Ambulance and EMS Transport Require

Specialized Coding
Dates of service

The date of service (DOS) for an ambulance service is the date the loaded ambulance
vehicle departs the point of pickup.

In the case of a ground transport, if the beneficiary is pronounced dead after the vehicle
is dispatched but before they are loaded into the vehicle; the DOS is the date of
dispatch.

In the case of an air transport, if the beneficiary is pronounced dead after the aircraft
takes off to pick up the beneficiary, the DOS is the date of the vehicle’s takeoff.

Note: You must report 8-digit dates in all date of birth fields. Providers have the option
of entering 6 or 8-digit dates in all other fields. Dates should be consistent

Healthcare Common Procedure Coding System (HCPCS)

HCPC Definition
S

A0426 Ambulance service, ALS (Advanced Life Support), non-emergency transport, Level 1

A0427 Ambulance service, ALS, emergency transport, Level 1

A0428 Ambulance service, BLS (Basic Life Support) non-emergency transport

A0429 Ambulance service, BLS, emergency transport

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, rural area volunteer ambulance

A0433 Ambulance service, ALS, level 2

A0434 Ambulance service, specialty care transport

A0425 BLS/ALS mileage, per statue mile

A0435 Fixed wing air mileage, per statute mile

A0436 Rotary wing air mileage, per statute mile

 A0888 Mileage Beyond the Nearest Facility (non-covered)

Emergency situations call for unique coding of non-

physician provider services.

Ambulance codes and guidelines are uniquely applicable to non-physician providers. To make
coding these services even more of a challenge, procedure codes relevant to emergency
medical service (EMS) providers aren’t found in the CPT® codebook. Instead, coding
guidelines for ambulance and EMS transport codes come primarily from Medicare transmittals
and MedLearn updates.
Payers generally cover ambulance services, including fixed and rotary wing services, for
patients whose medical condition is such that air transport is medically necessary. To assure
transport is medically necessary, you must consider both the patient’s condition and the
method of transportation. This can be a challenging process, which depends on the
documentation paramedics and emergency medical technicians (EMTs) provide in the field.

Differentiate Emergency vs. Non-emergency

Response

To prevent coding errors, use extreme care when differentiating emergency from non-
emergency transports. This often requires additional education for ambulance providers to
assure their documentation of a patient’s conditions accurately describes when an emergency
condition existed, or when an emergency transport was required.
CMS defines an emergency response as, “responding immediately at the BLS or ALS1 level
of service to a 911 call or the equivalent.” An immediate response is defined as a response by
the ambulance supplier that begins as quickly as possible to the call. Emergency response is
based on internal protocols, which consider the information received during the call. The call
does not have to come through a 911 system.
All scheduled transports are considered non-emergency, and include routine transports to
nursing homes, patient homes, and end-stage renal disease (ESRD) facilities.

Break Down Ambulance Services Categories

In the Ground Ambulance Services section of the ambulance fee schedule, there are

seven categories of ground ambulance services (“ground” refers to both land and

water transportation) and two categories of air ambulance services. The level of service

is based on the patient’s condition, not the vehicle used. This is a challenge for many

coders.

In addition to the HCPCS Level II procedure codes and standard set of modifiers (see

Chart A), a unique set of modifiers (see Chart B) are required to identify the origin and

destination, which are affixed to the procedure code. Mileage must also be calculated,

which presents additional challenges if this information is not clearly documented

(ambulance coders are all too familiar with programs that estimate mileage between

pick-up and drop-off points to assure accuracy for mileage calculations).

Chart A: Common modifiers for ambulance services

GY Use when billing for statutorily-excluded services. For example, patient trans
that does not meet the definition of any Medicare benefit. The provid
Refer to the payer’s modifier fact sheet for additional informa
QL Use when the patient is pronounced deceased after the ambulance is called. The
ambulance is called, but before transport. Ground providers can bill a BLS
See CMS Internet-Only Manual, 100-2, Medicare Benefits Policy Manual,
Air providers can use the appropriate air base rate code (fixed wing or rotary
be no rural allowance or mileage billed. View the article for air ambulance
Manual, 100-2, Medicare Benefits Policy Manual, chapter 10,
GM Use when more than one patient is transported in an ambulance and there are do
Used by both ground and air transports. See CMS Internet-Only Manual, 100-4,
chapter 15, section 30.1.2.
GA The provider or supplier has provided an Advance Beneficiary Notic

GZ The provider or supplier expects a medical necessity denial, but did not
There are only four situations where the Limitation of Liability provision app
approved ABN form is needed by an ambulance company to reverse the limitation
 
Chart B: Specialty modifiers for reporting ambulance services (including origin and destination
codes and their descriptions)

Modifier Description

D Diagnostic or therapeutic site other than P or H when these

E Residential, domiciliary, custodial facility (other t

G Hospital based ESRD facility

 H Hospital

I Site of transfer (e.g., airport or helicopter pad) between mo

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 on way to hospital

Ground Ambulance Services

 

A0425 Ground mileage, per statute mile requires documentation and/or calculation of mileage

between sites.
A0426 Ambulance service, advanced life support, nonemergency transport, level 1 (ALS1)
includes transportation by ground ambulance and medically necessary supplies and services.
The response personnel are required to document an ALS assessment, or to provide at least
one ALS intervention.
Advanced life support assessment is defined as:

1. Assessment performed by an ALS crew as part of an emergency response that was

necessary; or
2. The patient’s reported condition at the time of dispatch was such that only an ALS crew was
qualified to perform the assessment.

An ALS intervention includes procedures that are beyond the scope of an EMT-basic.
Personnel qualified for ALS are trained EMT-intermediates or paramedics.
Often, the ALS assessment does not indicate that the patient required a level of service
consistent with ALS, but that is only determined after the assessment is performed.
Documentation is critically important to identify signs and symptoms that required the
assessment and the results of the assessment, including the condition of the patient prior to
and during transport.
A0427 Ambulance service, advanced life support, emergency transport, level 1 (ALS1 –
 emergency): The provision of ALS1 services as an emergency response applies. For ALS1,
ALS2, and specialty care transport (SCT), the emergency condition is assumed, but
documentation is critical to support these services.
A0428 Ambulance service, basic life support, nonemergency transport (BLS) defines
transportation by ground ambulance vehicle, with medically necessary supplies and services,
as well as BLS services. The ambulance must be staffed by a qualified EMT-basic consistent
with state rules and regulations, which may vary from state to state. Coding for these services
requires an understanding of state regulations and the ambulance provider’s assurance that
providers meet the criteria for each level of transport. For example, only in some states is an
EMT-basic permitted to operate limited equipment on board the vehicle, assist more qualified
personnel in performing assessments and interventions, and establish a peripheral
intravenous (IV) line.

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

emergency) describes the provision of BLS services, but for response to an emergency.
Emergency response is defined as immediate response to a 911 (or similar) call. A call is
determined to be an emergency based on the information available to the dispatcher, who is
expected to follow existing protocols. Be familiar with these protocols for ambulance providers
to assure coding is consistent with dispatch and emergency criteria.
A0433 Advanced life support, level 2 (ALS2) requires three or more different administrations
of medications by IV push/bolus or by continuous infusion, excluding crystalloid, hypotonic,
isotonic, and hypertonic solutions (dextrose, normal saline, Ringer’s lactate), or medically
necessary ground transportation, supplies and services, and the provision of at least one of
the following ALS procedures:

 Manual defibrillation/cardioversion
 Endotracheal intubation including the monitoring and maintenance of an endotracheal tube
that was inserted prior to the transport, which also qualifies as an ALS2 procedure.
 Central venous line
 Cardiac pacing
 Chest decompression
 Surgical airway
 Intraosseous line

A0434 Specialty care transport (SCT) is an 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. SCT is required
 when a beneficiary’s condition requires ongoing care that must be provided by one or more
health professionals in an appropriate specialty area (e.g., emergency, critical care nursing,
emergency medicine, respiratory care, cardiovascular care, or a paramedic with additional
training).
Be cautious when using this code for chronic ventilator-dependent patients whose transport
would not qualify for SCT unless their condition is considered acute or the patient has
developed emergency signs and symptoms for other conditions.

Air Ambulance Services

The two categories of air ambulance services are fixed wing (airplane) and rotary wing
(helicopter). The air ambulance mileage rate is calculated per actual loaded (patient onboard)
miles flown, and is expressed in statute miles (not nautical miles).
A0430 Ambulance service, conventional air services, transport, one way (fixed wing). Fixed
wing air ambulance (FW) is used when the patient’s medical condition requires immediate and
rapid transportation that can’t be provided by ground ambulance either because the point of
pick-up is inaccessible, the nearest hospital with appropriate facilities is far away, or the road
is impassable due to heavy traffic or other obstacles. Mileage is identified with A0435 Fixed
wing air mileage, per statute mile.
A0431 Ambulance service, conventional air services, transport, one way (rotary wing). Rotary
wing air ambulance (RW) service is used when a patient requires rapid transportation due to
medical condition, and there are transportation challenges applicable to fixed wing
transportation (traffic, distance, etc.). Report mileage using A0436 Rotary wing air mileage,
per statute mile.
A0888 Noncovered ambulance mileage, per mile (e.g., for miles traveled beyond closest
appropriate facility). Report this code when the reason for the ambulance trip is not covered
by Medicare, and you do not expect Medicare payment.

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