Ambulance Billing Guidance

Ambulance Billing
Ambulance Billing HCPCS Codes
How to Bill Units with Transpiration HCPCS Codes
Using Ambulance Modifiers When Billing
Transportation Indicators
Related Content

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Ambulance Billing

Ambulance services are covered under Medicare Part B when the following conditions listed below are met:

A Medicare beneficiary is transported
The transportation is to the nearest appropriate destination
The transportation is medically necessary (i.e., the medical condition of the beneficiary is such that any other form of transportation is contraindicated)
The ambulance provider/supplier meets all applicable vehicle and staffing requirements (based on State law)
Gurney/wheelchair van transports do not meet staff, vehicle and equipment requirements (noncovered)

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Ambulance Billing HCPCS Codes

A0426 – ALS, non-emergency, level 1
A0427 – ALS, emergency transport, level 1
A0428 – BLS non-emergency
A0429 – BLS, emergency
A0430 – Conventional air services, one-way, fixed wing
A0431 – Conventional air services, one-way, rotary wing
A0432 – Paramedic Intercept, NY only
A0433 – ALS, level 2
A0434 – Specialty Care Transport (SCT)
A0425 – BLS/ALS ground mileage, per statute mile
A0435 – Fixed wing air mileage, per statute mile
A0436 – Rotary wing air mileage, per statute mile
A0888 – Mileage beyond nearest facility (non-covered)
A0999 – Unlisted ambulance service (use when billing for a denial with the GY modifier)

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How to Bill Units with Transportation HCPCS Codes

Report 1 unit with HCPCS codes: A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434.

For mileage, report the number of loaded miles (reported as fractional units) with HCPCs codes A0425, A0435 or A0436.

Round the total miles up to the nearest tenth of a mile and report the resulting number with the appropriate HCPCS code for ambulance mileage
Trips totaling 100 miles or greater, report mileage rounded up to the next whole number mile without the use of a decimal (e.g., 127.5 miles should be reported as 128)
Trips totaling less than one mile: Enter a “0” before the decimal (e.g., 0.7)

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Using Ambulance Modifiers When Billing

An origin and destination modifier for each trip provided must be included on the claim line. The origin and destination modifiers are created by combining two alpha characters. The first position alpha code indicates the origin (where the patient was picked up); the second alpha code indicates the destination (where the patient was dropped off).

Origin/Destination Modifiers:

D – Diagnostic/therapeutic site (other than P/H)
E – Residential/domiciliary/custodial facility
G – Hospital-based dialysis facility
H – Hospital
I – Site of Transfer (i.e., helicopter pad/airport) between modes of ambulance transfer
J – Nonhospital-based dialysis facility
N – Skilled Nursing Facility (participating only)
P – Physician’s Office
R – Residence
S – Scene of Accident
X – Immediate stop at physician’s office enroute

For ABN modifier usage, see our ABN web page.

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Transportation Indicators

When an ambulance claim is submitted for payment, one of the transportation indicators below may be included on the claim to indicate why it was necessary for the patient to be transported in a particular way or circumstance. The ambulance provider or supplier will place the transportation indicator in the “Extra Narrative” field (1500: block 19; EMC: Loop 2300/2400):

Air and Ground

C1 – Transportation indicator “C1” indicates an interfacility transport (to a higher level of care) determined necessary by the originating facility based upon EMTALA regulations and guidelines. The patient’s condition should also be reported on the claim with a code selected from either the emergency or non-emergency category on the list.
C2 – Transportation indicator “C2” indicates a patient is being transported from one facility to another because a service or therapy required to treat the patient’s condition is not available at the originating facility. The patient’s condition should also be reported on the claim with a code selected from either the emergency or non-emergency category on the list. In addition, the information about what service the patient requires that was not available should be included in the narrative field of the claim.
C3 – Transportation indicator “C3” may be included on claims as a secondary code where a response was made to a major incident or mechanism of injury. All such responses – regardless of the type of patient or patients found once on scene – are appropriately Advanced Level Service responses. A code that describes the patient’s condition found on scene should also be included on the claim, but use of this modifier is intended to indicate that the highest level of service available response was medically justified. Some examples of these types of responses would include patient(s) trapped in machinery, explosions, a building fire with persons reported inside, major incidents involving aircraft, buses, subways, trains, watercraft and victims entrapped in vehicles.
C4 – Transportation indicator “C4” indicates that an ambulance provided a medically necessary transport, but the number of miles on the claim form appear to be excessive. This should be used only if the facility is on divert status or a particular service is not available at the time of transport only. The provider or supplier must have documentation on file clearly showing why the beneficiary was not transported to the nearest facility and may include this information in the narrative field.

Ground Only

C5 – Transportation indicator “C5” has been added for situations where a patient with an ALS-level condition is encountered, treated and transported by a BLS-level ambulance with no ALS level involvement whatsoever. This situation would occur when ALS resources are not available to respond to the patient encounter for any number of reasons, but the ambulance service is informing you that although the patient transported had an ALS level condition, the actual service rendered was through a BLS-level ambulance in a situation where an ALS-level ambulance was not available. For example, a BLS ambulance is dispatched at the emergency level to pick up a 76-year old beneficiary who has undergone cataract surgery at the Eye Surgery Center. The patient is weak and dizzy with a history of high blood pressure, myocardial infarction, and insulin-dependent diabetes mellitus. Therefore, the on-scene ICD-10-CM equivalent of the medical condition is 780.02 (unconscious, fainting, syncope, near syncope, weakness, or dizziness – ALS Emergency). In this case, the ICD-10-CM code 780.02 would be entered on the ambulance claim form as well as transportation indicator C5 to provide the further information that the BLS ambulance transported a patient with an ALS-level condition, but there was no intervention by an ALS service. This claim would be paid at the BLS level.
C6 – Transportation indicator “C6” has been added for situations when an ALS-level ambulance would always be the appropriate resource chosen based upon medical dispatch protocols to respond to a request for service. If once on scene, the crew determines that the patient requiring transport has a BLS-level condition, this transportation indicator should be included on the claim to indicate why the ALS-level response was indicated based upon the information obtained in the operation’s dispatch center. Claims including this transportation indicator should contain two primary codes. The first condition will indicate the BLS-level condition corresponding to the patient’s condition found on-scene and during the transport. The second condition will indicate the ALS-level condition corresponding to the information at the time of dispatch that indicated the need for an ALS-level response based upon medically appropriate dispatch protocols.
C7 – Transportation indicator “C7” is for those circumstances where IV medications were required enroute. C7 is appropriately used for patients requiring ALS level transport in a non-emergent situation primarily because the patient requires monitoring of ongoing medications administered intravenously. Does not apply to self-administered medications. Does not include administration of crystalloid intravenous fluids (i.e., Normal Saline, Lactate Ringers, 5% Dextrose in Water, etc.). The patient’s condition should also be reported on the claim with a code selected from the list.

Air Only

All transportation indicators imply a clinical benefit to the time saved with transporting a patient by an air ambulance versus a ground or water ambulance.
D1 – Long Distance - patient's condition requires rapid transportation over a long distance.
D2 – Under rare and exceptional circumstances, traffic patterns preclude ground transport at the time the response is required.
D3 – Time to get to the closest appropriate hospital due to the patient's condition precludes transport by ground ambulance. Unstable patient with need to minimize out of hospital time to maximize clinical benefits to the patient.
D4 – Pick up point not accessible by ground transportation

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Ambulance Billing Guidance

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