Dual Diagnoses Required for Ambulance Transports

Per Novitas:

Effective with services rendered October 1, 2015, and later, ALL ambulance transports require dual diagnoses.  Providers should report the primary diagnosis as the most appropriate ICD-10 code that adequately describes the patient’s medical condition at the time of transport.  In addition, a secondary diagnosis must be reported which reflects the patient’s need for the ambulance service and ambulance personnel at the time of transport.  In order for claims to be processed and paid in a timely manner, it is important that claims submitted for ambulance services contain both the primary and secondary diagnosis.

Please refer to the Ambulance Local Coverage Article A54574 for a list of “suggested” ICD-10 codes that may be reported as a primary diagnosis. Please note that the list of diagnosis codes provided in A54574 is not an all-inclusive list. Other valid ICD-10 diagnoses codes that accurately describe the patient’s condition at the time of transport may be reported as a primary diagnosis.  Please refer to the Ambulance Local Coverage Determination (LCD) Policy L35162 for a list of four covered secondary diagnosis codes (Z codes).  The secondary diagnosis code should reflect why the transport is reasonable and necessary.  If the transport is not reasonable and necessary, the LCD provides a non-covered Z code.

Claims that do not report a primary diagnosis that describes the patient’s medical condition at the time of transport AND a covered secondary diagnosis that reflects the patient’s need for the ambulance service and ambulance personnel at the time of transport MAY be denied.

To correct any initial submissions, you may request a reopening of the claim. When conducting a reopening request, include a revised copy of the claim highlighting the service in question and include the appropriate primary and secondary ICD-10 code.

Claim corrections can also be submitted electronically via Novitasphere.  Please visit the Novitas Solutionswebsite and sign up for Novitasphere.  Novitasphere is a secured web-based Internet Portal for the Medicare Fee-for-Service Part B community to utilize as a more proficient interface with Novitas and the Medicare systems.  For example, Novitasphere allows customers to connect via the internet directly to Novitas Solutions to obtain beneficiary eligibility, perform claim corrections, check claim status, and submit claims as well as to retrieve and print remittance advices.  Additional information about Novitasphere and all of the features it offers is available on our website.

Any questions regarding ambulance services can be addressed by calling Novitas Solutions at the following phone numbers:

We will be hosting several webinars on the following dates.  Please join us to discuss this important topic.

Date Time Register
July 22, 2016 1-2 pm ET, 12-1 pm CT Click to Register
July 27, 2016 10-11 am ET, 9-10 pm CT Click to Register
August 4, 2016 2-3 pm ET, 1-2 pm CT Click to Register
August 10, 2016 11-12 am ET, 10-11 am CT Click to Register
September 1, 2016 2-3 pm ET, 1-2 pm CT Click to Register
September 8, 2016 11-12 am ET, 10-11 am CT Click to Register