Dissecting “The Misunderstoods”- Part I- Billing for ALS 2

Bloggers note- early last year we posted a popular 2-part series talking about a subject we affectionately called “The Misunderstoods.” Because we periodically field questions about these two levels of service and the complexity of documenting properly to obtain maximum reimbursement, we’re offering up the series again for those of you who may not have viewed it the first time around.

“The Misunderstoods”

There are two level of service categories that we lump into a bucket called “The Misunderstoods” of ambulance billing. Those billing levels are the Advanced Life Support, Level 2 (ALS 2) and the Specialty Care Transport (SCT).

There remains a cloud of uncertainty in our industry about how to properly document and apply the billing rules in order to collect the reimbursement that is due for these unique scenarios.

Dissecting “The Misunderstoods”- Part I- Billing for ALS 2

Today is Part One of a two-part series. This week we will tackle the ALS 2 scenario. Next week’s blog post will focus on proper application and billing for the SCT.

ALS 2 Defined

According to the Medicare Benefit Policy Manual, Chapter 10 – Ambulance Services, an ALS2 scenario is transportation by ground ambulance of a patient with the provision of either…

  • At least three separate administrations of one or more medications by IV push/bolus or by continuous infusion (excluding crystalloid fluids)


  • The provision of at least one of the ALS 2 procedures listed below:

· Manual defibrillation/cardioversion
· Endotracheal intubation
· Central venus line
· Cardiac pacing
· Chest decompression
· Surgical airway
· Intraosseous line

Medication Confusion

Seemingly, what confuses both providers and billing office personnel is the medication infusion provision.

First off, let’s be clear to explain that the medication portion only applies when medications are infused via IV push/bolus or continuous infusion. Crystalloid fluids are excluded from this provision. Our billing office is continually questioned as to the medications being three of the same medication or three different medications. The answer is…it can be either one.

However, the medications must be administered in single dosages. A single dose of medication administered fractionally on three separate occasions does not qualify for ALS 2 payment application. The Benefit Policy Manual explains;

“The fractional administration of a single dose…on three separate occasions does not qualify for ALS 2 payment.”

The manual goes on to explain that the administration of 1/3 of a qualifying dose 3 times does not equate to three qualifying doses.

ALS providers must be clear when documenting the dosages administered. Documentation in the Patient Care Report should clearly indicate the amount of the medication and how the medication was infused. Any ambiguity in documentation could negate the billing office’s ability to bill the claim and collect the proper level of reimbursement dollars at the ALS 2 level.

Previously Initiated

Another misunderstood portion of billing for ALS 2 arises from who initiated the infusion or the procedure.

Let’s say, for example, that your EMS agency is contacted to transport a patient from Hospital A to Hospital B for services not available at Hospital A. You arrive to find that your patient has an endotracheal tube in place.

Following the transport, the billing office is stressing over whether or not they can bill at the ALS 2 level because the ET tube was already in place and the procedure was not completed by one of your EMS Agency’s providers.

What healthcare provider initiated the ET tube is not a factor for billing. The monitoring and maintenance of the ET tube that was inserted prior to the involvement of your EMS Agency allows your billing office to bill at the ALS 2 level.

Of course, your EMS Agency providers that are part of this ambulance transport must paint a clear picture of the treatment and transport scenario accurately and truthfully describing all events surrounding the transport at all points….upon pick-up of the patient, during and throughout transport and then finally, upon arrival at the destination facility.

Providers must be careful to be specific about documenting the details of the monitoring activity that takes place once inside of the ambulance, as well.

Not all payers

We end this discussion with a caution. While Medicare definitely pays a higher reimbursement amount for the ALS2 level of service, not all payers do. Many States’ Medicaid programs do not pay additional nor do some even accept the A0433 HCPCS Procedure Code.

Your billing office must be aware of what HCPCS procedure codes will be accepted and rejected prior to submitting a claim for payment.

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