When a patient’s medical condition requires emergency transportation or the patient is non-ambulatory, ambulance services are the preferred method to ensure the patient receives the necessary level of care during the trip and arrives at the nearest, appropriate facility. Ambulance providers must be licensed according to the specific level of care they provide and bill for; consequently, all responders are required to hold the corresponding professional certifications and training qualifications. Depending on the requirements in your health plan’s state, where the ambulance service is furnished, basic-life-support [BLS] and advanced-life-support [ALS] transportation will require specific staffing levels and certifications for the first responders.
To ensure patient survival, first responders should bill for the level of care provided, as many medical conditions and situations necessitate higher levels of treatment and transportation. When appropriate, the ambulance provider may bill for disposable supplies or services commensurate with a higher level of care, such as defibrillation, IV drug therapy, and esophageal intubation. In addition to emergency service, health plans may also provide ambulance transportation as a benefit for patients who receive dialysis at a clinic. Finally, some medical situations may require some level of care from a first responder and no transportation to a facility, which is billable under a specific HCPCS code.
Ambulance Service Procedure Codes and Modifiers
Ground transportation with basic ground mileage is the most billed combination of ambulance service codes to a health plan. Air transportation is the most expensive but is billed less often.
Table 1 below categorizes the HCPCS codes by mode of transport, mileage, services, and supplies.
| Ground Transport | Air Transport | Mileage [All modes] | Supplies or Services | Specialty Transport |
| A0427 [ALS] | A0430 [Fixed wing] | A0425 [Ground] | A0382 [BLS} | A0225 [Neonatal] |
| A0429 [BLS] | A0431 [Rotary wing] | A0435 [Fixed wing] | A0384 [BLS] | A0424 [Extra staff] |
| A0436 [Rotary wing] | A0392 [ALS] | A0426 [ALS NEMT] | ||
| A0021 [Medicaid] | A0394 [ALS] | A0428 [BLS NEMT] | ||
| A0380 [BLS] | A0396 [ALS] | A0432 [Paramedic] | ||
| A0390 [ALS] | A0398 [ALS] | A0433 [ALS-2] | ||
| A0420 [Wait time] | A0434 [SCT] | |||
| A0422 [Oxygen] | ||||
| A0888 [Non-covered] | ||||
| A0998 [Treatment only] | ||||
| A0999 [Unlisted] |
Ambulance providers are required to submit a HCPCS modifier code that defines the origin and destination for the trip. The provider denotes the origin as the first letter, and the destination is the second letter in the two-character combination, which is carried as a modifier code in the medical claims data. Some combinations of origin and destination codes are inappropriate and unpayable for ambulance transportation, such as a physician’s office to a residence.
Table 2 below displays the origin/destination codes that must be combined to define the ambulance transportation scenario.
| Origin / Destination | Origin / Destination Code Description |
| D | Diagnostic or therapeutic site other than P or H when these are used as origin codes |
| E | Residential, domiciliary, custodial facility (other than 1819 facility) |
| G | Hospital based ESRD facility |
| H | Hospital |
| I | Site of transfer (e.g. airport or helicopter pad) between modes of ambulance transport |
| J | Freestanding ESRD facility |
| N | Skilled nursing facility |
| P | Physician’s office |
| R | Residence |
| S | Scene of accident or acute event |
| X | Intermediate stop at physician’s office on way to hospital (This is a destination code only) |
Less common billing scenarios include ambulance transportation with multiple patients in one trip, patients who expire prior to the ambulance arrival, patients that expire after the ambulance arrival and prior to loading, or patients who expire during the ambulance trip. Codoxo suggests reviewing federal and state regulations as well as your health plan policies regarding payment for less common ambulance transportation scenarios when one of the payment effective modifiers listed in Table 3 is present on the claim.
Table 3 below displays HCPCS modifiers that are payment effective based on the transportation scenario for an ambulance provider.
| HCPCS modifiers | Code Description |
| GM | Multiple patients on one ambulance trip |
| GW | Service not related to the hospice patient’s terminal condition. |
| GY | Item or service is statutorily excluded or does not meet the definition of any Medicare benefit |
| QL | Patient pronounced dead after ambulance called |
| QM | Ambulance service provided under arrangement by a provider of services |
| QN | Ambulance service furnished directly by a provider of services |
What are some examples of inappropriate or unsupported ambulance services?
While some ground, air, or specialty-care transportation scenarios can be scheduled and pre-authorized, nearly all emergency medical situations requiring ambulance transportation are post-service authorizations, which can lead to issues with verifying the necessity and legitimacy of an ambulance service. The potential for fraud, waste, abuse, and errors [FWAE] with ambulance services include, but are not limited to, billing for:
- Medically unnecessary services, i.e., billing for a wheelchair van for an ambulatory patient
- Services not rendered, i.e., no supporting documentation for billed services
- Excessive mileage, i.e., padding the mileage coding with additional miles
- Non-covered destinations, i.e., inappropriate origin and destination combinations
- Upcoding, i.e., billing ALS at a significantly higher percentage than BLS
- Kickback schemes, i.e., incentivizing facilities for referrals leading to unnecessary trips
- Falsifying trip reports, i.e., altering records to make the trip or services appear necessary
Numerous ambulance providers have been prosecuted and fined by federal and state law enforcement agencies for one or more of the above-listed issues. Please refer to the news articles and litigation defense websites listed in the references section for examples of ambulance providers prosecuted for fraud.
How can Codoxo assist your health plan with identifying potential FWAE with ambulance claims?
Codoxo’s AI Query is our generative AI query tool for Fraud Scope, allowing our partners to quickly and effectively query their claims data for billing and patient history scenarios. AI Query employs natural language to request and collect summary-level information as well as claim-line details from our partners’ claims data.
Codoxo used AI Query to identify thousands of ambulance transportation claim lines for one health plan totaling more than $2 million in payments, where no supporting facility claims or professional claims appeared in the patient histories on the same day or within two days after the ambulance service. Additionally, Codoxo’s AI compared the patient identities to the member file to ensure the patients were not listed as deceased. As part of the validation process with our partner plan, we reviewed several high-cost air transport claims, which included a deeper examination of patient and claims details. During one of the reviews, it became apparent that the patient was involved in a work-related accident, which prompted the plan to further assess their identification of such scenarios and implement improved claims management of subrogation issues. For the other claims, there was no record of the patient expiring and no record of a supporting facility or professional claim.
AI Query alleviates the burden for users by reducing the need to request, collect, organize, and sift through hundreds of thousands of claim lines and patient histories to identify unsupported ambulance claims. AI Query is an invaluable tool for health plans to identify common and novel billing scenarios related to potential fraud, waste, abuse, and errors.
If you are interested in learning more about Codoxo’s AI Query tool, contact us at info@codoxo.com.
To learn more about Fraud Scope, visit: https://www.codoxo.com/healthcare-fraud-scope/
References:
Centers for Medicare and Medicaid Services – Policies and guidance for ambulance services
Medicare Benefit Policy Manual: Chapter 10 – Ambulance Services
Department of Justice News
Office of Inspector General News
Guam Ambulance Company Owners Sentenced to Prison for Their Roles in Medicare Ambulance Fraud Scheme
Litigation, compliance, and defense websites
DOJ Targets Medicare Fraud Involving Ambulance and Ambulette Transportation Services