User Guide for the Cost Data Collection Instrument

First page Table of contents 1 Next page Last page

Animated publication

COST DATA COLLECTION

Medicare Ground Ambulance Data Collection System A User Guide for the Data Collection Instrument An Educational Resource from Cornerstone Adminisystems Inc.

Medicare Ground Ambulance Data Collection System A User Guide for the Data Collection Instrument

The ground ambulance cost data collection system obligates you to collect and report on a wide variety of data. Between 2020 and 2024 every ground ambulance service will be required to participate. Failure to comply will result in a 10% reduction to Medicare payments for a calendar year following the date which CMS determines your agency failed to report.

A System to Capture Data

In order to report data correctly, the data must be tracked according to the definitions and rules laid out by CMS. This means assessing your current accounting and data management practices and identifying the extent to which they do or do not enable you to track the data as required. As we work through the various data points in this guide, we need to remember that there are a wide range of EMS agency types. Some are nonaffiliated, some fire-based, others hospital-based, some exclusively provide non-emergency services, and so on. Considering this, CMS will provide an online survey-type tool called the data collection instrument for the actual reporting component of the program. As of this publication, the final version of this tool is not yet live, but CMS has provided a PDF version, which is what we used to create this guide. Importantly, the instrument uses skip logic, which means the selections you make in the early part of the survey dictate what questions you will see later in the process. In other words, not every data element we cover in this presentation will apply to your agency. With this in mind, we recommend you apply the following questions as you review the material:

 Does this data element apply to my agency?  If so, is it currently being tracked?  If yes, am I tracking it in a way that conforms to the program?  If not, what do I need to do to track it in the required way?

The Basics of the Program

1. CMS will send notification via mail/email to the correspondence address listed in your PECOS record and associated with your NPI, addressed to the Authorized Official on file. 2. You have 30 days to respond, indicating if you will collect data according to calendar year or fiscal year. Failure to respond automatically enrolls you in the calendar year option. 3. Once the collection period commences, you will need to track the data points relevant to your agency, in a way that enables you to then report those data points in the manner dictated by CMS. 4. Once your collection year is complete, a period will commence in which your agency will have up to 5 months to report. To do this, CMS will provide an online survey-type tool. 5. If an agency fails to report within the 5-month reporting period, or if the data provided is deemed insufficient, CMS will take no longer than 3 months after the close of the reporting period to decide if the 10% penalty is warranted. This penalty would be assessed on Medicare payments for DOS in the calendar year that follows the decision to impose the penalty.

Page | 2

How to Use This Document

For many, the instrument provided by CMS is hard to decipher. So, we have simplified the information it contains to make it easier to understand. As you read through, you will see we have organized things according to the same methodology deployed by CMS:

 Organizational Characteristics

 Facilities Costs  Vehicle Costs  Other Costs  Total Cost  Revenues

 Service Area

 Emergency Response Time

 Equipment, Consumables & Supplies

 Ground Ambulance Service Volume

 Service Mix  Labor Costs

As stated earlier, not all items will apply to your agency. For instance, if you are a career only, nonaffiliated ambulance service, then any item that pertains to cost allocations between shared services (with say, a fire department), or labor costs related to volunteers, would not apply. Likewise, there are agencies that are part of a parent organization that uses multiple NPIs to bill Medicare for ground ambulance services. In such cases, those agencies would need to track and allocate the portion of costs and revenues incurred at the level of the parent organization (also referred to as the central office) based on their existing organizational approach for allocating costs to specific NPIs. We have included reminders of this throughout the document (often in relation to tables), yet these reminders would only be relevant to those specific agencies. And speaking of tables, we have added them where applicable to translate the instrument and visualize what CMS wants to see. This does not mean these tables will be included in the final reporting tool. Rather, everything contained herein is simply our way of taking something complicated and trying to make it… less complicated.

For Cornerstone Clients

As your billing partner, we already have some of the required information, such as certain organizational characteristics and billing data. We will work with you to make sure you have the needed information when the time comes to report.

Disclaimer

This tool does not guarantee your agency will successfully collect or report on the required data. Cornerstone, nor any of its affiliates or subsidiaries, bears any responsibility for your use of this tool. Your agency is solely responsibility for the accurate, complete and timely submission of all data as explained by CMS.

Page | 3

23 Old Depot Road, New Cumberland, PA 17070

Definitions & Reference Documents

The following is a list of links to key documents:

 CMS webpage with link to selected agencies  CMS Data Collection Instrument (PDF)  CMS Quick Reference Guide  CMS Data Collection FAQs  CMS list of hospital and other provider types

In regard to calculating depreciation:

 CMS has stated that, in general, you will be able to use your organization’s standard approach to calculating depreciation expenses. If your organization calculates depreciation expense for multiple purposes, e.g. depreciation for tax incentive purposes vs. Generally Accepted Accounting Principles (GAAP) for standard auditing purposes, CMS asks that you report the depreciation expense according to GAAP.  As of this publication, CMS is working on an expense guide that will be posted on the Medicare Ambulances Services Center website .

Also, CMS includes some key definitions throughout the instrument. We’ve consolidated them here:

Responses, Transports & Standbys

 “Total responses” is defined as the total number of responses by your organization regardless of whether a ground ambulance was deployed and regardless of whether or not a patient was transported. This includes EMS responses that did not involve a ground ambulance (e.g., responses only involving a pickup truck or sport-utility vehicle (SUV), including quick response vehicle (QRV), a “fly-car,” or “sprint” vehicle). If more than one vehicle is sent to the scene, count this as one response. For fire department- based agencies, this would include emergency responses that only involved a fire truck or other fire/rescue vehicles; for a police/public safety-based department, include emergency responses that only involved a police car or other public safety vehicle.  A “ground ambulance response” is a response by a fully equipped and staffed ground ambulance, scheduled or unscheduled, with or without a transport, and with or without payment. If more than one vehicle is sent to the scene, count this as one response. Please note that every ground ambulance response will count towards your reported number of total responses, but not all responses are ground ambulance responses.  A “ground ambulance transport” is the use of a fully staffed and equipped ground ambulance responding to a request for service. It also provides a medically necessary transport.  A “paid transport” refers to a ground ambulance transport for which your organization has been paid in full or in part by a payer and/or patient only. Please note that in some questions CMS asks only about paid transports, and in other questions CMS is interested in both the paid transports and transports that are not paid, either because your agency did not bill for them or because your agency billed but did not collect payment for them  A “standby event” is an event where a ground ambulance is requested to be present on scene in case of an incident. Examples include fairs, concerts sporting events, police incidents, etc. These services may or may not be paid.

Page | 4

Levels & Types of Services

 An “emergency response” is a BLS or ALS1 level of service that has been provided in immediate response to a 911 call or the equivalent. An immediate response is one in which the ground ambulance organization begins as quickly as possible to take the steps necessary to respond to the call. This can include emergency transfers from a lower‐level to higher‐level of care.  “ALS 1” is the transportation by ground ambulance…and the provision of medically necessary supplies and services…including the provision of an ALS assessment by ALS personnel [emergency medical technician‐intermediate (EMT‐Intermediate) or paramedic] or at least one ALS intervention.” Qualifying ALS assessments and interventions are described in detail in the CMS manual.  “ALS 2” is the transportation by ground ambulance and the provision of medically necessary supplies and services including (1) at least three separate administrations of one or more medications by intravenous (IV) push/bolus or by continuous infusion (excluding crystalloid fluids) or (2) ground ambulance transport, medically necessary supplies and services, and the provision of at least one of the ALS2 procedures” listed in the CMS manual.  “BLS” is transportation by ground ambulance…and the provision of medically necessary supplies and services… including BLS ambulance services as defined by the state. The ambulance vehicle must be staffed by at least two people who meet the requirements of the state and local laws where the services are being furnished, and at least one of the staff members must be certified at a minimum as an emergency medical technician‐basic (EMT‐Basic) by the state or local authority where the services are being furnished and be legally authorized to operate all lifesaving and life‐sustaining equipment on board the vehicle. These laws may vary across or within states.  “SCT” is the inter‐facility transportation of a critically injured or ill beneficiary by a ground ambulance vehicle, including the provision of medically necessary supplies and services, at a level of service beyond the scope of the EMT‐Paramedic. SCT is necessary when a beneficiary’s condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area, for example, emergency or critical care nursing, emergency medicine, respiratory care, cardiovascular care, or an EMT‐Paramedic with additional training.”  “Inter‐facility transports” are transports where “the origin and destination are one of the following: a hospital or skilled nursing facility that participates in the Medicare program or a hospital‐based facility that meets Medicare’s requirements for provider‐based status.”  A “Paramedic Intercept” is an ALS level of service that CMS defines as “a rural area transport furnished by a volunteer ambulance company which is prohibited by state law from billing third party payers where services are provided by an entity that is under contract with the volunteer ambulance company that does not provide the transport but is paid for their paramedic intercept service (State of NY only meets these requirements).”  A “joint response” is our term for how CMS separately addresses those ALS agencies that respond/rendezvous with a BLS from another agency and administer an ALS intervention as part of a joint response.

Page | 5

23 Old Depot Road, New Cumberland, PA 17070

Certifications  An “EMT‐Basic” certification depends on state or local level.  An “EMT‐intermediate” is an individual who is qualified, in accordance with state and local laws, as an EMT‐Basic and who is also certified in accordance with state and local laws to perform essential advanced techniques and to administer a limited number of medications. Advanced‐EMT is another term used in the industry.  An “EMT‐Paramedic” possesses the qualifications of the EMT‐Intermediate and, in accordance with state and local laws, has enhanced skills that include being able to administer additional interventions and medications.  “Primary service area” is the area in which you are exclusively or primarily responsible for providing service at one or more levels and where it is highly likely a majority of pickups will occur.  “Secondary service area” is the area outside your primary service area but where you regularly provides services through mutual or auto‐aid agreements. This does not include areas where you provide services only under exceptional circumstances, e.g. natural disaster. Non‐Ambulance Vehicle  We refer to these simply as NAVs. They are non‐ambulance vehicles used to respond to ground ambulance calls or support ground ambulance operations that are not ambulances, e.g. SUVs, trucks, land or water rescue vehicles, fly‐cars, supervisory vehicles, etc. Service Area

Emergency Response Time

 The time from when the call comes in to when the ambulance or other EMS response vehicle arrives on the scene. o Note: If you don’t define it this way, you will have the opportunity to explain. Trip Time

 From the time the ambulance leaves the station to when that ambulance is available to take another call

Volunteer Hours

 The time from which the volunteer receives a call or a page to the time they are finished with their call as well as time spent in the station performing duties as if they were being paid.

Capital & Non‐Capital Equipment

 Capital medical equipment refers to equipment that can endure repeated use. It includes, but is not limited to, defibrillators, ventilators, monitors, or power lifts.  Capital non‐medical equipment refers to equipment that can endure repeated use. It includes, but is not limited to, computers, dispatch equipment, and furniture.

Page | 6

23 Old Depot Road, New Cumberland, PA 17070

Organizational Characteristics This section seeks to gather basic identification and contact info, as well as key defining characteristics.

NPI, Legal Business Name, Point of Contact

 Your NPI  If your agency uses more than one NPI

 Your legal business name  Name of contact person  Title of contact person  Phone for contact person  Email for contact person

Collection Period

 If you will collect and report based on calendar or fiscal year

Agency Type

 If you are for profit  If you are nonprofit (excluding gov’t)  If you are gov’t (any level)  If you are a public/private partnership

Agency Category

 If you are fire department‐based  If you are police or other public safety department‐based  If you are gov’t standalone  If you are hospital or other Medicare provider  If you are independent/proprietary organization primarily involving EMS  If you are independent/proprietary organization providing non‐emergency services

Shared Service

 If your agency shares operational costs, e.g. building, personnel, etc., with other operations.

Volunteers

 If your agency uses volunteer labor for any positions related to your ground ambulance service. o This would include volunteers even if they receive small stipends, allowances or other incentives from your organization. This would not include staff who are paid on an hourly or salary basis even if they perform some activities on a volunteer basis.

Page | 7

23 Old Depot Road, New Cumberland, PA 17070

911 Calls

 If your organization routinely provides ground ambulance responses to 911 calls  If you provide 911 emergency services around the clock for all days of the year in most or all of your service area

Ambulance Types

CMS considers ground ambulances to includes both land and water ambulances.

 If you operate a land‐based ambulance  If you operate a water‐based ambulance. o This would not include vehicles used exclusively for water rescues that do not meet the requirements to be a water ambulance in your jurisdiction.  If you operate air ambulance

Deployment Model

 The staff deployment model that best fits your agency:

o Static: same # of fully staffed ambulances no matter when o Dynamic: # varies depending on time of day/week o Combined: fixed # during certain times, dynamic others

Paramedic Intercepts & Joint Responses

See Definitions & Reference Documents for how CMS separately defines these two scenarios.

 If you provide paramedic intercept services in NY  If you provide joint responses outside of NY (also commonly referred to as paramedic intercept or ALS intercept services)

Page | 8

23 Old Depot Road, New Cumberland, PA 17070

Service Area This section applies if you have a primary or secondary service area (see Definitions & Reference Documents for Service Area).

Zip Codes

 In your primary service area  In your secondary service area

Trip Time

 The “average trip time” in minutes for both primary and secondary service areas (see Definitions & Reference Documents for Trip Time). Your options will include: o < 30

o 30‐60 o 61‐90 o 91‐120 o 121‐150 o > 150

Page | 9

23 Old Depot Road, New Cumberland, PA 17070

Emergency Response Time This section applies if your agency routinely provides ground ambulance responses to 911 calls.

Response Time & Statistics

 How your agency defines response time (you will have the following options) o Time from when the call comes in to when the ambulance or another EMS response vehicle arrives on scene. o Time as from the time the ambulance leaves the station to the time the ambulance or other EMS vehicle arrives on scene. o If your agency has another definition, be prepared to specify  If you are able to report response time statistics for your agency o If so  Average response time in primary service area  The response time below which 90% of emergency responses fall in primary service area  Average response time in secondary service area o If not  Your best estimate of the average response time in primary service area  Your best estimate of the response time below which 90% of emergency responses fall in primary service area  Your best estimate of the average response time in secondary service area  If your agency is required or incentivized to meet time targets o If so  The entity that determines response time targets  Your agency  Local municipality  County  Other (be prepared to specify)  If you are penalized for exceeding response time targets (penalties can take the form of reduced payments or a fine)

Page | 10

23 Old Depot Road, New Cumberland, PA 17070

Ground Ambulance Service Volume This section applies to an agency that routinely provides ground ambulance responses, transports, intercepts and/or standbys (see Definitions & Reference Documents).

Responses

 Your agency’s total responses  Your agency’s total number of ground ambulance responses  If your agency responds to calls with another non‐transporting agency, e.g. a local fire department, etc. o If so  The percentage of total ground ambulance responses including a non‐transporting agency  The kind of labor provided by the non‐transporting agency during these responses  Paramedic  Other EMT  Other (be prepared to specify)  The percentage share of ground ambulance responses in which the non‐transporting agency continues to provide medical care in the ambulance during transport  The percentage of ground ambulances responses in your secondary service area  The total number of ground ambulance responses that did not result in a transport, e.g. refusals, cancellations, etc.  Of the total number of ground ambulance responses that did not result in a transport, the percentage that received medical treatment on site

Transports

 Your agency’s total number of ground ambulance transports  Your agency’s total number of paid transports

Standbys

 If your agency participates in standby events

Paramedic Intercepts

 If your agency provides paramedic intercept services in NY; if so, the total number of responses  If your agency provides ALS assessments and/or interventions on joint responses (also commonly referred to as paramedic intercept services) outside of NY; if so, the total number of responses o Note: This does not include responses where your agency (as the intercepting ALS unit) actually billed for the transport

Page | 11

23 Old Depot Road, New Cumberland, PA 17070

Service Mix This section applies to ground ambulance responses and transports by type. If you are unable to provide an exact percentage, you will be prompted to select a percentage range. If you did not have any responses in a particular category, you will need to answer 0%.

 Percentage share of emergency responses  Percentage share of non‐emergency responses  Percentage of transports that used water‐based ambulances  Percentage of transports that are inter‐facility  Percentage of transports in each of the following.

o BLSN o BLSE o ALS1N

o ALS1 o ALS2 o SCT Note: Emergency transfers are classified by how they are billed.

Page | 12

23 Old Depot Road, New Cumberland, PA 17070

Labor Costs CMS has provided the following ground rules, which you’ll need to know so you can track accordingly.

 For shared services such as fire‐department, police/public safety, or hospital/other Medicare provider‐ based departments, labor costs are often split between EMS and other duties. When this happens, an agency will need to track those costs in a way that permits them to be allocated for reporting.  If your agency fits a shared services model, only include individuals whose responsibilities were either partly or entirely related to your ground ambulance operation.  You will need to know the classification of each staff member at the beginning of the collection period. This is the classification in which CMS requires each person be reported, regardless if the person changes positions later in the year. o Example: A person begins the year as an EMT‐B and six months later becomes a Paramedic. For program reporting purposes, CMS requires that person to be reported as an EMT‐B.  Regardless if an individual in the EMT/response category has other duties that would fall under administration/facilities, these individuals must be tracked and reported in the EMT/response category and not in any other category.  For administration/facilities not involved in EMT/response, but who nonetheless retained multiple roles, you will need to assign each individual to the category that best represents their primary activity.  You will need to track staff that have some ground ambulance responsibilities but do not have responsibilities in any of the other listed categories. When it comes time to report, you would report these as “other.”  Note: Outside contract services that include multiple services, in which labor is involved, will be reported in a separate section.

Labor Categories

CMS has established the following labor categories, in which each have paid (full and part‐time) and volunteer designations. These categories guide the rest of this section.

 EMT/Response  Administration/Facilities  Medical Director

Obviously, not all will apply to your agency and if so, disregard. For example, if your agency is a not affiliated with a fire department, then questions pertaining to allocating hours would not apply.

Let’s visualize this as a table:

Page | 13

23 Old Depot Road, New Cumberland, PA 17070

Paid

Applies to All

If Applicable

Hours Worked Annually (unrelated to ground ambulance or fire/police duties)

Total Hours Annually (for those with fire/police duties)

Number of Staff

Total Annual Compensation

Total Annual Hours

Provider

EMT‐B EMT‐I EMT‐P Nurse, Dr., resp. therapist, other EMR Ambulance driver (non‐EMR or EMT) Admin (clerical, HR, Billing, IT, etc.) Management (executives, officers)

EMT/

Response

Dispatch/call center Vehicle maintenance Facilities maintenance Other

Administration /Facilities

Medical Director

Volunteer

Applies to All

If Applicable

Hours Worked Annually (unrelated to ground ambulance or fire/police duties)

Total Hours Annually (for those with fire/police duties)

Number of Staff

Total Annual Compensation

Total Annual Hours

Provider

EMT‐B EMT‐I EMT‐P Nurse, Dr., resp. therapist, other EMR Ambulance driver (non‐EMR or EMT) Admin (clerical, HR, Billing, IT, etc.) Management (executives, officers)

EMT/

Response

Dispatch/call center Vehicle maintenance Facilities maintenance Other

Administration /Facilities

MD Medical Director *For agencies that have a parent organization, you will need to track and allocate to your NPI the portion of administrative labor costs incurred at the level of the parent organization, based on your organizational approach for allocating costs to specific NPIs.

What happens if you answer no for paid and volunteer?

If you answer no to both paid and volunteer for any category, you will be asked why. The system will provide you with three default responses:  This labor category is part of our ground ambulance operation but is paid for or provided at no cost by another entity. o If selected, you will be asked to report associated annual hours and associated costs.  One or more staff perform these functions but we assigned them to another category per the instructions  We do not have staff in this category and/or we contract with another organization for this role

Page | 14

23 Old Depot Road, New Cumberland, PA 17070

Total Annual Compensation

Regardless of category, when reporting total annual compensation, you will include salary/wages, benefits (healthcare, PTO, retirement, life insurance, and stipends), overtime, training time, callback & standby pay. Importantly, if one or more components of compensation costs are paid by another organization with which you have a business relationship, e.g. a municipality that you serve, you will need to obtain and include these costs . If the other organization is only able to provide total costs, e.g. total benefits costs across all staff, you will need to allocate to labor categories based on salary or wages across labor categories. For example, if total benefits were $60,000, and 1/3 rd of EMT/response staff salary and wages was for EMT‐B and 2/3 rd was for EMT‐ P, then $20,000 would contribute to EMT‐B and $40,000 would contribute to EMT‐P.

Total Annual Hours

Include only those staff whose EMT roles are with your agency. If a staff member is employed as an EMT with your agency but a firefighter with another agency, do not include those firefighter hours. Also, in this section, you will include total hours for staff for whom only some time was spent on EMS. For example, you have a paid firefighter/EMT who worked 2,000 hours, though not all hours were for EMS. Nonetheless, report 2,000 hours.

Hours Worked Annually (unrelated to ground ambulance or fire/police duties)

For staff with shared roles, you will track the hours worked annually that were not related to EMT/response activities or fire/police activities. Such responsibilities could include: air ambulance, working in a clinic, community paramedicine, community outreach, etc. Here, you will capture the share of hours, not the total.

Medical Director

If your agency contracts with a medical director rather than employing directly, you will need to track the total compensation for medical direction services that your agency paid, not the value of the medical director’s time

General Item

Of the staff who were partly or entirely related to your ground ambulance operation, you will need to track whether one or more individuals devoted a total of at least half time (1,000 hours annually or approximately 20 hours per week) to each of the following. Note: This would not include individuals whose services were part of an outside contracted service.

 Billing  Data analysis  Training  Medical quality assurance

Volunteer Compensation

You will need to report the total dollars spent if your agency provided stipends, honoraria, benefits and/or other compensation for volunteers, regardless if EMT/response, administration/facilities, or medical director.

Page | 15

23 Old Depot Road, New Cumberland, PA 17070

Facilities Costs CMS has broken this section down into three basic parts:

 Facility Information  Lease/Mortgage Costs  Insurance, Maintenance, Utilities & Taxes

Facility Information

If a shared service, % of square footage attributable to ground ambulance services

If facility was donated (no cost, except maintenance, utilities, insurance & taxes)

If your agency or another owns but has a mortgage

If your agency or another owns outright

If your agency or another rents

Square Footage

Facility ID/Function

Facility 1 Facility 2 Facility 3 Etc.

 You should include anything used for call center/dispatch, vehicle storage, and admin/EMT staff  You should not include facilities used by contracted entities that your agency does not occupy itself, e.g. a call center to which you pay a monthly fee for call services  If you had one building in which all functions occurred, list only that that one building  In those cases where non‐ambulance operations also occur, CMS states you can use your “best estimate.” For agencies that are fire department‐based: o Do not include garage, storage and staff areas used for fire response o Do include a share of office and common spaces related to both ambulance and other activities that is in proportion to your share of total responses that are ground ambulance responses, e.g. if half your calls are EMS, list half the square footage as the share

Page | 16

23 Old Depot Road, New Cumberland, PA 17070

Lease/Mortgage Costs

Annual depreciation (if owned & no mortgage)

Facility ID/Function Lease or rental costs

Mortgage & interest costs

Facility 1 Facility 2 Facility 3 Etc.

*For agencies that have a parent organization, you will need to track and allocate to your NPI the portion of other facilities costs incurred at the level of the parent organization, e.g. regional buildings or service facilities serving multiple NPIs, based on your organizational approach for allocating costs to specific NPIs.  Total costs in this context includes costs paid by another organization or entity on your behalf and includes costs for facilities that were partially related to your ground ambulance operations.  Do not include facilities that were donated or exceptions for which there was no cost.  Be mindful not to include these interest costs elsewhere.

Insurance, Maintenance, Utilities & Taxes

Expenditure

Amount

Total facilities‐related insurance costs Total facilities maintenance/improvement Total facilities utilities costs Total facilities taxes

*For agencies that have a parent organization, you will need to track and allocate to your NPI the portion of other facilities costs incurred at the level of the parent organization, e.g. regional buildings or service facilities serving multiple NPIs, based on your organizational approach for allocating costs to specific NPIs.  Total costs includes costs paid by another organization or entity on your behalf.  Total costs includes costs for facilities that were partially related to your ground ambulance operations.

 Total costs does not include donations or exceptions for which there was no cost.  Do not include labor costs if said labor costs were already included in labor section.  Do not include any taxes if included in the mortgage section.

Page | 17

23 Old Depot Road, New Cumberland, PA 17070

Vehicle Costs As stated earlier, CMS considers ground ambulances to include both land and water. Additionally, CMS wants to learn about non‐ambulance vehicles used in relation to your ground ambulance operation. In regard to the table below:  You will need to include all ground ambulances regardless whether the ambulance transported patients or whether you billed for transports made by this ambulance.  You will need to track the total number of ambulance and non‐ambulance miles. For land ambulance, this includes billed and unbilled. For water ambulance, this includes any miles for any reason. Likewise, for non‐ambulance, this includes any miles for any reason.

Owned

Question

Ambulance 1 Ambulance 2

Etc.

Was it used to transport patients? Was it donated? If not donated, what is its annual depreciated value? Was it remounted? If yes to remounted, what was the cost? Total miles (billed) during collection period Total miles (unbilled) during collection period

Leased

Was it used to transport patients? What was total lease cost?

Ground Ambulance

Total miles (billed) during collection period Total miles (unbilled) during collection period

Owned

Question

NAV 1

NAV 2

Etc.

What type of vehicle is this? Options will include fire truck, land rescue vehicle, water rescue vehicle, and vehicle that responds to emergencies but is not designed to transport patients Was this vehicle used to respond to ambulance calls or support ground ambulance operations? Was this vehicle donated? If not donated, what is its annual depreciated value? Total miles travelled during collection period Leased What type of vehicle is this? Options will include fire truck, land rescue vehicle, water rescue vehicle, and vehicle that responds to emergencies but is not designed to transport patients What was total lease cost?

Non‐Ambulance Vehicles (NAV)

*For agencies that have a parent organization, you will need to track and allocate to your NPI the portion of other vehicle costs incurred at the level of the parent organization, based on your organizational approach for allocating costs to specific NPIs.

Page | 18

23 Old Depot Road, New Cumberland, PA 17070

Other Costs Associated with Vehicles

This section pertains to all vehicles (ground ambulance, e.g. land and water, and NAV) used to respond to ambulance calls or support ground ambulance operations

If a shared service, the allocated cost