CurrentFlorida BluePolicy 18-061

Ambulance Services

Defines Florida Blue's reimbursement and billing rules for ground and air ambulance transports, including required modifiers, mileage reporting, and items bundled into the ambulance allowance; applies to all lines of business and providers billing Florida Blue.

Policy Summary

PayerFlorida Blue

PolicyAmbulance Services

Policy CodePolicy 18-061

Change TypeClarified billing forms; added revenue codes

Effective DateJul 19, 2018

Next Review Date

Key ActionReport the appropriate two-character origin/destination modifier (first = origin, second = destination) on each ambulance service line.

SourceLink

POLICY UPDATE CHANGES

Clarifying language added to indicate this policy applies to billing for services on a CMS-1500 or equivalent claim form, or a facility (UB-04) claim form.

Revenue codes were added to the policy.

A0425-A0436HCPCS codes listed

7 ground, 2 airService categories

Origin+DestinationModifier requirement

<=100 / >100Mileage rules

BundledInpatient round-trip

Policy Summary

PayerFlorida Blue

PolicyAmbulance Services

Policy CodePolicy 18-061

Change TypeClarified billing forms; added revenue codes

Effective DateJul 19, 2018

Next Review Date

Key ActionReport the appropriate two-character origin/destination modifier (first = origin, second = destination) on each ambulance service line.

SourceLink

On This Page

Ambulance Coverage and Billing Rules

Ambulance coverage rules

Coverage and billing rules for ambulance services.

Ambulance services are covered when billed in accordance with the policy's coding and billing requirements; each ambulance trip requires an appropriate transportation HCPCS code and the appropriate two-character origin/destination modifier (first position = origin, second position = destination).

Mileage must be reported for each trip and billed with the appropriate mileage HCPCS code: ground mileage with A0425 and air mileage with A0435/A0436.

ALL of the following

For trips up to 100 covered miles, round total miles up to the nearest tenth and report with a decimal (e.g., 99.9).
For trips totaling 100 covered miles and greater, round total miles up to the next whole mile and report without a decimal (e.g., 998.5 -> 999).

Items included (bundled) in the ambulance transportation allowance and not separately reimbursed: waiting time; disposable and non-disposable supplies (including but not limited to oxygen, inflatable leg and arm splints, backboards, and neck boards/collars); EKGs; drugs; extra attendants; and similar services.

Round-trip transports for hospital inpatients are included in the facility fee paid to the admitting hospital and are not reimbursed separately.

ALL of the following

To report transport with more than one patient onboard, use modifier GM on each service line and include the total number of patients transported on the claim line. GM may be used for ground and air transports.
Do not report ambulance transportation if the member was legally pronounced dead before the ambulance was dispatched. If the member is pronounced dead after dispatch, report the transport and append modifier QL (Patient pronounced dead after ambulance called).

HCPCS codes to be used for ambulance services include A0425–A0436 (ground and air transport codes including mileage and service level codes). Use the appropriate code for the service provided (e.g., A0426/A0427 for ALS1, A0428/A0429 for BLS, A0430/A0431/A0433/A0434 for air and specialty transports).

Revenue code guidance: Ambulance-related revenue lines include codes such as 540 (Ambulance/General), 542 (Ambulance/Medical Transport), 543 (Ambulance Heart Mobile), 545 (Air Ambulance), 546 (Neonatal Ambulance), and 548 (Telephone Transmission EKG - AMBULANCE).

Claims may be submitted on the appropriate claim form (CMS-1500 or equivalent for suppliers, or UB-04 for facility billing) as applicable to the provider type.

Ambulance Codes and Mileage Reporting

HCPCS ambulance codesHCPCS

A0425	Ground mileage, per statute mile
A0426	Ambulance service, advanced life support, non-emergency transport, level 1 (ALS 1)
A0427	Ambulance service, advanced life support, emergency transport, level 1 (ALS 1- emergency)
A0428	Ambulance service, basic life support, non-emergency transport (BLS)
A0429	Ambulance service, basic life support, emergency transport (BLS-emergency)
A0430	Ambulance service, conventional air services, transport, one way (fixed wing)
A0431	Ambulance service, conventional air services, transport, one way (rotary wing)
A0433	Advanced life support, level 2 (ALS 2)
A0434	Specialty care transport (SCT)
A0435	Fixed wing air mileage, per statute mile

1–10 of 11

1/2

Mileage rounding rules

Rounding for trips <= 100 milesRound total miles up to the nearest tenth of a mile and report with a decimal (example: 99.9).

Rounding for trips >= 100 milesRound total miles up to the next whole mile and report without a decimal (example: 998.5 -> 999).

Reporting formatReport ground mileage using the HCPCS mileage code (A0425) with the rounded value in the decimal format when required; air mileage is reported as actual statute miles for A0435/A0436.

Billing, Modifiers, and Special Reporting

Billing Rule

Modifier and special-case reporting

Use a two-character origin/destination modifier pair on every ambulance service line: the first character = origin, the second = destination. Do not omit this pair — failure to include a valid two-character modifier may result in claim return or denial. Include other applicable two-character or single-character modifiers on the same service line as needed (see items).

Origin/destination modifier = two alpha characters (first = origin, second = destination). Each alpha (except 'X') may represent an origin or destination; X is used only as a destination for an intermediate stop at a physician's office.
Examples of origin/destination codes: D = diagnosis/therapeutic site (other than P or H); E = residential/domiciliary/custodial facility; G = hospital-based ESRD facility; H = hospital; I = site of transfer (e.g., airport/helipad); J = freestanding ESRD facility; N = skilled nursing facility (SNF); P = physician's office; R = residence; S = scene of accident/acute event; X = intermediate stop at a physician's office (destination only).
When multiple patients are on the same ambulance trip, report modifier GM on each service line and include the total number of patients transported on the claim.
Use modifier QL when patient was pronounced dead after the ambulance was dispatched (do not report transport if patient pronounced dead before dispatch).
If ambulance service is provided under arrangement by a provider of services, report QM; if furnished directly by a provider of services, report QN. These are in addition to the two-character origin/destination modifier where applicable.

Ambulance Categories and Definitions

BLS — definition

TermBasic Life Support (BLS)

ScopeGround ambulance category including non-emergency and emergency BLS transports.

NotesGround ambulance services refer to both land and water transportation.

ALS1 — definition

TermAdvanced Life Support, Level 1 (ALS1)

ScopeGround ambulance category including non-emergency and emergency ALS1 transports (ALS1 and ALS1 - Emergency).

Notes