016.06.09 Ark. Code R. 022 - Provider Manual Update Transmittal #123 - Transportation

Section IITransportation

251.100 Ground Ambulance Mileage

Ground ambulance providers must use procedure code A0425 to claim mileage for ground ambulance transportation, regardless of licensure level of the provider or transporting ambulance. Mileage must be rounded to the nearest mile. Actual ground ambulance mileage should be documented on the ambulance provider's patient care report.

252.100 Ambulance Procedure Codes

A0382	A0390	A0398	A0422	A0425	A0426	A0427	A0429
J0150*	J0170*	J0280*	J0460*	J1094*	J1100*	J1160*	J1200*
J1265	J1940*	J2060*	J2175*	J2270*	J2310*	J2550*	J2560*
J3360*	J3410*	J3475*	J3480*	J3490*	93041*

*Procedure code can be billed only in conjunction with procedure code A0427.

Procedure Code	Required Modifier	Description
A0422	U1	Emergency, oxygen, helicopter air ambulance
A0425	Ground mileage per statute mile.
A0428	Ambulance service, ILS intermediate transport, mileage and disposable supplies billed separately
A0431	Ambulance service, emergency, basic pick-up, helicopter, one unit per day
A0434	Air Ventilator/Respiratory Therapist, one unit equals one hour (Round to the nearest hour.)
A0435	U1, UB	Piston propelled fixed wing air ambulance per mile
U2, UB	Turboprop fixed wing air ambulance per mile
U3, UB	Jet (fixed wing) one unit equals one mile
U4, UB	Piston propelled fixed wing air ambulance per hour (Round to the nearest hour.)
U5, UB	Turboprop fixed wing air ambulance per hour (Round to the nearest hour.)
U6, UB	Jet (fixed wing) one unit equals one hour (Round to the nearest hour.)
A0436	Emergency, per mile, loaded, helicopter air ambulance
T2002**	Non-emergency ground ambulance transportation, hospital to nursing facility

"Procedure code must be billed on a paper CMS-1500 claim form with the supporting documentation listed in section 213.100.

Notes

016.06.09 Ark. Code R. 022

8/12/2009