Medical Condition List and Appropriate Use
of Air Medical Transport
Position Statement of the Air Medical Physician Association
Approved by the AMPA Board of Trustees April 2002
BACKGROUND
The Balanced Budget Act of 1997 initiated a process to
convert all Medicare ambulance transport billing (including
air) to a fee structure. Previous to this, ambulance reimbursement was done for the private ambulance industry under a
fee structure reimbursement (commonly known as part B)
and, for hospital-based ambulance service, under cost-based
reimbursement (commonly known as Part A).
The new fee structure was developed in a process called
Negotiated Rule Making (NRM). The NRM process established relative value units for each type of transport, rural
modifiers, cost of living adjusters, and a phase-in schedule.
As part of the NRM process, the Medical Conditions Work
Group developed the Medical Condition List. This condition
list was developed to simplify the issue of medical necessity
for each level of transport and to reduce the importance of
ICD-9 codes to describe prehospital impressions. The Medical Condition List was developed because ICD-9 codes are
not designed to describe prehospital medical conditions. The
standardization of medical necessity for different types of
conditions created by the Medical Condition List will allow
medical necessity to be aligned with appropriate utilization
and will improve efficiency and simplify the billing and reimbursement process.
The Medical Condition List was under consideration for
possible inclusion in the final rule but was not included in
the final rule published February 27, 2002. A commitment to
develop the medical condition codes over the next 12
months was promised by the Center for Medicare and Medicaid Services (CMS) (formerly HCFA).
AMPA POSITION STATEMENT
AMPA supports the addition and adoption of the of the
Medical Condition List as submitted by the Medical Conditions Work Group as a rational method of determining medically appropriate utilization of medical transport.
Furthermore, it is AMPAs position, as detailed in the Medical Condition List, that the determination of medical appropriateness for interfacility medical transport is determined by
a physician, as documented on a written Certification of
Medical Necessity. Medical appropriateness of scene medical
transport is determined by the requesting authorized prehospital provider, based on regional policy and their best medical judgment at the time of the request for transport.
Further, AMPA supports that the Certificate of Medical Ne14
cessity for scene transport can be completed by the EMS control physician, receiving physician, or by the medical director of
the transport program. AMPA supports that consultation with
the transport provider medical direction is the optimal method
of determining the appropriate mode of safe patient transport
AMPA does not support the use of discharge ICD-9 codes
to retrospectively determine medical appropriateness, as this
may adversely restrict access to appropriate care and negates
the regional, environmental, and situational factors that are
also important in determining medical appropriateness.
AMPA does not support a specification of a time needed for
land transport as a general guideline. AMPA feels that, when a
time specification is made, it should be done regionally.
Air Medical Transport Guidelines
Detailed as appropriate by the Medical Condition List
AMPA supports the NRM work group recommendation
to replace the list of conditions in section 2120.4 B (Medical Appropriateness) with:
Acute neurological emergencies requiring emergent/time
sensitive interventions not available at the sending facility
Acute vascular emergencies requiring urgent/time sensitive interventions not available at sending facilities
Acute surgical emergencies requiring urgent/time sensitive
interventions not available at the sending facility
Critically ill patients with compromised hemodynamic/
respiratory function who require intensive care during
transport and whose time of transfer between critical care
units must be minimized during transport
Critically ill obstetric patients who require intensive care
during transport and whose time of transfer between facilities must be minimized to prevent patient/fetal morbidity
Acute cardiac emergencies requiring emergent/time-sensitive intervention not available at sending facility
Critically ill neonatal/pediatric patients with potentially
compromised hemodynamic/respiratory function, a metabolic acidosis greater than 2 hours postdelivery, sepsis, or
meningitis
Patients with electrolyte disturbances and toxic exposure
requiring immediate life-saving intervention
Transplantation patients (fixed wing vs. helicopter)
Patients requiring care in a specialty center not available
at the sending facility
Conditions requiring treatment in a hyperbaric oxygen
unit
Air Medical Journal 22:3
Burns requiring treatment in a burn treatment center
Potentially life- or limb-threatening trauma requiring
treatment at a trauma center, including penetrating eye
injuries
EMTALA physician-certified interfacility transfer (not a
patient request)
EMS regional or state-approved protocol identifies need
for on-scene air transport
doi:10.1067/mmj.2003.46
MEDICAL CONDITION LIST
When using this chart, use all codes that apply.
On-scene Condition
No.
(general)
On-scene Condition
(specific)
Service
Level
Comments and Examples
(not all-inclusive)
Emergency ConditionsNontraumatic
1 Abdominal pain
With other signs or symptoms
ALS
2 Abdominal pain
3 Abnormal cardiac
rhythm/Cardiac
dysrhythmia
4 Abnormal skin signs
5 Abnormal vital signs
(includes abnormal
pulse oximetry)
6 Abnormal vital signs
(includes abnormal
pulse oximetry)
7 Allergic reaction
Without other signs or symptoms
Potentially life-threatening
BLS
ALS
With symptoms
ALS
ALS
Without symptoms
BLS
Potentially life-threatening
ALS
8 Allergic reaction
9 Animal bites/sting/
envenomation
10 Animal bites/sting/
envenomation
11 Sexual assault
12 Sexual assault
13 Blood glucose
Other
Potentially life- or limb-threatening
BLS
ALS
Other
BLS
With injuries
With no injuries
Abnormal < 80 or > 250, with
symptoms
ALS
BLS
ALS
14 Respiratory arrest
ALS
15 Difficulty breathing
16 Cardiac arrest, resuscitation in progress
17 Chest pain (nontraumatic)
ALS
ALS
18
19
20
21
ALS
ALS
BLS
ALS
Choking episode
Cold exposure
Potentially life- or limb-threatening
Cold exposure
With symptoms
Altered level of consciousness (nontraumatic)
22 Convulsions/seizures
Seizing, immediate post-seizure,
post-ictal, or at risk of seizure
and requires medical monitoring/
observation
ALS
Nausea, vomiting, fainting, pulsatile mass, distention, rigid,
tenderness on exam, guarding
Bradycardia, junctional and ventricular blocks, nonsinus
tachycardias, PVCs > 6, bi and trigeminy, vtach,vfib, atrial
flutter, PEA, asystole
Diaphorhesis, cyanosis, delayed cap refill, poor turgor, mottled
Other emergency conditions
Other emergency conditions, rapid progression of symptoms,
prior hx of anaphylaxis, wheezing, difficulty swallowing
Hives, itching, rash, slow onset, local swelling, redness, erythema
Symptoms of specific envenomation, significant face, neck,
trunk, and extremity involvement; other emergency conditions
Local pain and swelling, special handling considerations and patient monitoring required
Altered mental status, vomiting, signs of dehydration, etc.
Apnea, hypoventilation requiring ventilatory assistance and
airway management
Dull, severe, crushing, substernal, epigastric, left-sided chest pain
associated with pain of the jaw, left arm, neck, back, and nausea, vomiting, palpitations, pallor, diaphoresis, decreased LOC
Temperature < 95 F,deep frostbite, other emergency conditions
Shivering, superficial frostbite, other emergency conditions
Acute condition with Glascow Coma Scale < 15
ALS
continues on next page
May-June 2003
15
Medical Condition List continued
On-scene Condition
No.
(general)
On-scene Condition
(specific)
Service
Level
Comments and Examples
(not all-inclusive)
Emergency ConditionsNontraumatic
23 Eye symptoms,
nontraumatic
24 Nontraumatic headache
25 Nontraumatic headache
26 Cardiac symptoms other
than chest pain
27 Cardiac symptoms
other than chest pain
28 Heat exposure
Acute vision loss and/or severe pain
BLS
With neurologic distress conditions
Without neurologic symptoms
Palpitations, skipped beats
ALS
BLS
ALS
Atypical pain or other symptoms
ALS
Potentially life-threatening
ALS
29 Heat exposure
30 Hemorrhage
With symptoms
Severe (quantity)
BLS
ALS
31 Hemorrhage
Potentially life-threatening
ALS
32 Infectious diseases
requiring isolation
procedures/public
health risk
33 Hazmat exposure
ALS
34 Medical device failure
ALS
35
36
BLS
ALS
37
38
39
40
41
42
43
16
Life- or limb-threatening malfunction, failure, or complication
Medical device failure
Health maintenance device failures
Neurologic distress
Facial drooping; loss of vision;
aphasia; difficulty swallowing;
numbness, tingling extremity;
stupor, delirium, confusion, hallucinations; paralysis, paresis (focal
weakness); abnormal movements;
vertigo; unsteady gait/balance;
slurred speech, unable to speak
Pain, acute and severe
Patient needs specialized handling
not otherwise specified to be moved: pain exacerbated
in this list
by movement
Pain, severe not otherAcute onset, unable to ambulate
wise specified in
or sit
this list
Pain, severe not otherwise specified in
this list
Back painnontrauSuspect cardiac or vascular etiology
matic (T and/or LS)
Back painnonNew neurologic symptoms
traumatic (T and/or LS)
Poisonsingested,
Adverse drug reaction,
injected, inhaled,
exposure by inhalation,
absorbed
poison injection or absorption
Alcohol intoxication,
Unable to care for self, unable to
drug overdose
ambulate, no risk to airway,
Persistent nausea and vomiting, weakness, hiccups, pleuritic pain,
feeling of impending doom, and other emergency conditions
Hot and dry skin, Temp > 105, neurologic distress, signs of heat
stroke or heat exhaustion, orthostatic vitals, other emergency conditions
Muscle cramps, perfuse sweating, fatigue
Uncontrolled or significant signs of shock, other emergency conditions
Active vaginal, rectal bleeding, hematemesis, hemoptysis, epistaxis,
active postsurgical bleeding
BLS
Toxic fume or liquid exposure via inhalation, absorption, oral, radiation, smoke inhalation
Malfunction of ventilator, internal pacemaker, internal defibrillator,
implanted drug delivery device
O2 supply malfunction, orthopedic device failure
BLS
BLS
Pain is the reason for the transport
ALS
Use severity scale (7-10 for severe pain), pt. receiving
prehospital pharmacologic intervention
ALS
Other emergency conditions, absence of or decreased leg pulses,
pulsatile abdominal mass, severe tearing abdominal pain
Neurologic distress list
ALS
ALS
BLS
Air Medical Journal 22:3
Medical Condition List continued
On-scene Condition
No.
(general)
On-scene Condition
(specific)
Service
Level
Comments and Examples
(not all-inclusive)
Emergency ConditionsNontraumatic
(suspected)
44 Alcohol intoxication,
drug overdose
(suspected)
45 Postoperative procedure complications
no other symptoms
All others, including airway at
risk, pharmacologic intervention, cardiac monitoring
Major wound dehiscence,
evisceration, or requires special
handling for transport
46 Pregnancy complication/
childbirth/labor
47 Psychiatric/behavioral
Abnormal mental status; drug
withdrawal
48 Psychiatric/behavioral
Threat to self or others, severe
anxiety, acute episode or exacerbation of paranoia, or disruptive behavior
49 Sick person
Fever with associated symptoms
(headache, stiff neck, etc.)
50 Sick Person
Fever without associated symptoms
51 Sick person
No other symptoms
52 Sick person
Nausea and vomiting, diarrhea,
severe and incapacitating
53 Unconscious, fainting,
Transient unconscious episode or
syncope
found unconscious
54 Near syncope, weakness Acute episode or exacerbation
or dizziness
55 Medical/legal
State or local ordinance requires
ambulance transport under certain
conditions
ALS
BLS
Orthopedic appliance; prolapse
ALS
ALS
,
BLS
Suicidal, homicidal, hallucinations, violent, disoriented, DTs
withdrawal symptoms, transport required by state law/court order
ALS
BLS
BLS
> 102 in adults, > 104 in children
With other emergency conditions
ALS
ALS
ALS
BLS
Minor with no guardian; DWI arrest at MVA for evaluation; arrests
and medical conditions (psych, drug OD)
Emergency ConditionsTrauma
56 Major trauma
As defined by ACS Field Triage
Decision Scheme
ALS
Trauma with one of the following: Glascow < 14; systolic BP
< 90; RR < 10 or > 29; all penetrating injuries to head, neck,
torso, extremities proximal to elbow or knee; flail chest; com
bination of trauma and burns; pelvic fracture; 2 or more long
bone fractures; open or depressed skull fracture; paralysis; se
vere mechanism of injury including: ejection, death of anoth
er passenger in same patient compartment, falls > 20, 20
deformity in vehicle or 12 deformity of patient compart
ment, auto pedestrian/bike, pedestrian thrown/run over, mo
torcycle accident at speeds > 20 mph and rider separated
from vehicle
57 Other trauma
Need to monitor or maintain
airway
ALS
Decreased LOC, bleeding into airway ,trauma to head, face or
neck
58 Other trauma
Major bleeding
ALS
Uncontrolled or significant bleeding
59 Other trauma
Suspected fracture/dislocation
BLS
requiring splinting/immobilization
for transport
Spinal, long bones, and joints including shoulder elbow,
wrist, hip, knee, and ankle, deformity of bone or joint
60 Other trauma
Penetrating extremity injuries
BLS
Isolated with bleeding stopped and good CSM
61 Other trauma
Amputationdigits
BLS
continues on next page
May-June 2003
17
Medical Condition List continued
On-scene Condition
No.
(general)
On-scene Condition
(specific)
Service
Level
Comments and Examples
(not all-inclusive)
Emergency ConditionsTrauma
62 Other trauma
Amputationall other
ALS
63 Other trauma
Suspected internal, head,
chest, or abdominal injuries
ALS
,
Signs of closed head injury, open head injury, pneumothorax
hemothorax, abdominal bruising, positive abdominal signs
on exam, internal bleeding criteria, evisceration
64 Other trauma
Severe pain requiring pharmacologic pain control
ALS
See severity scale
65 Other trauma
Trauma NOS: it is up to the
provider to provide sufficient
documentation to support
this claim
BLS
Ambulance required because injury associated with other
emergency conditions or other reasons for transport exist,
such as special patient handling or patient safety issues
66 Burns
Majorper ABA
ALS
Partial thickness burns > 10% TBSA; involvement of face,
hands, feet, genitalia, perineum, or major joints; third degree
burns; electrical ; chemical; inhalation; burns with preexisting medical disorders; burns and trauma
67 Burns
Minorper ABA
BLS
Other burns than listed above
68 Lightning
ALS
69 Electrocution
ALS
70 Near Drowning
71 Eye injuries
Reason for Transport
No.
(general)
Acute vision loss or blurring,
severe pain or chemical exposure,
penetrating, severe lid lacerations
Reason for Transport
(specific)
ALS
BLS
Service
Level
Comments
Non-emergency
72 Bed confined (at the
time of transport)
73 ALS monitoring,
required
74 ALS monitoring,
required
75 ALS monitoring,
required
76 ALS monitoring,
required
77 BLS monitoring
required
78 BLS monitoring
required
79 BLS monitoring
required
80 Specialty care
monitoring
18
Unable to get up without assistance, BLS
ambulate, or sit in a chair or wheel
chair
Cardiac/hemodynamic monitoring
ALS
en route
Advanced airway management
ALS
IV meds required en route
ALS
Chemical restraint
ALS
Suctioning required en route
Patient is going to a medical procedure, treatment, testing, or
evaluation that is medically necessary
Expectation monitoring is needed before and after transport
Ventilator dependent, apnea monitor, possible intubation
needed, deep suctioning
Does not apply to self-administered IV medications
BLS
Per transfer instructions
Airway control/positioning required BLS
en route
Third party assistance/attendant
BLS
required to apply, administer, or
regulate or adjust oxygen en route
Level of service provided to a critiSCT
cally injured or ill patient beyond
the scope of the national paramedic
curriculum
Per transfer instructions
Does not apply to patient capable of self-administration of
portable or home O2. Patient must require oxygen therapy
and be so frail as to require assistance
Air Medical Journal 22:3
Medical Condition List continued
Reason for Transport
No.
(general)
Reason for Transport
(specific)
Service
Level
Comments
Non-emergency
81 Medical conditions
Patient safety: danger to self or
that contraindicate
others; in restraints
transport by other means
82 Medical conditions that Patient safety: danger to self
contraindicate tranor others; monitoring
sport by other means
83 Medical conditions that Patient safety: danger to self
contraindicate tranor others; seclusion (flight risk)
sport by other means
84 Medical conditions that Patient safety: risk of falling
contraindicate tranoff wheelchair or stretcher while
sport by other means
in motion
85 Medical conditions that
Special handling en route: isolation
contraindicate transport
by other means
86 Medical conditions that
contraindicate transport by other means
87 Medical conditions that
contraindicate transport by other means
88 Medical conditions that
contraindicate transport by other means
89 Medical conditions that
contraindicate transport by other means
90 Medical conditions
that contraindicate
transport by other
means
BLS
Refer to definition in the CFR sec. 482.13(e)
BLS
Behavioral or cognitive risk such that patient requires
monitoring for safety
BLS
Behavioral or cognitive risk such that patient requires
attendant to assure patient does not try to exit the
ambulance prematurely. [CFR sec. 482.13(f)(2) for definition]
Patients physical condition is such that patient risks
injury during vehicle movement despite restraints.
Indirect indicators include MDS criteria
Includes patients with communicable diseases or
hazardous material exposure who must be isolated from
public or whose medical condition must be protected from public
exposure; surgical drainage complications
Morbid obesity that requires additional personnel or equipment
to transfer
BLS
BLS
Special handling en route:
patient size
BLS
Special handling en route: ortho
pedic device
BLS
Backboard, halotraction, use of pins and traction, etc.
Special handling en route: > 1 person BLS
for physical assistance in transfers
Special handling en route: severe
pain
BLS
Special handling en route:
positioning requires specialized
handling
BLS
Pain must be aggravated by transfers or moving vehicle such that
trained expertise of EMT required (pain scale). Pain is present, but
is not sole reason for transport
Requires special handling to avoid further injury (eg, with > grade
2 decubiti on buttocks). Generally does not apply to shorter
transfers < 1 hour; Positioning in wheelchair or standard
car seat inappropriate due to contractures or recent extremity
fractures (postop hip as an example)
Interfacility
91 EMTALA-certified interfacility transfer to a
higher level of care
92 Service not available
at originating facility,
and must meet one
or more emergency
or non-emergency
conditions
93 Service not covered
Physician has made the determination that this transfer is
needed Carrier only needs
to know the level of care and
mode of transport
BLS, ALS,
SCT,
Air
Excludes patient-requested EMTALA transfer
BLS, ALS,
SCT,
Air
Specify what service is not available
Indicates to carrier that claim
should be automatically denied
doi:10.1067/mmj.2003.46
May-June 2003
19
