Part B service-specific review - ambulance services (HCPCS code A0428 with A0425)

On August 17, 2020, medical review activity resumed, as directed by CMS, with implementation of post-payment service-specific medical record review.

First Coast is tasked with preventing inappropriate Medicare payments. One of the ways this is conducted is through medical review of claims. This helps to ensure that Medicare pays for services that are covered, coded correctly, and medically reasonable and necessary. 

High level results and top denial / partial denial reasons are listed below for the post-payment service specific reviews for ambulance service (HCPCS codes A0428 and A0425) that have been conducted by First Coast. If you have questions about your individual results, please contact the nurse reviewer assigned to your review for additional information. 

Ambulance services (October 2020) 

Top full / partial denial reasons

The most common reasons for denial or partial denials are the following:

• Level of care / incorrect coding – N/A
• Medical necessity – Documentation did not support medical necessity of transport. Documentation did not provide details on why patients were unable to go safely by other means.
  • Patient could have been safely transported by some other means.
  • Documentation did not contain a detailed description of the patient’s condition at the time of transport.
• Insufficient documentation – N/A
• Billing errors – N/A