CMS Pub. 100-04, ch. 15, § 30.2

For SNF Part A, the cost of medically necessary ambulance transportation to receive most

services included in the RUG rate is included in the cost for the service. Payment for the SNF

claim is based on the RUGs, which takes into account the cost of such transportation to receive

the ancillary services.

Refer to Pub. 100-04, Medicare Claims Processing Manual, chapter 6 - SNF Inpatient Part A

Billing, Section 20.3.1 - Ambulance Services, for additional information on SNF consolidated

billing and ambulance transportation.

Refer to Pub. 100-04, Medicare Claims Processing Manual, chapter 3 - Inpatient Hospital

Billing, section 10.5 - Hospital Inpatient Bundling, for additional information on hospital

inpatient bundling of ambulance services.

In general, the A/B MAC (A) processes claims for Part B ambulance services provided by an

ambulance supplier under arrangements with hospitals or SNFs. These providers bill A/B

MACs (A) using only Method 2.

The provider must furnish the following data in accordance with A/B MAC (A) instructions.

The A/B MAC (A) will make arrangements for the method and media for submitting the data:

• A detailed statement of the condition necessitating the ambulance service;

• A statement indicating whether the patient was admitted as an inpatient. If yes

the name and address of the facility must be shown;

• Name and address of certifying physician;

• Name and address of physician ordering service if other than certifying

physician;

• Point of pickup (identify place and completed address);

• Destination (identify place and complete address);

• Number of loaded miles (the number of miles traveled when the beneficiary was

in the ambulance);

• Cost per mile;

• Mileage charge;

• Minimum or base charge; and

• Charge for special items or services. Explain.

A. General

The reasonable cost per trip of ambulance services furnished by a provider of services may not

exceed the prior year’s reasonable cost per trip updated by the ambulance inflation factor. This

determination is effective with services furnished during Federal Fiscal Year (FFY) 1998

(between October 1, 1997, and September 30, 1998). Providers are to bill for Part B ambulance

services using the billing method of base rate including supplies, with mileage billed separately

as described below.

The following instructions provide billing procedures implementing the above provisions.

B. Applicable Bill Types

The appropriate type of bill (13X, 22X, 23X, 83X, and 85X) must be reported. For SNFs,

ambulance cannot be reported on a 21X type of bill.

C. Value Code Reporting

For claims with dates of service on or after January 1, 2001, providers must report on every Part

B ambulance claim value code A0 (zero) and the related ZIP Code of the geographic location

from which the beneficiary was placed on board the ambulance in the Value Code field. The

value code is defined as “ZIP Code of the location from which the beneficiary is initially placed

on board the ambulance.” Providers report the number in dollar portion of the form location

right justified to the left of the dollar/cents delimiter.

More than one ambulance trip may be reported on the same claim if the ZIP Codes of all points

of pickup are the same. However, since billing requirements do not allow for value codes (ZIP

Codes) to be line item specific and only one ZIP Code may be reported per claim, providers

must prepare a separate claim for a beneficiary for each trip if the points of pickup are located in

different ZIP Codes.

For claims with dates of service on or after April 1, 2002, providers must report value code 32

(multiple patient ambulance transport) when an ambulance transports more than one patient at a

time to the same destination. Providers must report value code 32 and the number of patients

transported in the amount field as a whole number to the left of the delimiter.

NOTE: Information regarding the claim form locator that corresponds to the Value Code field

is found in Pub.100-04, Medicare Claims Processing Manual, Chapter 25 - Completing and

Processing the Form CMS-1450 Data Set.

D. Revenue Code/HCPCS Code Reporting

Providers must report revenue code 054X and, for services provided before January 1, 2001,

one of the following CMS HCPCS codes for each ambulance trip provided during the billing

period:

A0030 (discontinued 12/31/2000); A0040 (discontinued 12/31/2000);

A0050 (discontinued 12/31/2000); A0320 (discontinued 12/31/2000); A0322 (discontinued

12/31/2000); A0324 (discontinued 12/31/2000); A0326 (discontinued 12/31/2000); A0328,

(discontinued 12/31/2000); or A0330 (discontinued 12/31/2000).

In addition, providers report one of A0380 or A0390 for mileage HCPCS codes. No other

HCPCS codes are acceptable for reporting ambulance services and mileage. Providers report

one of the following revenue codes:

0540;

0542;

0543;

0545;

0546; or

0548.

Do not report revenue codes 0541, 0544, or 0547.

For claims with dates of service on or after January 1, 2001, providers must report revenue

code 540 and one of the following HCPCS codes for each ambulance trip provided during the

billing period:

A0426; A0427; A0428; A0429; A0430; A0431; A0432; A0433; or A0434.

Providers using an ALS vehicle to furnish a BLS level of service report HCPCS code, A0426

(ALS1) or A0427 (ALS1 emergency), and are paid accordingly. In addition, all providers

report one of the following mileage HCPCS codes: A0380; A0390; A0435; or A0436.

Since billing requirements do not allow for more than one HCPCS code to be reported for per

revenue code line, providers must report revenue code 0540 (ambulance) on two separate and

consecutive lines to accommodate both the Part B ambulance service and the mileage HCPCS

codes for each ambulance trip provided during the billing period. Each loaded (e.g., a patient is

onboard) 1-way ambulance trip must be reported with a unique pair of revenue code lines on the

claim. Unloaded trips and mileage are NOT reported.

However, in the case where the beneficiary was pronounced dead after the ambulance is

called/dispatched but before the ambulance arrives at the scene: Payment may be made for a

BLS service if a ground vehicle is dispatched or at the fixed wing or rotary wing base rate, as

applicable, if an air ambulance is dispatched. Neither mileage nor a rural adjustment would be

paid. The blended rate amount will otherwise apply. Providers or suppliers report the A0428

(BLS) non-emergency or A0429 (BLS) emergency transport HCPCS code if an emergency

response and modifier QL (Patient pronounced dead after ambulance called) in “HCPCS/Rates”

instead of the origin and destination modifier for ground vehicles. In addition to the QL

modifier, institutional-based providers report modifier QM or QN. If the time of death

pronouncement is after takeoff to point of pickup but before the beneficiary is loaded on-board

the air ambulance, air ambulance providers or suppliers bill the A0430 or A0431 depending on

the type of aircraft and modifier QL.

If the ambulance is called/dispatched but the beneficiary dies on the scene prior to the arrival of

the ambulance: Payment may be made for BLS service if a ground vehicle is dispatched or at

the fixed wing or rotary wing base rate, as applicable, if an air ambulance is dispatched.

Neither mileage nor a rural adjustment would be paid. Providers or suppliers report the A0428

(BLS) non-emergency or A0429 (BLS) emergency transport HCPCS code if an emergency

response and modifier QL for ground vehicles. Air ambulance providers or suppliers bill the

A0430 or A0431 depending on the type of aircraft and modifier QL, if the time of death

pronouncement is after takeoff to point of pickup but before the beneficiary is loaded on-board

the air ambulance.

If the beneficiary dies after the ambulance is dispatched but before the beneficiary is loaded

onboard the ambulance (before or after arrival at the point-of-pickup): Medicare payment

determination is provider’s or supplier’s BLS base rate, no mileage or rural adjustment; providers or

suppliers report the A0428 (BLS) non-emergency or A0429 (BLS) emergency transport HCPCS

code if an emergency response and modifier QL. However, if the beneficiary dies after pickup,

prior to or upon arrival at the receiving facility: Medically necessary level of service furnished

will be the payment determination.

NOTE: Information regarding the claim form locator that corresponds to the HCPCS code is

found in Pub. 100-04, Medicare Claims Processing Manual, Chapter 25 - Completing and

Processing the Form CMS-1450 Data Set.

E. Modifier Reporting

See the above Section 30 (A) (Modifiers Specific to Ambulance Service Claims) for

instructions regarding the usage of modifiers.

F. Line-Item Dates of Service Reporting

Providers are required to report line-item dates of service per revenue code line. This means

that they must report two separate revenue code lines for every ambulance trip provided during

the billing period along with the date of each trip. This includes situations in which more than

one ambulance service is provided to the same beneficiary on the same day. Line-item dates of

service are reported in the Service Date field.

NOTE: Information regarding the claim form locator that corresponds to the Service Date is

found in Pub. 100-04, Medicare Claims Processing Manual, Chapter 25 - Completing and

Processing the Form CMS-1450 Data Set.

G. Service Units Reporting

For line items reflecting HCPCS code A0030, A0040, A0050, A0320, A0322, A0324, A0326,

A0328, or A0330 (services before January 1, 2001) or code A0426, A0427, A0428, A0429,

A0430, A0431, A0432, A0433, or A0434 (services on and after January 1, 2001), providers

are required to report in Service Units each ambulance trip provided during the billing period.

Therefore, the service units for each occurrence of these HCPCS codes are always equal to one.

In addition, for line items reflecting HCPCS code A0380 or A0390, the number of loaded miles

must be reported. (See examples below.)

Therefore, the service units for each occurrence of these HCPCS codes are always equal to one.

In addition, for line items reflecting HCPCS code A0380, A0390, A0435, or A0436, the number

of loaded miles must be reported.

H. Total Charges Reporting

For line items reflecting HCPCS codes A0426, A0427, A0428, A0429, A0430, A0431, A0432,

A0433, or A0434;

Providers are required to report in Total Charges the actual charge for the ambulance service

including all supplies used for the ambulance trip but excluding the charge for mileage. For line

items reflecting HCPCS code A0380, A0390, A0435, or A0436, report the actual charge for

mileage.

NOTE: There are instances where the provider does not incur any cost for mileage, e.g., if the

beneficiary is pronounced dead after the ambulance is called but before the ambulance arrives at

the scene. In these situations, providers report the base rate ambulance trip and mileage as

separate revenue code lines. Providers report the base rate ambulance trip in accordance with

current billing requirements. For purposes of reporting mileage, they must report the

appropriate HCPCS code, modifiers, and units as a separate line item. For the related charges,

providers report $1.00 in FL48 for non- covered charges. A/B MACs (A) should assign

remittance adjustment Group Code OA to the $1.00 non- covered mileage line, which in turn

informs the beneficiaries and providers that they each have no liability.

Prior to submitting the claim to CWF, the A/B MAC (A) will remove the entire revenue code

line containing the mileage amount reported in Non-covered Charges to avoid non-acceptance

of the claim.

NOTE: Information regarding the claim form locator that corresponds to the Charges fields is

found in Pub. 100-04, Medicare Claims Processing Manual, Chapter 25 - Completing and

Processing the Form CMS-1450 Data Set.

EXAMPLES: The following provides examples of how bills for Part B ambulance services

should be completed based on the reporting requirements above. These examples reflect

ambulance services furnished directly by providers. Ambulance services provided under

arrangement between the provider and an ambulance company are reported in the same manner

except providers report a QM modifier instead of a QN modifier.

EXAMPLE 1: Claim containing only one ambulance trip:

Providers report as follows:

Revenue

Code

HCPCS/

Modifiers

Date of

Service

Units Total Charges

0540 A0428RHQN 082701 1 (trip) 100.00

0540 A0380RHQN 082701 4 (mileage) 8.00

EXAMPLE 2: Claim containing multiple ambulance trips:

Providers report as follows:

Revenue

Code

HCPCS Modifiers Date of

Service

Units Total

Charges

#1 #2

0540 A0429 RH QN 082801 1 (trip) 100.00

0540 A0380 RH QN 082801 2 (mileage) 4.00

0540 A0330 RH QN 082901 1 (trip) 400.00

0540 A0390 RH QN 082901 3 (mileage) 6.00

EXAMPLE 3: Claim containing more than one ambulance trip provided on the same day:

Providers report as follows:

Revenue

Code

HCPCS Modifiers Date of

Service

Units Total

Charges

0540 A0429 RH QN 090201 1 (trip) 100.00

0540 A0380 RH QN 090201 2 (mileage) 4.00

Revenue

Code

HCPCS Modifiers Date of

Service

Units Total

Charges

0540 A0429 HR QN 090201 1 (trip) 100.00

0540 A0380 HR QN 090201 2 (mileage) 4.00

I. Edits

FISS edits to assure proper reporting as follows:

• For claims with dates of service on or after January 1, 2001, each pair of revenue

codes 0540 must have one of the following ambulance HCPCS codes - A0426,

A0427, A0428, A0429, A0430, A0431, A0432, A0433, or A0434; and one of the

following mileage HCPCS codes - A0435, A0436 or for claims with dates of

service on or after April 1, 2002, A0425;

• For claims with dates of service on or after January 1, 2001, the presence of an

origin and destination modifier and a QM or QN modifier for every line item

containing revenue code 0540;

• The units field is completed for every line item containing revenue code 0540;

• For claims with dates of service on or after January 1, 2001, the units field is

completed for every line item containing revenue code 0540;

• Service units for line items containing HCPCS codes A0426, A0427, A0428,

A0429, A0430, A0431, A0432, A0433, or A0434 always equal “1"

For claims with dates of service on or after July 1, 2001, each 1-way ambulance trip, line- item

dates of service for the ambulance service, and corresponding mileage are equal.