CMS Pub. 100-04, ch. 19, § 80.3.1

Medically necessary ambulances provided by an IHS ambulance supplier are paid based

upon Chapter 15 of Pub. 100-04, Medicare Claims Processing Manual. Suppliers must

report an origin and destination code for each ambulance service billed.

Modifier Reporting -

Origin and destination modifiers used for ambulance services are created by combining

two alpha characters. Each alpha character, with the exception of “x”, represents an

origin code or a destination code. The pair of alpha codes creates one modifier. The first

position alpha code equals origin; the second position alpha code equals destination.

Origin and destination codes are listed below:

D - Diagnostic or Therapeutic Center other than P or H when these are used as

origin codes

E - Residential, Domiciliary, Custodial Facility (Other than an 1819 Facility)

G - Hospital based dialysis facility (hospital or hospital related)

H - Hospital

I - Site of Transfer (e.g., airport or helicopter pad) between modes of ambulance

transport

J - Nonhospital based dialysis facility

N - SNF (1819 Facility)

P - Physician's Office (Includes health maintenance organization (HMO) non-hospital facility, clinic, etc.)

R - Residence

S - Scene of Accident or Acute Event

X - (Destination code only) intermediate stop at physician's office enroute to the

hospital (includes HMO non-hospital facility, clinic, etc.)

All claims processing requirements in Chapter 15 of Pub. 100-04, Medicare Claims

Processing Manual, shall apply to ambulance claims submitted by IHS independent

ambulance suppliers.

The MSN is suppressed.