Guidelines/Instructions:
Submit CPT modifier 76 with ambulance transports (HCPCS codes A0425-A0999) indicate that a second trip occurred on the same date of service with the same origin/destination modifiers.

This modifier may be submitted with a second, same day 'identical ambulance transport' when the transports are:

• On the same date of service
• For the same Medicare beneficiary
• For the same billed amount
• Submitted with the same HCPCS code

Example: Two identical, medically necessary round-trip ambulance transports take place for the same beneficiary on the same date of service. In this example, the trips are between a residence and hospital.

• Submit the first round-trip ambulance transport claim with HCPCS code/modifer A0428RH on first detail line and HCPCS code/modifier A0425RH on second detail line
• Submit the second round-trip ambulance transport claim with HCPCS code/modifer and CPT modifier A0428RH76 on first detail line and HCPCS code/modifer and CPT modifier A0425RH76 on the second detail line
• Note: it is important to submit the origin/destination HCPCS modifiers in the first position and CPT modifier 76 in the second position

Important: Supporting documentation must be maintained to support the medical necessity of all ambulance transports.

Palmetto GBA will not change a code submitted or add any modifier that may be required for payment when processing your claim.