GPCI))*CF)]+ 
[MAR*#MILES]
    Air-Rural:
    Payment Rate = [(1+RA)*(((RVU*0.5)+((RVU* 0.5)*GPCI))*CF)]+ 
[(1+RA)*(MAR*#MILES)]

Legend for Formulas

Symbol and Meaning
  less than or equal to.
>  greater than.
*  multiply.
CF  conversion factor (ground = $157.52; air = 1.0).

[[Page 55091]]

GPCI  practice expense portion of the geographic practice cost index 
from the physician fee schedule.
#MILES  number of miles the beneficiary was transported.
MGR  mileage ground rate (5.0).
MAR  mileage air rate (fixed wing rate = 6.0, helicopter rate = 
16.0).
RA  rural air adjustment factor (0.50 on entire claim).
Rate  maximum allowed rate from ambulance fee schedule.
RG  rural ground adjustment factor amount (0.50 on first 17 miles).
RVUs  relative value units (from chart).

    Notes: The GPCI is determined by the address of the point of 
pickup.

Table 2

    EXAMPLES: The following examples demonstrate the use of the 
proposed ambulance fee schedule amounts and how they would be used 
during the first year (2001). Examples 1 through 4 relate to 
independent supplier claims, and Example 5 relates to hospital based 
supplier claims.

    Example 1: Ground Ambulance, Urban (Independent Supplier)   
    A Medicare beneficiary residing in Baltimore, Maryland, was 
transported via ground ambulance from his or her home to the nearest 
appropriate hospital 2 miles away. An emergency response was 
required, and an ALS assessment was performed. The level of service 
furnished would be ALS1-Emergency.
    Assuming that the beneficiary was placed on board the ambulance 
in Baltimore, it would be an urban trip. Therefore, no rural payment 
rate would apply. In Baltimore, the GPCI = 1.039. The fee schedule 
amount would be calculated as follows--

Payment Rate = [(RVU* (0.3+ (0.7*GPCI)))*CF]+ [MGR*#MILES]
Payment Rate = [(1.9*(0.3+(0.7*1.039)))*157.52]+[5*2]
Payment Rate = [(1.9*(0.3+(.7273)))*157.52]+[10]
Payment Rate = [(1.9*(1.0273))*157.52]+[10]
Payment Rate = [(1.95187)*157.52]+[10]
Payment Rate = [307.4585624]+[10]
Payment Rate = 317.4585624
Payment Rate = $317.46 (subject to Part B deductible and coinsurance 
requirements)

    Because 2001 would be the first year of a 4-year transition 
period, the ambulance fee schedule payment rate would be multiplied 
by 20 percent and added to 80 percent of the payment calculated by 
the current payment system. The payment rate for Year 2 (2002) would 
be calculated by multiplying the ambulance fee schedule payment rate 
by 50 percent and adding the result to 50 percent of the current 
payment system amount. The payment rate for Year 3 (2003) would be 
calculated by multiplying the ambulance fee schedule payment rate by 
80 percent and adding the result to 20 percent of the current 
payment system amount. The payment rate for Year 4 (2004) would be 
based solely on the ambulance fee schedule.
    Assuming the inflation indexed charge (IIC) in 2001, the 
reasonable charge rate for this service in Maryland would be $315.62 
($303.00 for HCPCS A0310, $6.31  x  2 miles for A0390). Therefore, 
the total allowed charge for this service during 2001 would be:

Old HCPCS Code(s) = A0310 and A0390
New HCPCS Code(s) = A0427 and A0425

----------------------------------------------------------------------------------------------------------------
                                               Reasonable new                   Fee schedule  x   Total allowed
            Reasonable charge IIC              charge  x  80%    Fee schedule          20%            charge
----------------------------------------------------------------------------------------------------------------
$315.62.....................................         $252.50          $317.46           $63.49          $315.99
----------------------------------------------------------------------------------------------------------------

    Assuming that the Part B deductible has been met, the program 
would pay 80 percent, and beneficiary's liability would be 20 
percent, representing the Part B coinsurance amount:

------------------------------------------------------------------------
                                                           Beneficiary
                 Medicare Payment (80%)                     Liability
                                                              (20%)
------------------------------------------------------------------------
$252.79................................................          $63.20
------------------------------------------------------------------------

    Example 2: Ground Ambulance, Rural (Independent Supplier)   
    A Medicare beneficiary residing in Cottle County, Texas, was 
transported via ground ambulance from his or her home to the nearest 
appropriate facility located in Quanah, Texas. Cottle County, where 
the beneficiary was placed on board the ambulance, is a non-MSA and, 
therefore, is rural. A rural payment rate would apply. The total 
distance from the beneficiary's home to the facility was 36 miles. A 
BLS nonemergency assessment was performed. Under our proposal, the 
level of service would be BLS (nonemergency).
    For this part of Texas, the GPCI = 0.888. The proposed ambulance 
fee schedule amount would be calculated as follows--

36 mile trip = 17 miles at the rural payment rate plus 19 miles at 
the regular rate.

Payment Rate = [(RVU* (0.3+ (0.7*GPCI)))*CF]+ 
[(((1+RG)*MGR)*#MILES17)+ (MGR*#MILES>17)]
Payment Rate = [(1.00*(0.3+ (0.7*0.888)))*157.52]+ 
[(((1+0.5)*5)*17)+ (5*19)]
Payment Rate = [(1.00* (0.3+0.6216))* 157.52]+ [((1.5*5)*17)+95]
Payment Rate = [(1.00*0.9216)*157.52]+[(7.5*17)+95]
Payment Rate = [0.9216*157.52]+[127.50+95]
Payment Rate = [145.170432]+[222.50]
Payment Rate = 367.670432
Payment Rate = $367.67 (subject to Part B deductible and coinsurance 
requirements)

    Under the proposal, since 2001 would be the first year of a 4-
year transition period, the ambulance fee schedule payment rate 
would be multiplied by 20 percent and added to 80 percent of the 
payment calculated by the current payment system. The payment rate 
for Year 2 (2002) would be calculated by multiplying the ambulance 
fee schedule payment rate by 50 percent and adding the result to 50 
percent of the current payment system amount. The payment rate for 
Year 3 (2003) would be calculated by multiplying the ambulance fee 
schedule by 80 percent and adding the result to 20 percent of the 
current payment system amount. The payment rate for Year 4 (2004) 
would be based solely on the ambulance fee schedule.
    Assuming the inflation indexed charge (IIC) in 2001, the 
reasonable charge rate for this service in Texas would be $292.44 
($152.76 for HCPCS A0300, $3.88  x  36 miles for A0380). Therefore, 
the total allowed charge for this service during 2001 under our 
proposal would be:

Old HCPCS Code(s) = A0300 and A0380
New HCPCS Code(s) = A0428 and A0425

----------------------------------------------------------------------------------------------------------------
                                               Reasonable new                   Fee schedule  x   Total allowed
            Reasonable charge IIC              charge  x  80%    Fee schedule          20%            charge
----------------------------------------------------------------------------------------------------------------
$292.44.....................................         $233.95          $367.67           $73.53          $307.48
----------------------------------------------------------------------------------------------------------------

    Assuming that the Part B deductible was met, the program would 
pay 80 percent, and the beneficiary's liability would be 20 percent, 
representing the Part B coinsurance amount:

------------------------------------------------------------------------
                                                           Beneficiary
                 Medicare Payment (80%)                  Liability (20%)
------------------------------------------------------------------------
$245.98................................................          $61.50
------------------------------------------------------------------------

    Example 3: Air Ambulance, Urban (Independent Supplier)   
    A Medicare beneficiary was involved in an automobile accident 
along a busy interstate near Detroit, Michigan. A helicopter

[[Page 55092]]

transported the beneficiary to the nearest appropriate facility 
located within the city limits of Detroit. The total distance from 
the accident to the facility was 14 miles. The level of service was 
rotary wing.
    Assuming that the patient was placed on board the air ambulance 
within the Detroit MSA, and because this is not a Goldsmith county, 
the trip would be urban. Therefore, no rural payment rate would 
apply. In the Detroit metropolitan area, the GPCI = 1.022. The 
ambulance fee schedule amount would be calculated as follows--

Payment Rate = [((UBR*0.5)+ ((UBR*0.5)* GPCI))]+ [MAR*#MILES]
Payment Rate = [((2573.00*0.5)+ ((2573.00*0.5)*1.022))]+ [16.00*14]
Payment Rate = [(1286.50+ ((1286.50)*1.022))]+ [224]
Payment Rate = [(1286.50+1314.803)]+[224]
Payment Rate = [2601.303]+[224]
Payment Rate = [2825.303]
Payment Rate = $2,825.30 (subject to Part B deductible and 
coinsurance requirements)

    Because 2001 would be the first year of a 4-year transition 
period, the payment rate from the ambulance fee schedule would be 
multiplied by 20 percent and added to 80 percent of the payment 
calculated by the current payment system. The payment rate for Year 
2 (2002) would be calculated by multiplying the ambulance fee 
schedule by 50 percent and adding the result to 50 percent of the 
current payment system amount. The payment for Year 3 (2003) would 
be calculated by multiplying the ambulance fee schedule by 80 
percent and adding the result to 20 percent of the current payment 
system amount. The payment for Year 4 (2004) would be based solely 
on the ambulance fee schedule.
    Assuming the inflation indexed charge (IIC) in 2001, the 
reasonable charge rate for this service in Michigan is $1,982.26. 
Therefore, the total allowed charge for this service during 2001 
would be:

Old HCPCS Code = A0040
New HCPCS Code = A0431 and A0436

----------------------------------------------------------------------------------------------------------------
                                               Reasonable new                   Fee schedule  x   Total allowed
            Reasonable charge IIC              charge  x  80%    Fee schedule          20%            charge
----------------------------------------------------------------------------------------------------------------
$1,982.26...................................       $1,585.81        $2,825.30          $565.06        $2,150.87
----------------------------------------------------------------------------------------------------------------

    Assuming that the Part B deductible has been met, the program 
would pay 80 percent and the beneficiary's liability would be 20 
percent, representing the Part B coinsurance amount:

------------------------------------------------------------------------
                                                           Beneficiary
                 Medicare Payment (80%)                  Liability (20%)
------------------------------------------------------------------------
$1,720.70..............................................         $430.17
------------------------------------------------------------------------

    Example 4: Air Ambulance, Rural (Independent Supplier)   
    A Medicare beneficiary was transported via helicopter from a 
rural county in Arizona to the nearest appropriate facility. The 
total distance from point of pick-up to the facility was 86 miles. 
The level of service was rotary wing.
    Because the point of pick-up was in a rural, non-MSA area, this 
transport would be a rural trip under the proposed rule. Therefore, 
a rural payment rate would apply. In Arizona, the GPCI = 0.971. The 
ambulance fee schedule amount would be calculated as follows--

Payment Rate = [(1+RA)*((UBR*0.5)+ ((UBR*0.5)*GPCI))] 
+[(1+RA)*(MAR*#MILES)]
Payment Rate = [(1+0.5)*(((2573.00*0.5)+ ((2573.00*0.5)*0.971))]+ 
[(1+0.5)*(16*86)]
Payment Rate = [(1.5)*((1286.50)+ (1286.50*0.971))]+ [(1.5)*(1376)]
Payment Rate = [(1.5)*(1286.50+1249.192)]+[2064]
Payment Rate = [(1.5)*2535.692]+[2064]
Payment Rate = 4599.692
Payment Rate = $4,599.69 (subject to Part B deductible and 
coinsurance requirements)

    Because 2001 is the first year of a 4 year transition period, 
this payment rate from the proposed fee schedule would then be 
multiplied by 20 percent and added to 80 percent of the payment 
calculated by the current payment system. Year 2 would be calculated 
by multiplying the fee schedule by 50 percent and adding the result 
to 50 percent of the current payment system amount. Year 3 would be 
calculated by multiplying the fee schedule by 80 percent and adding 
20 percent of the current payment system amount. Year 4 (2004) is 
based solely on the fee schedule amount.
    Assuming the inflation indexed charge (IIC) for the example in 
question, in 2001 the reasonable charge rate for this service in 
Arizona would be $1,564.80. Therefore, the total allowed charge for 
this service during 2001 would be:

Old HCPCS Code = A0040
New HCPCS Code = A0431 and A0436

----------------------------------------------------------------------------------------------------------------
                                               Reasonable new                   Fee schedule  x   Total allowed
            Reasonable charge IIC              charge  x  80%    Fee schedule          20%            charge
----------------------------------------------------------------------------------------------------------------
$1,564.80...................................       $1,251.84        $4,599.69          $919.94        $2,171.78
----------------------------------------------------------------------------------------------------------------

    Assuming that the Part B deductible has been met, the program 
would pay 80 percent and 20 percent would be the beneficiary's 
liability:

------------------------------------------------------------------------
                                                           Beneficiary
                 Medicare payment (80%)                  liability (20%)
------------------------------------------------------------------------
$1,737.42..............................................         $434.36
------------------------------------------------------------------------

    Example 5: Ground Ambulance, Rural (Hospital Based Supplier) A 
Medicare beneficiary residing in a rural area in the state of Iowa 
was transported via ground ambulance from her home located in a 
rural area (non-MSA) to the nearest appropriate facility (Hospital 
A). Because the point of pick-up is in a rural area, under our 
proposal, a rural payment rate would apply. The total distance from 
the beneficiary's home to Hospital A is 14 miles. A BLS nonemergency 
transport was furnished. The level of service would be BLS 
(nonemergency).
    For Iowa, the GPCI = 0.882. The ambulance fee schedule amount 
would be calculated as follows--

14 mile trip = 14 miles at the rural payment rate plus 0 miles at 
the regular rate.

    The HCPCS codes to be used under the fee schedule are A0428 and 
A0425.

Payment Rate = [(RVU*(0.3+(0.7*GPCI)))*CF]+ 
[(((1+RG)*MGR)*#MILES17)+ (MGR*#MILES>#7)]
Payment Rate = [(1.00*(0.3+(0.7*0.882) ))*157.52]+ 
[(((1+0.5)*5)*14)+(5*0)]
Payment Rate = [(1.00*(0.3+0.6174))*157.52]+ [((1.5*5)*14)+0]
Payment Rate = [(1.00*0.9174)*157.52]+ [(7.5*14)+0]
Payment Rate = [0.9174*157.52]+[105+0]
Payment Rate = [144.508848]+[105]
Payment Rate = 249.508848
Payment Rate = $249.51 (subject to Part B deductible and coinsurance 
requirements)

    Since 2001 would be the first year of a proposed 4-year 
transition period, the ambulance fee schedule payment rate would be 
multiplied by 20 percent. The total payment under the proposed fee 
schedule for 2001 is:

Payment Rate = Fee Schedule * Transition Percentage
Payment Rate = 249.51*0.2
Payment Rate = 49.902
Payment Rate = $49.90


[[Page 55093]]


    The remaining 80 percent of the payment rate is determined by 
the current payment system. For FIs, the current payment calculation 
is as follows.
    Assume that Hospital A's charge (HCB) for a BLS-nonemergency 
service is $220.00, its charge for mileage (HCM) is $4.00 per mile, 
and its past year's cost-to-charge ratio (CCR) is 0.9.
    Assuming that the beneficiary's Medicare Part B deductible has 
been met, the beneficiary's coinsurance liability for 2001 would be:

Total Charge = HCB+(HCM*#MILES)
Total Charge = 220+(4*14)
Total Charge = 220+56
Total Charge = $276.00 (Current system)

For 2001, the coinsurance is equal to 20 percent of:
Total rate = (0.80*Current System)+(0.20*FS)
Total rate = (0.80*276)+(49.90)
Total rate = (220.80)+(49.90)
Total rate = $270.70
Coinsurance = 0.20*270.70 = $54.14

For 2001, the transition payment rate is equal to:
Transition payment rate = [0.80*current rate]+[0.20*FS]
Transition Payment Rate = [0.80*((HCB)+ (HCM*#MILES))*CCR]+ 
[0.20*FS]
Transition Payment Rate = [0.80*((220)+ (4*14))*0.9]+[49.90]
Transition Payment Rate = [0.80*((220)+ (56))*0.9]+[49.90]
Transition Payment Rate = [0.80*(276)*0.9]+[49.90]
Transition Payment Rate = [198.72]+[49.90]
Transition Payment Rate = $248.62

    Assuming the part B deductible is met:
Medicare program payment = (transition payment rate)-(coinsurance)
Medicare program payment = 248.62-54.14
Medicare program payment = $194.48

    Under our proposal, the payment rate for Year 2 (2002) would be 
calculated by multiplying the ambulance fee schedule payment rate by 
50 percent and adding the result to 50 percent of the current 
payment system amount. The payment rate for Year 3 (2003) would be 
calculated by multiplying the ambulance fee schedule by 80 percent 
and adding the result to 20 percent of the current payment system 
amount. The payment rate for Year 4 (2004) would be based solely on 
the ambulance fee schedule.

C. Alternatives Considered

    While there were many alternatives considered during the course of 
the negotiated rulemaking process, the statute requires that total 
program expenditures not exceed what the payments would have been 
without the fee schedule. All of the alternatives considered did not 
change total program expenditures. The alternatives varied in the 
manner in which the total amount of program expenditures might be 
distributed among the entities that furnish ambulance services to 
Medicare beneficiaries. For example, the Committee considered other 
geographical adjustment factors, other relative values for the levels 
of ambulance service, other definitions for the levels of ambulance 
service and other definitions for ``rural entities'', but it did not 
adopt them for various reasons. (A full description of these 
alternatives may be found at the website: www.hcfa.gov/medicare/ambmain.htm.)

D. Conclusion

    We anticipate that the proposed ambulance fee schedule amounts for 
entities that have received lower than average payment rates 
historically would be relatively higher and the fee schedule amounts 
for entities that have received higher than average payment rates 
historically would be relatively lower. Generally, this would mean 
higher rates in the future for rural transports, lower rates in the 
future for urban transports, and higher rates in the future for air 
ambulance services. The ambulance fee schedule will have a leveling 
effect on coinsurance liability. While beneficiaries in those areas of 
historically higher than average payment rates would benefit from lower 
coinsurance liability, beneficiaries in areas of historically lower 
than average payment rates would experience an upward adjustment of 
coinsurance liability. Beneficiaries would also benefit in those cases 
in which suppliers previously did not accept assignment and billed the 
beneficiary the difference between the Medicare program allowed amount 
and their actual charge, because under the fee schedule all suppliers 
must accept assignment. We anticipate that the integrity of the 
Medicare Part B Trust Fund will be protected by the continuance of the 
inflation factors prescribed in the statute.
    In accordance with the provisions of Executive Order 12866, this 
regulation was reviewed by the Office of Management and Budget.

List of Subjects Affected

42 CFR Part 410

    Health facilities, Health professions, Kidney diseases, 
Laboratories, Medicare, Rural areas, X-rays.

42 CFR Part 414

    Administrative practice and procedure, Health facilities, Health 
professions, Kidney diseases, Medicare, Reporting and recordkeeping 
requirements, Rural areas, X-rays.

    For the reasons set forth in the preamble, 42 CFR chapter IV is 
proposed to be amended:

PART 410--SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS

    I. Part 410 is amended as set forth below:
    1. The authority citation for part 410 continues to read as 
follows:

    Authority: Secs. 1102 and 1871 of the Social Security Act (42 
U.S.C. 1302 and 1395hh).

Subpart B--Medical and Other Health Services

    2. Section 410.40 is amended by:
    A. Revising paragraph (b).
    B. Revising paragraph (d)(1).
    C. Republishing the introductory paragraph (d)(3).
    D. Adding new paragraphs (d)(3)(iii), (d)(3)(iv), and (d)(3)(v).
    The revisions and additions read as follows:


Sec. 410.40  Coverage of ambulance services.

* * * * *
    (b) Levels of service. Medicare covers the following levels of 
ambulance service: basic life support ((BLS) emergency and 
nonemergency), advanced life support, level 1 ((ALS1) emergency and 
nonemergency), advanced life support, level 2 (ALS2), paramedic 
intercept (PI), specialty care transport (SCT), fixed wing transport 
(FW), and rotary wing transport (RW). See Sec. 414.605 for a definition 
of each level of services.
* * * * *
    (d) Medical necessity requirements--(1) General rule. Medicare 
covers ambulance services, including fixed wing and rotary wing 
ambulance services, only if they are furnished to a beneficiary whose 
medical condition is such that other means of transportation would be 
contraindicated. While physician certification allows the ambulance 
supplier to assert that the transportation was reasonable and 
necessary, the beneficiary's medical record must support the coverage 
of the transportation. For nonemergency ambulance transportation, the 
following criteria must be met to ensure that ambulance transportation 
is medically necessary:
    (i) The beneficiary is unable to get up from bed without 
assistance.
    (ii) The beneficiary is unable to ambulate.
    (iii)The beneficiary is unable to sit in a chair or wheelchair.
    These criteria, as defined, are not meant to be the sole criterion 
in determining medical necessity. They are one factor to be considered 
when

[[Page 55094]]

making medical necessity determinations.
* * * * *
    (3) Special rule for nonemergency, unscheduled ambulance services. 
Medicare covers nonemergency, unscheduled ambulance services, provided 
medical necessity is established under one of the following 
circumstances:
* * * * *
    (iii) If the ambulance provider or supplier is unable to obtain a 
signed physician certification statement from the beneficiary's 
attending physician, a signed physician certification statement must be 
obtained from either the physician, physician assistant (PA), nurse 
practitioner (NP), clinical nurse specialist (CNS), registered nurse 
(RN), or discharge planner, who is employed by the hospital or facility 
where the beneficiary is being treated, and who has personal knowledge 
of the beneficiary's condition at the time the ambulance transport is 
ordered or the ambulance service was furnished; and,
    (iv) If the ambulance provider or supplier is unable to obtain the 
required physician certification statement within 21 calendar days 
following the date of the service, the ambulance supplier must document 
its attempts to obtain the requested physician certification statement 
and may then submit the claim. Acceptable documentation must include a 
signed return receipt from a U.S. Postal Service or other similar 
service. This documentation will serve as proof that the ambulance 
supplier attempted to obtain the required signature from the attending 
physician.
    (v) In all cases, the provider or supplier must keep appropriate 
documentation on file and, upon request, present it to the contractor. 
The presence or absence of the signed physician certification statement 
or signed return receipt does not definitively demonstrate that the 
ambulance transport was medically necessary. The ambulance provider or 
supplier must meet all other coverage criteria for payment to be made.
* * * * *

PART 414--PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES

    II. Part 414 is amended as set forth below:
    1. The authority citation for part 414 continues to read as 
follows:

    Authority: Secs. 1102, 1871, and 1881(b)(1) of the Social 
Security Act (42 U.S.C. 1302, 1395hh, 1395rr(b)(1)).

    2. Section 414.1 is revised to read as follows:


Sec. 414.1  Basis and scope.

    This part implements the indicated provisions of the following 
sections of the Act:

1802--Rules for private contracts by Medicare beneficiaries.
1820--Rules for Medicare reimbursement for telehealth services.
1833--Rules for payment for most Part B services.
1834(a) and (h)--Amounts and frequency of payments for durable 
medical equipment and for prosthetic devices and orthotics and 
prosthetics.
1834(l)--Establishment of a Fee Schedule for Ambulance Services.
1848--Fee schedule for physician services.
1881(b)--Rules for payment for services to ESRD beneficiaries.
1887--Payment of charges for physician services to patients in 
providers.

    3. A new subpart H, consisting of Secs. 414.601 through 414.625, is 
added to read as follows:
Subpart H--Fee Schedule for Ambulance Services
Sec.
414.601   Purpose.
414.605   Definitions.
414.610   Basis of payment.
414.611   Coding system.
414.615   Transition for implementation of the ambulance fee 
schedule.
414.620   Publication of the ambulance services fee schedule.
414.625   Limitation on review.

Subpart H--Fee Schedule for Ambulance Services


Sec. 414.601  Purpose.

    This subpart implements section 1834(l) of the Act, by establishing 
a fee schedule for the payment of ambulance services. Section 1834(l) 
of the Act requires that payment for all ambulance services otherwise 
payable on a reasonable charge system or retrospective reasonable cost 
reimbursement system be made under the ambulance fee schedule effective 
for services furnished after January 1, 2000.


Sec. 414.605  Definitions.

    As used in this subpart, the following definitions apply to both 
land and water (hereafter referred to as ``ground'') and to air 
services:
    Advanced Life Support (ALS) assessment is an assessment performed 
by an ALS crew that results in the determination that the patient's 
condition requires an ALS level of care, even if no other ALS 
intervention is performed.
    Advanced Life Support, Level 1 (ALS1) means transportation by 
ambulance vehicle and medically necessary supplies and ancillary 
services, plus an ALS assessment by an ALS provider or the provision of 
at least one ALS intervention.
    Advanced Life Support, Level 2 (ALS2) means transportation by 
ambulance vehicle and medically necessary supplies and ancillary 
services, plus the administration of at least three different 
medications and the provision of at least one of the following ALS 
procedures:
    (1) Manual defibrillation/cardioversion.
    (2) Endotracheal intubation.
    (3) Central venous line.
    (4) Cardiac pacing.
    (5) Chest decompression.
    (6) Surgical airway.
    (7) Intraosseous line.
    Advanced Life Support (ALS) intervention means a procedure beyond 
the scope of an emergency medical technician-basic (EMT-Basic).
    Advanced Life Support (ALS) provider means an individual trained to 
the level of the EMT-Intermediate or paramedic. The EMT-Intermediate is 
defined as having the knowledge and skills identified for the EMT-
Basic, but also as qualified to perform essential advanced techniques 
and to administer a limited number of medications. The EMT-Paramedic is 
defined as possessing the competencies of the EMT-Intermediate, but 
also has enhanced skills that include being able to administer 
additional interventions and medications.
    Basic Life Support (BLS) means transportation by ambulance vehicle 
and medically necessary supplies and ancillary services, plus the 
provision of BLS ambulance services. The EMT-Basic, in addition to 
being able to operate limited equipment on board the vehicle and being 
able to assist in performing assessments and interventions, is 
qualified to function as minimum staff for an ambulance and, to 
establish a peripheral intravenous (IV) line.
    Conversion Factor (CF) is a nationally uniform dollar value, 
multiplied by relative value units for a service to produce a payment 
amount.
    Emergency Response means responding immediately to an emergency 
medical condition. An immediate response is one in which the ambulance 
supplier begins as quickly as possible to take the steps necessary to 
respond to the call.
    Fixed Wing Air Ambulance (FW) means transportation by a fixed wing 
aircraft that is certified as a fixed wing air ambulance and such 
ancillary services as may be medically necessary.
    Geographic Adjustment Factor (GAF) means the practice expense (PE) 
portion of the geographic practice cost index

[[Page 55095]]

(GPCI) from the physician fee schedule as applied to a percentage of 
the base rate. For ground ambulance services, the PE portion of the 
GPCI is applied to 70 percent of the base rate. For air ambulance 
services, the practice expense (PE) portion of the GPCI is applied to 
50 percent of the base rate.
    Goldsmith Modification means the methodology for the identification 
of rural census tracts that are located within large metropolitan 
counties of at least 1,225 square miles, but are so isolated from the 
metropolitan core of that county by distance or physical features so as 
to be more rural than urban in character.
    Loaded Mileage means the number of miles for which the Medicare 
beneficiary is transported in the ambulance vehicle.
    Paramedic ALS Intercept (PI) means EMT-Paramedic services furnished 
by an entity that does not furnish the ambulance transport. See 
Sec. 410.40(c) of this chapter for criteria governing direct payment.
    Point of Pick-up means the location of the beneficiary at the time 
he or she is placed on board the ambulance.
    Relative value units (RVUs) measure the value of ambulance services 
relative to the value of a base level ambulance service.
    Rotary Wing Air Ambulance (RW) means transportation by a helicopter 
that is certified as an ambulance and such ancillary services as may be 
medically necessary.
    Rural adjustment factor (RAF) means an adjustment applied to 
services at the point of pick-up in a rural area and added to the base 
payment rate.
    Services in a Rural area means services that are furnished in an 
area outside a Metropolitan Statistical Area (MSA) or a New England 
County Metropolitan Area (NECMA) or an area within an MSA identified as 
rural, using the Goldsmith modification.
    Specialty Care Transport (SCT) means interfacility transportation 
by an ambulance vehicle, including medically necessary supplies and 
ancillary services, of a critically injured or ill patient at a level 
of service beyond the scope of the EMT-Paramedic. SCT is necessary when 
a patient's condition requires ongoing care that must be furnished by 
one or more health professionals in an appropriate specialty area (for 
example, nursing, emergency medicine, respiratory care, cardiovascular 
care, or a paramedic with additional training).


Sec. 414.610  Basis of payment.

    (a) Method of payment. Medicare payment for ambulance services is 
based on the lesser of the actual charge or the applicable fee schedule 
amount. The fee schedule payment for ambulance services equals a base 
rate for the level of service plus payment for mileage and applicable 
adjustment factors. All ambulance services (regardless of the vehicle 
(for example, ALS or BLS) furnishing the service or of any local or 
State ordinances) are paid under the fee schedule specified in this 
subpart.
    (b) Mandatory assignment. Effective with implementation of the 
ambulance fee schedule described in Sec. 414.601, for services 
furnished on or after January 1, 2001, all payments made for ambulance 
services are made on an assignment-related basis. Ambulance suppliers 
must accept the Medicare allowed charge as payment in full and may not 
bill or collect from the beneficiary any amount other than the unmet 
Part B deductible and Part B coinsurance amounts. Violations of this 
requirement may subject the provider or supplier to sanctions, as 
provided by law. There is no transitional period for mandatory 
assignment of claims.
    (c) Formula for computation of payment amounts. The fee schedule 
payment amount for ambulance services is computed according to the 
following:
    (1) Relative value units. The relative value unit (RVU) scale for 
the ambulance fee schedule is as follows:

------------------------------------------------------------------------
                                                          Relative value
                      Service level                        units (RVUs)
------------------------------------------------------------------------
BLS.....................................................            1.00
BLS--Emergency..........................................            1.60
ALS1....................................................            1.20
ALS1--Emergency.........................................            1.90
ALS2....................................................            2.75
SCT.....................................................            3.25
PI......................................................            1.75
------------------------------------------------------------------------

    (i) Ground ambulance service levels. RVUs for ground ambulance 
services are multiplied by a CF and adjusted by the GAF and rural 
adjustment factor (RAF), as appropriate, in order to determine the 
respective payment rates.
    (ii) Air ambulance service levels. The base payment rate for air is 
adjusted by the GAF and RAF, as appropriate, in order to determine the 
amount of payment. There are no RVUs for air ambulance services because 
there are only two types of air ambulance services: fixed wing (FW) and 
rotary wing (RW).
    (iii) Loaded mileage. Payment is made for each loaded mile. Air 
mileage is based on loaded miles flown, as expressed in statute miles. 
There are three mileage payment rates for ground and water, FW, and RW.
    (iv) Geographic adjustment factor (GAF). For ground ambulance 
services, the PE portion of the GPCI from the physician fee schedule is 
applied to 70 percent of the base rate. For air ambulance services, the 
PE portion of the physician fee schedule GPCI is applied to 50 percent 
of the base rate.
    (v) Rural adjustment factor (RAF). For ground ambulance services, a 
50 percent increase is applied to the mileage rate for each of the 
first 17 miles; the regular mileage allowance applies to every mile 
over 17 miles. For air ambulance services, a 50 percent increase is 
applied to the total payment for air services; that is, the adjustment 
applies to the sum of the base rate and the mileage.
    (2) Payment Rates. Payment, in accordance with this section, 
represents payment in full (subject to applicable Medicare Part B 
deductible and coinsurance requirements as described in subpart G of 
part 409 of this chapter) for all costs (routine, ancillary, and 
capital-related) associated with furnishing inpatient SNF services to 
Medicare beneficiaries other than costs associated with operating 
approved educational activities as described in Sec. 413.85 of this 
chapter.
    (d) Point of pick-up. The zip code of the point of pick-up must be 
reported on each claim for ambulance services, so that the correct GAF 
and RAF may be applied, as appropriate.
    (e) Updates. The CF is updated annually for inflation by a factor 
equal to the payment amounts provided under the fee schedule for 
services furnished in CY 2001 and each subsequent year at amounts under 
the fee schedule for services furnished during the previous year. The 
CF is increased by the percentage increase in the consumer price index 
for all urban consumers (U.S. city average) for the 12-month period 
ending with June of the previous year reduced in 2001 and 2002 by 1 
percentage point.
    (f) Adjustments. The CF may be adjusted to take into account 
factors that, as determined by the Secretary, show data that results in 
a significantly different aggregate payment of items and services paid 
under the ambulance fee schedule.


Sec. 414.611  Coding system.

    All claims for services for which the amount of payment is 
determined under Sec. 414.610 must include a code (or codes) from the 
uniform coding system specified by the Secretary that identifies the 
services furnished.

[[Page 55096]]

Sec. 414.615  Transition for implementation of the ambulance fee 
schedule.

    The fee schedule for ambulance services will be phased in over 4 
years beginning January 1, 2001. Payment for services furnished during 
the transition period are made based on a combination of the fee 
schedule payment for ambulance services and the amount the carrier 
would have paid absent the fee schedule for ambulance services, as 
follows:
    (a) For services furnished in CY 2001, the payment is based 80 
percent on the reasonable charge-based payments for independent 
suppliers and 80 percent on reasonable cost for providers, plus 20 
percent of the ambulance fee schedule amount. The reasonable charge or 
reasonable cost portion of payment in CY 2001 is equal to the 
reasonable charge or reasonable cost for CY 2000, multiplied by the 
statutory inflation factors for ambulance services.
    (b) For services furnished in CY 2002, the payment is based 50 
percent on the reasonable charge or reasonable cost, as applicable, 
plus 50 percent of the ambulance fee schedule amount. The reasonable 
charge and reasonable cost portion in CY 2002 is equal to the supplier 
or provider's reasonable charge or reasonable cost for CY 2001, 
multiplied by the statutory inflation factors for ambulance services.
    (c) For services furnished in CY 2003, the payment is based 20 
percent on the reasonable charge or reasonable cost, plus 80 percent of 
the ambulance fee schedule amount. The reasonable charge and reasonable 
cost in CY 2003 for each supplier or provider respectively is equal to 
the supplier or provider's reasonable charge or reasonable cost for CY 
2002, multiplied by the statutory inflation factors for ambulance 
services.
    (d) For services furnished in CY 2004 and thereafter, the payment 
is based solely on the ambulance fee schedule amount.
    (e) Updates. The portion of the transition payment that is based on 
the existing payment methodology (that is, the non fee schedule 
portion) is updated annually for inflation by a factor equal to the 
projected consumer price index for all urban consumers (U.S. city 
average), from March to March for claims paid under cost reimbursement 
and from June to June for claims paid under reasonable charges, minus 1 
percentage point. The portion of the transition payment that is based 
on the ambulance fee schedule is updated annually for inflation as 
described in Sec. 414.610(e).


Sec. 414.620  Publication of the ambulance services fee schedule.

    Each year, HCFA will publish updates to the fee schedule for 
ambulance services.


Sec. 414.625  Limitation on review.

    There shall be no administrative or judicial review under sections 
1869 of the Act or otherwise of the amounts established under the fee 
schedule for ambulance services, including but not limited to matters 
described in section 1834(l)(2) of the Act.

(Catalog of Federal Domestic Assistance Program No. 93.774, 
Medicare--Supplementary Medical Insurance Program)

    Dated: August 15, 2000.
Nancy-Ann Min DeParle,
Administrator, Health Care Financing Administration.

    Dated: August 31, 2000.
Donna E. Shalala,
Secretary.

    Note: The following addendum will not appear in the Code of 
Federal Regulations.


                                                   Addendum A
                             [** When using this chart, use all codes that apply **]
----------------------------------------------------------------------------------------------------------------
                       On-scene condition       On-scene condition                         Comments and examples
         #                 (general)                (specific)             Svc. Lev.        [not all-inclusive]
----------------------------------------------------------------------------------------------------------------
                                      Emergency Conditions (non-traumatic)
----------------------------------------------------------------------------------------------------------------
1.................  Abdominal pain.........  With other signs or      ALS                 Nausea, vomiting,
                                              symptoms.                                    fainting, pulsatile
                                                                                           mass, distention,
                                                                                           rigid, tenderness on
                                                                                           exam, guarding.
2.................  Abdominal pain.........  Without other signs or   BLS                 ......................
                                              symptoms.
3.................  Abnormal cardiac rhythm/ Potentially life-        ALS                 Bradycardia,
                     Cardiac dysrythmia.      threatening.                                 junctional and
                                                                                           ventricular
                                                                                           blocks,non-sinus
                                                                                           tachycardias, PVC's
                                                                                           >6, bi and trigeminy,
                                                                                           vtach,vfib, atrial
                                                                                           flutter, PEA,
                                                                                           asystole.
4.................  Abnormal skin signs....  .......................  ALS                 Diaphorhesis,
                                                                                           cyanosis, delayed cap
                                                                                           refill, poor turgor,
                                                                                           mottled.
5.................  Abnormal vital signs     With symptoms..........  ALS                 Other emergency
                     (includes abnormal                                                    conditions.
                     pulse oximetry).
6.................  Abnormal vital signs     Without symptoms.......  BLS                 ......................
                     (includes abnormal
                     pulse oximetry).
7.................  Allergic reaction......  Potentially life-        DALS                Other emergency
                                              threatening.                                 conditions, rapid
                                                                                           progression of
                                                                                           symptoms, prior hx.
                                                                                           of anaphylaxis,
                                                                                           wheezing, difficulty
                                                                                           swallowing.
8.................  Allergic reaction......  Other..................  BLS                 Hives, itching, rash,
                                                                                           slow onset, local
                                                                                           swelling, redness,
                                                                                           erythema.
9.................  Animal bites/sting/      Potentially life or      ALS                 Symptoms of specific
                     envenomation.            limb-threatening.                            envenomation,
                                                                                           significant face,
                                                                                           neck, trunk, and
                                                                                           extremity
                                                                                           involvement; other
                                                                                           emergency conditions.
10................  Animal bites/sting/      Other..................  BLS                 Local pain and
                     envenomation.                                                         swelling, special
                                                                                           handling
                                                                                           considerations and
                                                                                           patient monitoring
                                                                                           required.
11................  Sexual assault.........  With injuries..........  ALS                 ......................
12................  Sexual assault.........  With no injuries.......  BLS                 ......................
13................  Blood glucose..........  Abnormal- 80 or >250,    ALS                 Altered mental status,
                                              with symptoms.                               vomiting, signs of
                                                                                           dehydration, etc.

[[Page 55097]]

 
14................  Respiratory arrest.....  .......................  ALS                 Apnea, hypoventilation
                                                                                           requiring ventilatory
                                                                                           assistance and airway
                                                                                           management.
15................  Difficulty breathing...  .......................  ALS                 ......................
16................  Cardiac arrest--         .......................  ALS                 ......................
                     Resuscitation in
                     progress.
17................  Chest pain (non-         .......................  ALS                 Dull, severe,
                     traumatic).                                                           crushing, substernal,
                                                                                           epigastric, left
                                                                                           sided chest pain
                                                                                           associated with pain
                                                                                           of the jaw, left arm,
                                                                                           neck, back, and
                                                                                           nausea, vomiting,
                                                                                           palpitations, pallor,
                                                                                           diaphoresis,
                                                                                           decreased LOC.
18................  Choking episode........  .......................  ALS                 ......................
19................  Cold exposure..........  Potentially life or      ALS                 Temperature 95F, deep
                                              limb threatening.                            frost bite, other
                                                                                           emergency conditions.
20................  Cold exposure..........  With symptoms..........  BLS                 Shivering, superficial
                                                                                           frost bite, and other
                                                                                           emergency conditions.
21................  Altered level of         .......................  ALS                 Acute condition with
                     consciousness (non-                                                   Glascow Coma Scale15.
                     traumatic).
22................  Convulsions/Seizures...  Seizing, immediate post- ALS                 ......................
                                              seizure, post-ictal,
                                              or at risk of seizure
                                              & requires medical
                                              monitoring/observation.
23................  Eye symptoms, non-       Acute vision loss and/   BLS                 ......................
                     traumatic.               or severe pain.
24................  Non traumatic headache.  With neurologic          ALS                 ......................
                                              distress conditions.
25................  Non traumatic headache.  Without neurologic       BLS                 ......................
                                              symptoms.
26................  Cardiac Symptoms other   Palpitations, skipped    ALS                 ......................
                     than chest pain.         beats.
27................  Cardiac symptoms other   Atypical pain or other   ALS                 Persistent nausea and
                     than chest pain.         symptoms.                                    vomiting, weakness,
                                                                                           hiccups, pleuritic
                                                                                           pain, feeling of
                                                                                           impending doom, and
                                                                                           other emergency
                                                                                           conditions.
28................  Heat Exposure..........  Potentially life-        ALS                 Hot and dry skin,
                                              threatening.                                 Temp>105, neurologic
                                                                                           distress, signs of
                                                                                           heat stroke or heat
                                                                                           exhaustion,
                                                                                           orthostatic vitals,
                                                                                           other emergency
                                                                                           conditions.
29................  Heat exposure..........  With symptoms..........  BLS                 Muscle cramps, profuse
                                                                                           sweating, fatigue.
30................  Hemorrhage.............  Severe (quantity)......  ALS                 Uncontrolled or
                                                                                           significant signs of
                                                                                           shock, other
                                                                                           emergency conditions.
31................  Hemorrhage.............  Potentially life-        ALS                 Active vaginal, rectal
                                              threatening.                                 bleeding,
                                                                                           hematemesis,
                                                                                           hemoptysis,
                                                                                           epistaxis, active
                                                                                           post-surgical
                                                                                           bleeding.
32................  Infectious diseases      .......................  BLS                 ......................
                     requiring isolation
                     procedures / public
                     health risk.
33................  Hazmat Exposure........  .......................  ALS                 Toxic fume or liquid
                                                                                           exposure via
                                                                                           inhalation,
                                                                                           absorption, oral,
                                                                                           radiation, smoke
                                                                                           inhalation.
34................  Medical Device Failure.  Life or limb             ALS                 Malfunction of
                                              threatening                                  ventilator, internal
                                              malfunction, failure,                        pacemaker, internal
                                              or complication.                             defibrillator,
                                                                                           implanted drug
                                                                                           delivery device.
35................  Medical Device Failure.  Health maintenance       BLS                 O2 supply malfunction,
                                              device failures.                             orthopedic device
                                                                                           failure.
36................  Neurologic Distress....  Facial drooping; loss    ALS                 ......................
                                              of vision; aphasia;
                                              difficulty swallowing;
                                              numbness, tingling
                                              extremity; stupor,
                                              delirium, confusion,
                                              hallucinations;
                                              paralysis, paresis
                                              (focal weakness);
                                              abnormal movements;
                                              vertigo; unsteady gait/
                                              balance; slurred
                                              speech, unable to
                                              speak.
37................  Pain, acute and severe   Patient needs            BLS                 ......................
                     not otherwise            specialized handling
                     specified in this list.  to be moved: pain
                                              exacerbated by
                                              movement.
38................  Pain, severe not         Acute onset, unable to   BLS                 Pain is the reason for
                     otherwise specified in   ambulate or sit.                             the transport.
                     this list.
39................  .......................  Pain, severe not         ALS                 Use severity scale (7-
                                              otherwise specified in                       10 for severe pain),
                                              this list.                                   pt. receiving pre-
                                                                                           hospital
                                                                                           pharmacologic
                                                                                           intervention.

[[Page 55098]]

 
40................  Back pain--non-          Suspect cardiac or       ALS                 Other emergency
                     traumatic (T and/or      vascular etiology.                           conditions, absence
                     LS).                                                                  of or decreased leg
                                                                                           pulses, pulsatile
                                                                                           abdominal mass,
                                                                                           severe tearing
                                                                                           abdominal pain.
41................  Back pain--non-          New neurologic symptoms  ALS                 Neurologic distress
                     traumatic (T and/or                                                   list.
                     LS).
42................  Poisons, ingested,       Adverse drug reaction,   ALS                 ......................
                     injected, inhaled,       poison exposure by
                     absorbed.                inhalation, injection
                                              or absorption.
43................  Alcohol intoxication,    Unable to care for       BLS.
                     drug overdose            self; unable to
                     (suspected).             ambulate; no risk to
                                              airway; no other
                                              symptoms.
44................  Alcohol intoxication,    All others, including    ALS.
                     drug overdose            airway at risk,
                     (suspected).             pharmacological
                                              intervention, cardiac
                                              monitoring.
45................  Post--operative          Major wound dehiscence,  BLS                 Orthopedic appliance;
                     procedure                evisceration, or                             prolapse.
                     complications.           requires special
                                              handling for transport.
46................  Pregnancy complication/  .......................  ALS                 ......................
                     Childbirth/Labor.
47................  Psychiatric/Behavioral.  Abnormal mental status;  ALS                 Suicidal, homicidal,
                                              drug withdrawal.                             hallucinations,
                                                                                           violent, Disoriented,
                                                                                           DT's, withdrawal
                                                                                           symptoms, transport
                                                                                           required by state law/
                                                                                           court order.
48................  Psychiatric/Behavioral.  Threat to self or        BLS                 ......................
                                              others, severe
                                              anxiety, acute episode
                                              or exacerbation of
                                              paranoia, or
                                              disruptive behavior.
49................  Sick Person............  Fever with associated    ALS                 ......................
                                              symptoms (headache,
                                              stiff neck, etc.).
50................  Sick Person............  Fever without            BLS                 >102 in adults; >104
                                              associated symptoms.                         in children.
51................  Sick Person............  No other symptoms......  BLS                 With other emergency
                                                                                           conditions
52................  Sick Person............  Nausea and vomiting,     ALS                 ......................
                                              diarrhea, severe and
                                              incapacitating.
53................  Unconscious, Fainting,   Transient unconscious    ALS                 ......................
                     Syncope.                 episode or found
                                              unconscious.
54................  Near syncope, weakness   Acute episode or         ALS                 ......................
                     or dizziness.            exacerbation.
55................  Medical/Legal..........  State or local           BLS                 Minor with no
                                              ordinance requires                           guardian; DWI arrest
                                              ambulance transport                          at MVA for
                                              under certain                                evaluation; arrests
                                              conditions.                                  and medical
                                                                                           conditions (psych,
                                                                                           drug OD).
----------------------------------------------------------------------------------------------------------------
                                          Emergency Conditions--Trauma
----------------------------------------------------------------------------------------------------------------
56................  Major trauma...........  As defined by ACS Field  ALS                 Trauma with one of the
                                              Triage Decision Scheme.                      following: Glascow
                                                                                           14; systolic BP90;
                                                                                           RR10 or >29; all
                                                                                           penetrating injuries
                                                                                           to head, neck, torso,
                                                                                           extremities proximal
                                                                                           to elbow or knee;
                                                                                           flail chest;
                                                                                           combination of trauma
                                                                                           and burns; pelvic
                                                                                           fracture; 2 or more
                                                                                           long bone fractures;
                                                                                           open or depressed
                                                                                           skull fracture;
                                                                                           paralysis; severe
                                                                                           mechanism of injury
                                                                                           including: ejection,
                                                                                           death of another
                                                                                           passenger in same
                                                                                           patient compartment,
                                                                                           falls >20'', 20''
                                                                                           deformity in vehicle
                                                                                           or 12'' deformity of
                                                                                           patient compartment,
                                                                                           auto pedestrian/bike,
                                                                                           pedestrian thrown/run
                                                                                           over, motorcycle
                                                                                           accident at speeds
                                                                                           >20 mph and rider
                                                                                           separated from
                                                                                           vehicle.
57................  Other trauma...........  Need to monitor or       ALS                 Decreased LOC,
                                              maintain airway.                             bleeding into airway,
                                                                                           trauma to head, face
                                                                                           or neck.
58................  Other trauma...........  Major bleeding.........  ALS                 Uncontrolled or
                                                                                           significant bleeding.
59................  Other trauma...........  Suspected fracture/      BLS                 Spinal, long bones,
                                              dislocation requiring                        and joints including
                                              splinting/                                   shoulder elbow,
                                              immobilization for                           wrist, hip, knee, and
                                              transport.                                   ankle, deformity of
                                                                                           bone or joint.
60................  Other trauma...........  Penetrating extremity    BLS                 Isolated with bleeding
                                              injuries.                                    stopped and good CSM.
61................  Other trauma...........  Amputation--digits.....  BLS                 ......................

[[Page 55099]]

 
62................  Other trauma...........  Amputation--all other..  ALS                 ......................
63................  Other trauma...........  Suspected internal,      ALS                 Signs of closed head
                                              head, chest, or                              injury, open head
                                              abdominal injuries.                          injury, pneumothorax,
                                                                                           hemothorax, abdominal
                                                                                           bruising, positive
                                                                                           abdominal signs on
                                                                                           exam, internal
                                                                                           bleeding criteria,
                                                                                           evisceration.
64................  Other trauma...........  Severe pain requiring    ALS                 See severity scale.
                                              pharmacologic pain
                                              control.
65................  Other trauma...........  Trauma NOS: it is up to  BLS                 Ambulance required
                                              the provider to                              because injury is
                                              furnish sufficient                           associated with other
                                              documentation to                             emergency conditions
                                              support this claim.                          or other reasons for
                                                                                           transport exist such
                                                                                           as special patient
                                                                                           handling or patient
                                                                                           safety issues.
66................  Burns..................  Major--per ABA.........  ALS                 Partial thickness
                                                                                           burns > 10% TBSA;
                                                                                           involvement of face,
                                                                                           hands, feet,
                                                                                           genitalia, perineum,
                                                                                           or major joints;
                                                                                           third degree burns;
                                                                                           electrical; chemical;
                                                                                           inhalation; burns
                                                                                           with preexisting
                                                                                           medical disorders;
                                                                                           burns and trauma;
67................  Burns..................  Minor--per ABA.........  BLS                 Other burns than
                                                                                           listed above.
68................  Lightning..............  .......................  ALS                 ......................
69................  Electrocution..........  .......................  ALS                 ......................
70................  Near Drowning..........  .......................  ALS                 ......................
71................  Eye injuries...........  Acute vision loss or     BLS
                                              blurring, severe pain
                                              or chemical exposure,
                                              penetrating, severe
                                              lid lacerations.
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
                    Reason for transport       Reason for transport
       #                 (general)                  (specific)            Svc. Lev.             Comments
----------------------------------------------------------------------------------------------------------------
                                                  Non-Emergency
----------------------------------------------------------------------------------------------------------------
72.............  Bed confined (at the time  *Unable to get up without  BLS              Patient is going to a
                  of transport).             assistance; and.                            medical procedure,
                                            *Unable to ambulate; and.                    treatment, testing, or
                                            *Unable to sit in a chair                    evaluation that is
                                             or wheelchair.                              medically necessary.
73.............  ALS monitoring, required.  Cardiac/hemodynamic        ALS              Expectation monitoring
                                             monitoring required en                      is needed before and
                                             route.                                      after transport.
74.............  ALS monitoring, required.  Advanced airway            ALS              Ventilator dependent,
                                             management.                                 apnea monitor, possible
                                                                                         intubation needed, deep
                                                                                         suctioning.
75.............  ALS monitoring, required.  IV meds required en route  ALS              Does not apply to self-
                                                                                         administered IV
                                                                                         medications.
76.............  ALS monitoring, required.  Chemical restraint.......  ALS              ........................
77.............  BLS monitoring required..  Suctioning required en     BLS              Per transfer
                                             route.                                      instructions.
78.............  BLS monitoring required..  Airway control/            BLS              Per transfer
                                             positioning required en                     instructions.
                                             route.
79.............  BLS monitoring required..  Third party assistance/    BLS              Does not apply to
                                             attendant required to                       patient capable of self-
                                             apply, administer, or                       administration of
                                             regulate or adjust                          portable or home O2.
                                             oxygen en route.                            Patient must require
                                                                                         oxygen therapy and be
                                                                                         so frail as to require
                                                                                         assistance.
80.............  Specialty care monitoring  A level of service         SCT              ........................
                                             provided to a critically
                                             injured or ill patient
                                             beyond the scope of the
                                             national paramedic
                                             curriculum.


----------------------------------------------------------------------------------------------------------------
 
----------------------------------------------------------------------------------------------------------------
81.......  Medical           Patient Safety: Danger to   In restraints.............  BLS        Refer to
            conditions that   self or others.                                                    definition in
            contraindicate                                                                       the CFR--sec.
            transport by                                                                         482.13(e).
            other means.
82.......  Medical           Patient safety: Danger to   Monitoring................  BLS        Behavioral or
            conditions that   self or others.                                                    cognitive risk
            contraindicate                                                                       such that
            transport by                                                                         patient
            other means.                                                                         requires
                                                                                                 monitoring for
                                                                                                 safety.

[[Page 55100]]

 
83.......  Medical           Patient safety: Danger to   Seclusion (Flight risk)...  BLS        Behavioral or
            conditions that   self or others.                                                    cognitive risk
            contraindicate                                                                       such that
            transport by                                                                         patient
            other means.                                                                         requires
                                                                                                 attendant to
                                                                                                 assure patient
                                                                                                 does not try to
                                                                                                 exit the
                                                                                                 ambulance
                                                                                                 prematurely.
                                                                                                 CFR sec.
                                                                                                 482.13(f)(2)
                                                                                                 for definition.
84.......  Medical           Patient safety              Risk of falling off wheel   BLS        Patient's
            conditions that                               chair or stretcher while               physical
            contraindicate                                in motion.                             condition is
            transport by                                                                         such that
            other means.                                                                         patient risks
                                                                                                 injury during
                                                                                                 vehicle
                                                                                                 movement
                                                                                                 despite
                                                                                                 restraints.
                                                                                                 Indirect
                                                                                                 indicators
                                                                                                 include MDS
                                                                                                 criteria.
85.......  Medical           Special handling en route.  Isolation.................  BLS        Includes
            conditions that                                                                      patients with
            contraindicate                                                                       communicable
            transport by                                                                         diseases or
            other means.                                                                         hazardous
                                                                                                 material
                                                                                                 exposure who
                                                                                                 must be
                                                                                                 isolated from
                                                                                                 public or whose
                                                                                                 medical
                                                                                                 condition must
                                                                                                 be protected
                                                                                                 from public
                                                                                                 exposure;
                                                                                                 surgical
                                                                                                 drainage
                                                                                                 complications.
86.......  Medical           Special handling en route.  Patient Size..............  BLS        Morbid obesity
            conditions that                                                                      which requires
            contraindicate                                                                       additional
            transport by                                                                         personnel or
            other means.                                                                         equipment to
                                                                                                 transfer.
87.......  Medical           Special handling en route.  Orthopedic device.........  BLS        Backboard,
            conditions that                                                                      halotraction,
            contraindicate                                                                       use of pins and
            transport by                                                                         traction, etc.
            other means.
88.......  Medical           Special handling en route.  1 person for physical       BLS        ................
            conditions that                               assistance in transfers.
            contraindicate
            transport by
            other means.
89.......  Medical           Special handling en route.  Severe pain...............  BLS        Pain must be
            conditions that                                                                      aggravated by
            contraindicate                                                                       transfers or
            transport by                                                                         moving vehicle
            other means.                                                                         such that
                                                                                                 trained
                                                                                                 expertise of
                                                                                                 EMT required
                                                                                                 (pain scale).
                                                                                                 Pain is
                                                                                                 present, but is
                                                                                                 not sole reason
                                                                                                 for transport.
90.......  Medical           Special handling en route.  Positioning requires        BLS        Requires special
            conditions that                               specialized handling.                  handling to
            contraindicate                                                                       avoid further
            transport by                                                                         injury (such as
            other means.                                                                         with >grade 2
                                                                                                 decubiti on
                                                                                                 buttocks).
                                                                                                 Generally does
                                                                                                 not apply to
                                                                                                 shorter
                                                                                                 transfers of 1
                                                                                                 hour.
                                                                                                Positioning in
                                                                                                 wheelchair or
                                                                                                 standard car
                                                                                                 seat
                                                                                                 inappropriate
                                                                                                 due to
                                                                                                 contractures or
                                                                                                 recent
                                                                                                 extremity
                                                                                                 fractures--post-
                                                                                                 op hip as an
                                                                                                 example.
----------------------------------------------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
                                        Reason for
       #            Reason for           transfer                     Ser. Lev.                    Comments
                transfer (general)      (specific)
----------------------------------------------------------------------------------------------------------------
                                                 Inter-facility
----------------------------------------------------------------------------------------------------------------
91............  EMTALA-certified    Physician has made  BLS, ALS, SCT, FW, RW...............  Excludes patient-
                 inter-facility      the determination                                         requested EMTALA
                 transfer to a       that this                                                 transfer.
                 higher level of     transfer is
                 care.               needed--Carrier
                                     only needs to
                                     know the level of
                                     care and mode of
                                     transport.
92............  Service not         ..................  BLS, ALS, SCT, FW, RW...............  Specify what
                 available at                                                                  service is not
                 originating                                                                   available.
                 facility, and
                 must meet one or
                 more emergency or
                 non-emergency
                 conditions.
93............  Service not         Indicates to
                 covered.            Carrier that
                                     claim should be
                                     automatically
                                     denied.
----------------------------------------------------------------------------------------------------------------

[FR Doc. 00-23195 Filed 9-11-00; 8:45 am]
BILLING CODE 4120-01-P