Ambulance billing Modifiers and sample Ambulance claim

Ambulance & Hospital Claim

Ambulance claim using a CMS 1500 and a hospital claim that includes both an institutional claim using a UB 04 and a professional claim using a CMS 1500.




Does Medicare reimburse for ambulance transportation to and from a physician's office?

Answer:  

No. Transport to a physician's office is covered only under the following circumstance:

The ambulance transport is enroute to a Medicare covered destination as described in the Medicare Benefit Policy Manual (Pub. 100-02, Chapter 10, §10.3)
During the transport, the ambulance stops at a physician's office because of the patient's dire need for professional attention, and immediately thereafter, the ambulance continues to the covered destination

In such cases, the patient will be deemed to have been transported directly to a covered destination, and payment may be made for a single transport and the entire mileage of the transport, including any additional mileage traveled because of the stop at the physician's office


Ambulance Modifiers


Ambulance claims are billed with the following modifiers. The first digit indicates the place of origin, and the  destination is indicated by the second digit. The modifiers most commonly used are:


Harvard Pilgrim requires two-digit HCPCS ambulance service modifiers be submitted in the first modifier field for all ambulance services with the exception of HCPCS code A0998 (please see comment in Provider Billing Guidelines coding grid above). Absence of the two-digit HCPCS ambulance service modifier may cause your claim to deny. Combine one-digit modifiers to form a two-digit modifier (the first digit identifies the ambulance’s place of origin; the second digit identifies the destination) and bill using the appropriate two-digit HCPCS ambulance service modifiers, as follows (but not limited to):

APPLICABLE CODES

The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this guideline does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Coverage Determination Guidelines may apply.

Ambulance claims are billed with the following modifiers. The first digit indicates the place of origin, and the destination is indicated by the second digit. The modifiers most commonly used are:

Bill all lines with the appropriate HCPCS origin/destination modifier


Alpha Code    Description

D Diagnostic or therapeutic site other than P or H
E Residential, domiciliary, custodial facility (nursing home, not SNF)
G Hospital-based ESRD facility
H Hospital
I Site of transfer (e.g., airport or helicopter pad) between modes of ambulance transport
J Freestanding ESRD facility
N Skilled Nursing Facility
P Physician’s office
R Residence
S Scene of accident or acute event
X Intermediate stop at physician’s office in route to hospital


The following modifiers are considered secondary modifiers; Do not bill these modifiers in the first position.

GM Multiple patients on one trip
QM Ambulance service provided under arrangement by a provider of services
QN Ambulance service furnished directly by a provider of services

I received a denial for my submission of a specialty care transport code. What could be wrong?

Answer:

Did you submit a payable trip? CMS advises in IOM Manual Publication 100-02, Chapter 10, Section 30.1.1 that Specialty Care Transport (SCT) HCPCS code A0434 is the interfacility transportation of a critically injured or ill beneficiary by a ground ambulance, including the provision of medically necessary supplies and services, at a level of service beyond the scope of the EMT Paramedic.

Did you submit a modifier combination that is not payable, such as HCPCS modifiers HR? SCT is interfacility. We encourage you to review the requirements for billing this service as the beneficiary’s condition must be such to require ongoing care, etc.


If a patient is being transported to a wound care center located within a hospital or on hospital grounds, which destination modifier would be used when filing the claim?

Answer:
This depends on how the facility is licensed. If it is licensed as a physician’s office, then the appropriate HCPCS modifier would be P. If it is licensed as a hospital, then you would use HCPCS modifier H. If the facility is licensed as neither a physician’s office nor a hospital, then HCPCS modifier D (Diagnostic or therapeutic site other than P or H) would be appropriate. You will need to verify this with the wound care center.

Please note: HCPCS modifier D would also be appropriate for an independent diagnostic testing facility, cancer treatment center or radiation therapy center.



If a patient is transported by ambulance to hospice prior to the initial assessment and development of the plan of care, what destination modifier do I use?

Answer:
There is no specific modifier designated for hospice. You would use the appropriate HCPCS modifier based on the location of where the patient is receiving the service. The most common HCPCS modifiers for hospice providers would be:

'H' (hospital),
'E' (residential, domiciliary, custodial facility), or
'N' (skilled nursing facility)
Please keep in mind that all other coverage requirements must be satisfied. For instance, a transport from 'R' (residence) to 'E' (residential, domiciliary, custodial facility) would not be covered because it is essentially a transport between two residences.

If it is determined that the claim should be submitted to Medicare Part B, please consider adding HCPCS modifier GW (service not related to the hospice patient’s terminal condition) to your claim.

Ambulance HCPCS Codes

       HCPCS Code               Description


A0422      Ambulance (ALS or BLS) oxygen and oxygen supplies, life sustaining situation

A0424  Extra ambulance attendant, ground (ALS or BLS) or air (fixed or rotary winged); (requires  medical review) A0425 Ground mileage, per statute mile

A0426 Ambulance service, advanced life support, nonemergency transport, level 1 (ALS 1)

A0427 Ambulance service, advanced life support, emergency transport, level 1 (ALS 1 - emergency)

A0428  Ambulance service, basic life support, nonemergency transport, (BLS)

A0429  Ambulance service, basic life support, emergency transport (BLS, emergency)

A0430  Ambulance service, conventional air services, transport, one way (fixed wing)

A0431   Ambulance service, conventional air services, transport, one way (rotary wing)

A0432   Paramedic intercept (PI), rural area, transport furnished by a volunteer ambulance company which is prohibited by state law from billing third-party payers

A0433 Advanced life support, level 2 (ALS 2)

A0434 Specialty care transport (SCT)

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