Ambulance modifiers
Modifiers identifying the place of origin and destination of the ambulance trip must be submitted on all ambulance claims. The modifier is to be placed next to the Health Care Procedure Coding System code billed.
Origin and destination modifiers used for ambulance services are created by combining two alpha characters. The first letter must describe the origin of the transport, and the second letter must describe the destination.
Note: Claims submitted without origin and destination modifiers will be rejected as unprocessable. First Coast will no longer be issuing additional documentation requests to solicit required missing claim data.
These modifiers should be reported first on the claim. The additional modifiers listed below should be reported after the origin and destination modifiers.
Example: If a patient is transported from their residence to the hospital, the modifier to describe the origin and destination would be "RH".
Use the following modifiers for ambulance billing:
| Origin/Destination | 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) |
Additional modifiers
| Origin/Destination | Description |
|---|---|
| GM | Multiple patients on one ambulance trip |
| QL |
Patient pronounced dead after ambulance called Reference: Ground Ambulance Transport Services and Deceased Beneficiaries |
In addition, institutional-based providers must report one of the following modifiers with every HCPCS code to describe whether the service was provided under arrangement or directly.
| Origin/Destination | Description |
|---|---|
| QM | Ambulance service provided under arrangement by a provider of services |
| QN | Ambulance service furnished directly by a provider of services |
Transports not medically necessary
| Origin/Destination | Description |
|---|---|
| GY | Item or service is statutorily excluded or does not meet the definition of any Medicare benefit |
Use modifier GY to report ambulance services for patients whose conditions do not meet the requirements for coverage or for whom ambulance transportation is non-covered.
Note: Ambulance transports involving hospice patients should be referred to the Hospice contractor for coverage and billing guidance.
Hospice
Ambulance transports involving hospice patients should be referred to the hospice contractor for coverage and billing guidance.
| Origin/Destination | Description |
|---|---|
| GW | Service not related to the hospice patient's terminal condition. |
Use the GW modifier when service not related to the hospice patient's terminal condition.