Ambulance Transports: Two Trips on the Same Date of Service

Guidelines and 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. Or, when the origin/destination modifiers are different but the ambulance transports are submitted with the same HCPCS code.

This modifier should be submitted with each additional trip for 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 #1
Two identical, medically necessary round-trip ambulance transports take place for the same beneficiary on the same date of service with the same origin/destination modifiers. 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

Example #2
Two or more identical, medically necessary round-trip ambulance transports take place for the same beneficiary on the same date of service with different origin/destination modifiers. In this example, the trips are between a hospital and skilled nursing facility and hospital to residence.

• Submit the first round-trip ambulance transport claim with HCPCS code/modifier A0428HN on first detail line and HCPCS code/modifier A0425HN on second detail line
• Submit the second round-trip ambulance transport claim with HCPCS code/modifier and CPT modifier A0428HR76 on first detail line and HCPCS code/modifier and CPT modifier A0425RHR76 on the second detail line
• Submit any additional claims after the second trip with the 76 CPT modifier and the applicable origin/destination modifiers

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. Identical services submitted without the 76 CPT modifier may be denied as a duplicate and will need to be resubmitted with the appropriate modifiers.

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

References