HCPCS Modifiers in Ambulance Billing and Coding - Medical Billers and Coders

It is well known that Modifiers cover a broad scope of information. Although, the ICD-10 codes correspond to parts of the body, yet there are also modifiers for ambulance services and mammograms. These modifiers have been provided so as to indicate that the service or procedure has been altered by some specific circumstance, but has not been changed in definition or code.

However, here we will be focusing on the Healthcare Common Procedure Coding System (HCPCS), also nicknamed 'hicks-picks" modifiers that directly affects reimbursement with respect to Ambulance Billing and coding. HCPCS modifiers also allow for greater accuracy in coding and can be extremely important in the reimbursement process, making for a more effective Revenue Cycle Management (RCM) process.

Few pointers to remember when employing modifiers:

  • Modifiers identifying the place of origin and destination of the ambulance trip must be submitted on all ambulance claims. The first letter must describe the origin of the transport, and the second letter must describe the destination.
  • Modifiers may be appended to HCPCS/CPT codes only if the clinical circumstances justify the use of the modifier. A modifier should not be appended to an HCPCS/CPT code solely to bypass an NCCI edit if the clinical circumstances do not justify its use. If the Medicare program imposes restrictions on the use of a modifier, the modifier may only be used to bypass an NCCI edit if the Medicare restrictions are fulfilled.
  • Certain coding forms provide space for multiple modifiers but payers don't always take note of modifiers listed after the first two.
  • Level II HCPCS codes are, like Level I, five characters long, but Level II codes are alphanumeric, with a letter occupying the first character of the code. These codes, like those in ICD-10 and CPT, are grouped together by the services they describe and are in numeric order.
  • HCPCS modifiers, like CPT modifiers, are always two characters and are added to the end of an HCPCS or CPT code with a hyphen. When differentiating between a CPT modifier and an HCPCS modifier: if the modifier has a letter in it, it's an HCPCS modifier. If that modifier is entirely numeric, it's a CPT modifier.

The following is a list of the only valid modifiers to be used by ambulance suppliers:

Code Description
D Diagnostic or therapeutic site other than "P" or "H"
E The residential, domiciliary, custodial facility, nursing home other than SNF (other than 1819 facility)

Hospital-based dialysis facility (hospital or hospital-related) which includes:

  • Hospital administered/Hospital located
  • Non-Hospital administered/Hospital located
H Hospital
I The site of transfer (e.g., airport, ferry, or helicopter pad) between modes of ambulance transport

Non-hospital-based dialysis facility

  • Non-Hospital administered/Non-Hospital located
  • Hospital administered/Non-Hospital located
N Skilled Nursing Facility (SNF) (1819 Facility)
P Physician's Office (includes HMO non-hospital facility, clinic, etc.)
R Residence
S The scene of Accident or Acute Event
X Destination Code Only) Intermediate stop at physician's office en route to the hospital (includes HMO non-hospital facility, clinic, etc.)

Additional modifiers for ambulance services:

GY Use when billing for statutorily excluded services. Example - Patient transport is for a non-covered condition that does not meet the definition of any Medicare benefit. The provider is expecting a denial.
QL Use when the patient is pronounced deceased after the ambulance is called. The patient is pronounced dead after the ambulance is called but before transport. Ground providers can bill a BLS service along with the QL modifier. Air providers can use the appropriate air base rate code (fixed wing or rotary wing) with the QL modifier. There will be no rural allowance or mileage billed.
GM When more than one patient is transported in an ambulance and document details of the transport. Used by both ground and air transports.
GA The provider or supplier has provided an Advance Beneficiary Notice (ABN) to the patient.
GZ The provider or supplier expects a medical necessity denial; however, did not provide an Advance Beneficiary Notice (ABN) to the patient. There are only four situations where the Limitation of Liability provision applies to ambulance suppliers. In those situations, a CMS-approved Advance Beneficiary Notice form is needed by an ambulance company to reverse the limitation of liability.

Stuck at medical billing? Know what are challenges in Credentialing, Charge Entry, Payment Posting, Benefits/Eligibility Verification, Prior Authorization, Filing claims, AR Follow Ups, Old AR, Claim Denials, resubmitting rejections with Medical Billing Company – Medical Billers and Coders.

Proper usage of the above HCPCS codes in ambulance billing and coding, along with meticulous documentation, will help in the reimbursement process and lower denial claims which affect the Revenue Cycle Management process.

Published By - Medical Billers and Coders
Published Date - Apr-04-2016 Back

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