Medicare’s 2023 Physician Fee Schedule: Ambulance Provisions

The Centers for Medicare and Medicaid Services (CMS) released its Medicare Physician Fee Schedule (PFS) proposed rule for calendar year (CY) 2023 on July 7. The PFS proposal includes ground ambulance provisions.

Click here to access the proposed rule.

Stakeholder comments are due on September 5, 2022.

The ground ambulance proposals mostly represent “clean-up provisions,” and no major policies have been earmarked in this proposed rule.

The following is a look at TEMSA’s high-level overview of the ground ambulance proposals.

Medical Necessity and Documentation Requirements for Nonemergency, Scheduled Repetitive Ambulance Services

CMS provides a timeline of the program beginning on page 1016.

In the proposal, CMS expressed concern about the payment effect on certain populations, and CMS asked for feedback regarding policy clarifications:

“Inconsistent application of payments for medically necessary, nonemergent, repetitive, scheduled ambulance services has the potential to disproportionately and substantially impact communities of color, underserved communities (including rural communities), and modest- income beneficiaries. Further, these communities may disproportionately suffer from conditions for which nonemergent, repetitive, scheduled ambulance services are necessary, creating access to care issues with corresponding clinical complications. We believe that improving clarity in our regulatory provisions will have positive impacts on the health and well-being of beneficiaries. Therefore, we are proposing and requesting public comment on policy clarifications to ensure beneficiaries receive the care they need.”

CMS is proposing several items:

“Section 410.40 describes the Medicare Part B ambulance benefit, generally. Because medical necessity is a requirement of the statutory requirement at section 1861(s)(7) of the Act, the requirements for coverage are more fully explained in paragraph (e) of § 410.40, starting with general rules covering all Part B ambulance services, and the special rules that only apply to nonemergency, scheduled, repetitive ambulance services are situated in paragraph (e)(2). For the reasons discussed above, we propose to modify existing language in § 410.40(e)(2)(ii) and add additional language to provide needed clarity and ensure consistent application of the nonemergency, scheduled, repetitive ambulance service benefit. We solicit comments on our proposal.

“We propose at § 410.40(e)(2)(ii) to retain the existing language stating that in all cases, the provider or supplier must keep appropriate documentation on file and, upon request, present it to CMS (OMB control number 0938-0969). We are maintaining the language that states that the ambulance service must meet all program coverage criteria including vehicle and staffing requirements. We are also maintaining the language that states that a signed PCS does not alone demonstrate that transportation by ground ambulance was medically necessary. We are clarifying that the PCS, and additional documentation from the beneficiary’s medical record, may be used to support a claim that transportation by ground ambulance is medically necessary. Further, we are clarifying that the PCS and additional documentation must provide detailed explanations, that are consistent with the beneficiary’s current medical condition, that explains the beneficiary’s need for transport by an ambulance, as described at 410.41(a). Finally, we are clarifying that coverage includes observation or other services rendered by qualified ambulance personnel, as described in 410.41(b).”

Ground Ambulance Data Collection

The CY 2022 final rule resulted in three items for the Medicare Ground Ambulance Data Collection System, and it can be found on page 1060::

  • A new data collection period beginning between January 1, 2023, and December 31, 2023, and a new data reporting period beginning between January 1, 2024, and December 31, 2024, for selected ground ambulance organizations in year 3.
  • Aligning the timelines for the application of penalties for not reporting data with our new timelines for data collection and reporting and the data collected will be publicly available beginning in 2024.
  • Revisions to the Medicare Ground Ambulance Data Collection Instrument that include better accounting for labor hours across different categories of personnel and better distinguishing between accrual and cost basis accounting methodologies.

2023 Proposal

Proposes changes and clarifications to the Medicare Ground Ambulance Data Collection Instrument, and these can be categorized in four different categories:

  • Editorial changes for clarity and consistency.
  • Updates to reflect the web-based system.
  • Clarifications responding to feedback from questions from interested parties and testing.
  • Typos and Technical Corrections.

A draft of the updated instrument can be found here.