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Jurisdiction 11 Part B
Ambulance Transports: Two Trips on the Same Date of Service

Guidelines/Instructions:
Submit CPT modifier 76 with ambulance transports (HCPCS codes A0425-A0999) to 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/modifier 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/modifier and CPT modifier A0428RH76 on first detail line and HCPCS code/modifier 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.

References:
Medicare Claims Processing Manual, Chapter 15, Section 30.1.2; and the Medicare policy Benefit Manual, Chapter 10, Section 10.3.10


 

last updated on 10/02/2012
ver 1.0.43