Do you handle ambulance billing every day? Are claim denials eating your revenue? Ambulance CPT codes have complex rules. Studies show 35% of ambulance claims get denied. Wrong codes cost practices thousands each year. Medicare pays over $6 billion for ambulance services annually. Proper coding helps you get paid faster.
Ambulance services use specific HCPCS codes. These codes replace traditional CPT codes for transport. Each transport type has different code requirements. Medicare and insurance companies review ambulance claims closely. About 60% of ambulance transports are emergency calls. The remaining 40% are scheduled non-emergency transports. Understanding codes prevents most billing problems.
This guide explains ambulance codes in simple terms. We show the right codes to use. You will learn the doc requirements too. Proper billing ensures your practice gets paid. Medical need rules must always be followed. Transportation distance affects billing and pay rates.
Understanding Ambulance CPT Codes
Ambulance services use HCPCS codes, not CPT codes. These codes are specific to transport billing. Understanding codes prevents claim denials and delays.
HCPCS vs CPT Codes
Ambulance services use A codes from HCPCS. CPT codes do not cover ambulance transport. A0425 through A0436 are main transport codes. Each code covers different service levels. Insurance companies need HCPCS codes for ambulance. Using the wrong code type causes automatic denials.
Types of Ambulance Services
Basic Life Support covers non-emergency transports safely. Advanced Life Support provides critical care during transport. Specialty Care Transport handles high-risk patient needs. Air ambulance includes helicopter and fixed-wing transport. Water ambulance serves areas accessible only by boat.
Code Structure and Components
Base codes cover the initial service provided. Mileage codes bill for the distance traveled during transport. Origin and destination modifiers show transport locations clearly. Service level modifiers indicate the type of care provided. Loading fees may apply in some situations. Wait time can be billed under certain circumstances.
Common Ambulance HCPCS Codes
Specific codes cover different ambulance service levels. Understanding each code prevents billing errors. Wrong codes lead to denials and payment delays.
Basic Life Support Codes
A0428 covers basic life support emergency transport. A0429 bills basic life support non-emergency transport. These codes include basic medical care during transport. Oxygen use is included in the base rate. Basic monitoring equipment use is covered, too. No advanced procedures allowed under these codes.
Advanced Life Support Codes
ALS codes allow advanced medical procedures during transport. Paramedics must be present for ALS billing. Advanced airway management procedures are covered under ALS. Cardiac monitoring and IV therapy are included in the rate. Docs must show medical need for ALS level.
Mileage and Additional Codes
A0425 bills ground mileage per mile traveled. A0435 covers fixed-wing air ambulance mileage billing. A0436 bills rotary-wing air ambulance mileage rates. Each mile must be documented on the trip sheet. Loading fees use code A0424 when applicable. Extra attendant codes apply for special situations.
Non-Emergency Ambulance CPT Codes
Non-emergency transport has strict Medicare requirements. Medical need must be proven for payment. Scheduled transports need different documents than emergency calls.
Scheduled Transport Requirements
Patient must be bed-confined for non-emergency transport. Other transportation methods must be medically safe. A physician must order ambulance transport in writing. Written order must be in the patient’s chart. An ambulance must be medically needed for the condition. Transportation to and from dialysis is commonly billed.
Non-Emergency Code Usage
A0429 bills basic life support non-emergency transport. A0426 covers ALS non-emergency when medically needed. Doc requirements are stricter for non-emergency than for emergency. Medical needs must be clearly documented. Prior authorization is often needed for scheduled transports.
Documentation for Non-Emergency
- Physician certification statement needed for transport
- Patient condition docs showing medical need
- Prove that other transport methods are unsafe clearly
Modifiers for Ambulance Billing
Modifiers provide additional info about ambulance transports. Origin and destination modifiers are always needed.
Origin and Destination Modifiers
The first character shows the transport origin location clearly. The second character indicates the destination location for transport. D represents diagnostic or therapeutic site location. E means residential or custodial facility. G indicates a hospital-based dialysis facility. H represents the hospital location for transport.
Service Level Modifiers
GM modifier indicates multiple patients transported together. QL modifier shows the patient pronounced dead after transport. QM shows ambulance service provided under arrangement. QN indicates ambulance furnished directly by the provider. TN modifier shows the rural transport pickup point. These modifiers affect pay rates and requirements.
Special Circumstance Modifiers
- HS indicates family or self-reported condition
- RH shows the rural start point for transport
- SH indicates second or third home health visit
Medicare Guidelines
Medicare has strict rules for ambulance billing. These rules are often stricter than commercial insurance. Understanding Medicare prevents costly billing errors.
Medicare Coverage Criteria
Transport must be medically needed for the condition. Patient’s condition requires ambulance transport. Other transportation must be unsafe by conditions. Transport must be to the nearest appropriate facility. The beneficiary must be enrolled in Medicare Part B.
Medicare Reimbursement Rates
Base rate varies by geographic location. Rural areas receive higher base rate payments. Mileage pay is set per mile traveled. Air ambulance rates are much higher than ground. Medicare sets a fee schedule updated annually. Understanding rates helps with financial planning decisions. Claims must be submitted within filing deadlines.
Medicare Documentation Standards
Ambulance trip report needed for all transports. Physician certification is needed for repetitive scheduled transports. Docs must support the medical need claimed clearly. Medicare audits need a complete doc review always. Missing docs result in payment demands. Keep all docs for at least seven years.
Conclusion
Ambulance codes use HCPCS, not CPT codes. Proper code selection prevents most claim denials. Docs must prove medical need for transport. Modifiers provide needed location and service info. Non-emergency transports always have stricter doc requirements. Medicare rules must be followed for government patients. Staff training is essential for ambulance billing success.
FAQs
What codes are used for ambulance billing?
HCPCS A codes are used for ambulance billing. CPT codes do not cover ambulance transports. Codes range from A0425 through A0436. Each code covers different service levels and transport types.
Do all ambulance transports need prior authorization?
No, emergency transports do not need prior auth. Non-emergency scheduled transports often need prior auth. Medicare requires physician certification for repetitive transports.
How is ambulance mileage billed?
Ground mileage uses code A0425 per mile traveled. Air ambulance uses codes A0435 or A0436. Each mile must be documented on the trip sheet. Mileage calculated from pickup to destination location.
What documentation is required for non-emergency transport?
A physician’s order in writing is always needed. Medical needs must be documented clearly. Patient must be bed-confined for transport. Proof that other transportation is unsafe is required.
Can the family request an ambulance for convenience?
No, Medicare does not cover convenience transports. Transport must be medically needed for payment. Social transports are never covered by insurance. Medical condition must warrant ambulance-level of care.
