CAC Medicare Coverage and Medical Necessity for Ambulance Transport Flashcards
6 cards from real CAC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 CAC Medicare Coverage and Medical Necessity for Ambulance Transport flashcards as text
What is the significance of the condition code 'QL' on a Medicare ambulance claim?
Answer: Patient is pronounced dead after ambulance is called
Condition code QL indicates the patient was pronounced dead after the ambulance was en route, which affects how the claim is processed and reimbursed.
Under the Medicare Ambulance Fee Schedule, how many Geographic Service Areas (urban, rural, super-rural) affect the ambulance base rate?
Answer: Three
Medicare's Ambulance Fee Schedule uses three geographic categories — urban, rural, and super-rural — each with different percentage adjustments to the national base rate.
When Medicare is secondary payer (MSP), what must the ambulance biller do before submitting to Medicare?
Answer: Submit to the primary insurer first and include the primary's payment or denial information with the Medicare claim
When Medicare is the secondary payer, the biller must first obtain an explanation of benefits (EOB) from the primary insurer and include it with the Medicare secondary claim.
What is the Medicare coverage requirement for 'treat and release' or 'no transport' ambulance calls?
Answer: Generally not covered; Medicare requires actual transport to a covered destination
Medicare generally does not reimburse treat-and-release calls without transport because coverage requires transport to a Medicare-approved destination.
Which federal program oversees Medicare ambulance supplier enrollment and assigns the National Provider Identifier (NPI)?
Answer: CMS (Centers for Medicare & Medicaid Services)
CMS administers Medicare enrollment for ambulance suppliers through the PECOS system and the NPI is assigned through the National Plan and Provider Enumeration System (NPPES).
What does the Medicare 'look-back' period for medical necessity documentation require for non-emergency ambulance transport?
Answer: Documentation must reflect the patient's condition at the time of transport, typically within 48 hours of the service date
Medicare requires that the medical necessity documentation for non-emergency transport reflect the patient's condition at the time of the transport, not a general historical condition.