Carrier – Ambulance Services - Claims Processing (Rev. 1040, 09-11-06)

by  Jared Staheli
June 25th, 2015

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) nonhospital 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.

References:

• Pub 100-04 Medicare Claims Processing Manual - Chapter 19