Attention: Ambulance Providers Ambulance Policy Update

Clinical Coverage Policy 15, Ambulance Services, is available on the Division of Medical Assistance (DMA) Clinical Coverage Policy web page effective Feb. 1, 2016. (See link below.) This policy supersedes the previously published Ambulance Manual.

Institution–based ambulance providers file claims using UB-04/8371, institutional claim format. Independent/private ambulance providers file claims using the CMS 1500/837P professional claim format.

Independent/private ambulance providers file one of the following Health Care Procedure Coding System (HCPCS) codes for each ambulance trip and for mileage, when applicable, on separate details on the claim: A0425, A0426, A0427, A0428, A0429, A0430, A0431, A0433, A0435, A0436 and T2003.

Institution-based providers will file RC 540, ambulance general class, with one of the above HCPCS codes for each ambulance trip, when applicable, on separate details on the claim.

All ambulance providers must report an origin and destination modifier for each ambulance trip provided. Origin and destination modifiers for ambulance services are created by combining two alpha characters. The first position character equals origin, the second position alpha character equals destination. Each alpha character, except for “X� represents an origin code or a destination code and they create one modifier. Modifier descriptions are listed in HCPCS. Provider shall refer to the applicable edition for the code description as it is no longer documented in the policy.

There are three new Explanations of Benefits (EOBs) that will post on the paper Remittance Advice (RA) for ambulance services claims:

02400 - AMBULANCE CLAIMS REQUIRE AN ORIGIN DESTINATION MODIFIER

02401 - MORE THAN ONE AMBULANCE MODIFIER WAS SUBMITTED ON SAME CLAIM LINE. IF THERE WERE MULTIPLE INDIVIDUAL TRIPS ON THE SAME DAY RESUBMIT AS SEPARATE CLAIM LINES WITH DOCUMENTATION FOR RECONSIDERATION OF PAYMENT

57740 - MISSING OR INSUFFICIENT DOCUMENTATION TO SUPPORT PAYMENT OF AN AMBULANCE SERVICE BILLED WITH SAME DATE OF SERVICE AS A PAID AMBULANCE SERVICE

Ambulance providers may see a slight increase in denials if another ambulance claim was submitted with the same date of service. Ambulance providers should submit documentation electronically instead of paper for more efficient and quicker claim resolution and possibly expedited payment.

Ambulance Providers should reference the updated Fact Sheet and billing Job Aid – Submit an Ambulance Claim available in SkillPort on the NCTracks Provider Portal, as well as the DMA Clinical Coverage Policies webpage.

[This article was derived from the February 2016 Medicaid Bulletin.]