Ambulance Modifiers Table

Created 10/15
The following chart has been developed to assist providers in understanding how the Kansas Medical
Assistance Program (KMAP) handles specific modifiers. It is imperative providers understand the
importance of using these modifiers correctly. Improper coding could result in a delayed, denied or
incorrect payment for the service(s) submitted.

Origin and destination modifiers are used to make up a two-letter modifier for ambulance services.
Each of the modifiers may be used to make up the first and/or second half of the two-letter modifier.
The modifier in the first position must describe the origin of the transport. The second letter must describe
the destination. (Example: If a patient is transported from one hospital to another, the two-letter modifier
submitted should be “HH” indicating a hospital-to-hospital transport).

The KMAP website offers additional information on the use of codes and modifiers.
• On the public website, access the following links.
o Provider manuals
o Current coverage and pricing information
• Log on to the secure website.
o From the Publications tab, click Provider Manuals.
o From the main menu, click Pricing and Limitations for current coverage and pricing
information.

CPT codes, descriptors, and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All
rights reserved. Applicable FARS/DFARS apply. Information is available on the American Medical Association website.
The following are the origin and destination modifiers along with their descriptions to be used by
ambulance suppliers.

Modifier Description
D Diagnostic or therapeutic site other than P or H
E Residential, domiciliary, custodial facility, nursing home other than skilled nursing facility (SNF) -
1819 facility
G Hospital-based dialysis facility (hospital or hospital-related) which includes:
- Hospital administered/Hospital located
- Nonhospital administered/Hospital located
H Hospital
I Site of transfer (e.g. airport, ferry, or helicopter pad) between modes of ambulance transport
J Nonhospital-based dialysis facility
- Nonhospital administered/Nonhospital located
- Hospital administered/Nonhospital located
N SNF (1819 facility)
P Physician's office (includes HMO nonhospital facility, clinic, etc.)
R Residence
S Scene of accident or acute event
X Destination code only. Intermediate stop at physician's office en route to the hospital (includes
HMO nonhospital facility, clinic, etc.)

The following are additional modifiers along with their descriptions for ambulance services.

Modifier Description
GA The provider or supplier has provided an Advance Beneficiary Notice (ABN) to the patient.
GM Use when more than one patient is transported in an ambulance and document details of the
transport. Used by both ground and air transports.
GY Use when billing for a statutorily excluded services. Example - Patient transport is for a
noncovered condition that does not meet the definition of any Medicare benefit. The provider is
expecting a denial.
GZ The provider or supplier expects a medical necessity denial; however, did not provide an ABN to
the patient.
QL Use when the patient is pronounced deceased after the ambulance is called. The patient is
pronounced dead after the ambulance is called but before transport. Ground providers can bill a
BLS service along with modifier QL.
QN Ambulance furnished directly by provider of services.
TP Modifiers TP and TQ can be used on procedure codes A0021-A0999. KMAP will deny the service
TQ if these modifiers are billed with any code other than those listed.