Local Coverage Article Billing and Coding

Billing and Coding: Ambulance Services (Ground Ambulance)

A54574

Expand All | Collapse All

Contractor Information

Article Information

General Information

Article ID
A54574
Article Title
Billing and Coding: Ambulance Services (Ground Ambulance)
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
10/01/2021
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2021 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2021 American Dental Association. All rights reserved.

Copyright © 2013 - 2022, the American Hospital Association, Chicago, Illinois. Reproduced by CMS with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312-893-6816. Making copies or utilizing the content of the UB-04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. To license the electronic data file of UB-04 Data Specifications, contact Tim Carlson at (312) 893-6816. You may also contact us at ub04@aha.org.

CMS National Coverage Policy

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L35162, Ambulance Services (Ground Ambulance). Please refer to the LCD for reasonable and necessary requirements.

Coding Guidance

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

The Medicare ambulance benefit is for transportation of a beneficiary. Payment for ambulance services is only made to the provider/supplier that provides the transport regardless of how many providers/suppliers respond to a request for an ambulance.

In order for claims to be processed and paid in a timely manner it is important that claims submitted for ambulance services contain all of the required information. The information in this Article is intended to assist ambulance provider/suppliers in the proper submission of claims to ensure timely and accurate processing.

Reporting ambulance services certifies to Medicare that the ambulance provider believes the code description reasonably reflects the condition of the patient at the time of transport and that the patient’s condition was consistent with the requirements of the Medicare ambulance transportation benefit.

It is the provider’s responsibility to supply the contractor with information describing the condition of the patient that necessitated ambulance transportation. Medicare recognizes limitations of usual ambulance personnel for establishing a diagnosis and recognizes, therefore, that diagnosis coding of a patient’s condition using ICD-10-CM codes when reporting ambulance services may be less specific than for services reported by other professional providers. Also, selected ICD-10-CM diagnosis codes from the CMS condition code list are included with instructions to use them in a manner that is contrary to usual ICD-10-CM coding conventions. Providers who submit ICD-10-CM diagnosis codes should choose the code that best describes the patient’s condition at the time of transport.

The contractor recognizes that ambulance suppliers are currently not required to submit ICD-10-CM codes on their claims if filing on a 1500 claim form or utilizing an electronic version other than the 5010 version of the 837P, though their doing so facilitates timely claim adjudication. Claims without an ICD-10-CM diagnosis code are adjudicated manually utilizing the information contained in the claim’s narrative field and/or medical records (the trip/run sheet and any other records supplied to Medicare by the provider upon our request). Ambulance suppliers utilizing the 5010 version of the 837P are required to submit ICD-10-CM diagnosis code(s).

Please note that the ICD-10-CM codes provided in this Article do not represent an all-inclusive list of acceptable diagnoses. Due to the large number of diagnosis codes available, the codes are being provided only as a list of suggested diagnoses codes in an effort to assist providers/suppliers.

Providers/suppliers may choose a diagnosis code from the provided list in the coding section of this Article to report as the primary diagnosis code or they may choose a diagnosis code from the ICD-10-CM manual that accurately depicts the patient’s condition at the time of transport.

Providers should report the most appropriate ICD-10 code that adequately describes the patient’s medical condition at the time of transport as the primary diagnosis. In addition, a secondary diagnosis, from ICD-10 Code Group 3 below, must be reported.

While reporting of applicable diagnoses codes is an important part of submitting claims for ambulance services, there are other key items that need to be reported correctly in order for proper processing. The following are a few reminders of key elements that are required on all ambulance claims. (Please refer to the CMS Internet Only Manual, 100-04, Chapter 15 for complete billing requirements).

  • Date of Service: The date of service reported on the claim should be the date that the ambulance departs the point of pickup with the patient on board.
  • ZIP Code of the point of pick up: The Zip code for the location where the patient is at the time that they are placed on board the ambulance must be reported on all claims. Electronic billers must report the ZIP code for the point of origin and destination. All Zip codes should be reported with 5 numbers.
  • Service Units: For each ambulance trip represented by HCPCS codes A0426, A0427, A0428, A0429, A0433 and A0434 the units of service should be one. The units of service for HCPCS code A0425 should represent the number of loaded miles.

Coding Information

CPT/HCPCS Codes

Group 1

(9 Codes)
Group 1 Paragraph

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.

Group 1 Codes
CodeDescription
A0425 Ground mileage
A0426 Als 1
A0427 Als1-emergency
A0428 Bls
A0429 Bls-emergency
A0433 Als 2
A0434 Specialty care transport
A0888 Noncovered ambulance mileage
A0999 Unlisted ambulance service

CPT/HCPCS Modifiers

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(297 Codes)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following is a list of suggested ICD-10 codes that may be used as a primary diagnosis for transport to acute care, or for the transport on to another facility for specialty or other care.

Please note that a secondary diagnosis code is required. Secondary diagnosis codes are listed in Group 3 below.

Group 1 Codes
CodeDescription
A41.9 Sepsis, unspecified organism
B89 Unspecified parasitic disease
B96.89 Other specified bacterial agents as the cause of diseases classified elsewhere
B99.9 Unspecified infectious disease
D49.89 Neoplasm of unspecified behavior of other specified sites
E10.65 Type 1 diabetes mellitus with hyperglycemia
E10.69 Type 1 diabetes mellitus with other specified complication
E11.65 Type 2 diabetes mellitus with hyperglycemia
E11.69 Type 2 diabetes mellitus with other specified complication
E15 Nondiabetic hypoglycemic coma
E16.1 Other hypoglycemia
E16.2 Hypoglycemia, unspecified
E86.0 Dehydration
E86.1 Hypovolemia
E86.9 Volume depletion, unspecified
F05 Delirium due to known physiological condition
F06.8 Other specified mental disorders due to known physiological condition
F10.10 Alcohol abuse, uncomplicated
F10.120 Alcohol abuse with intoxication, uncomplicated
F10.121 Alcohol abuse with intoxication delirium
F10.129 Alcohol abuse with intoxication, unspecified
F10.188 Alcohol abuse with other alcohol-induced disorder
F10.231 Alcohol dependence with withdrawal delirium
F10.239 Alcohol dependence with withdrawal, unspecified
F11.10 Opioid abuse, uncomplicated
F12.10 Cannabis abuse, uncomplicated
F12.90 Cannabis use, unspecified, uncomplicated
F13.10 Sedative, hypnotic or anxiolytic abuse, uncomplicated
F14.10 Cocaine abuse, uncomplicated
F15.10 Other stimulant abuse, uncomplicated
F15.920 Other stimulant use, unspecified with intoxication, uncomplicated
F15.929 Other stimulant use, unspecified with intoxication, unspecified
F16.10 Hallucinogen abuse, uncomplicated
F18.10 Inhalant abuse, uncomplicated
F19.10 Other psychoactive substance abuse, uncomplicated
F19.939 Other psychoactive substance use, unspecified with withdrawal, unspecified
F19.99 Other psychoactive substance use, unspecified with unspecified psychoactive substance-induced disorder
F23 Brief psychotic disorder
F29 Unspecified psychosis not due to a substance or known physiological condition
F41.1 Generalized anxiety disorder
F41.8 Other specified anxiety disorders
F41.9 Anxiety disorder, unspecified
F63.89 Other impulse disorders
F99 Mental disorder, not otherwise specified
G40.909 Epilepsy, unspecified, not intractable, without status epilepticus
G40.919 Epilepsy, unspecified, intractable, without status epilepticus
G43.909 Migraine, unspecified, not intractable, without status migrainosus
G43.919 Migraine, unspecified, intractable, without status migrainosus
G45.9 Transient cerebral ischemic attack, unspecified
G81.90 Hemiplegia, unspecified affecting unspecified side
G82.20 Paraplegia, unspecified
G82.50 Quadriplegia, unspecified
G89.11 Acute pain due to trauma
G89.18 Other acute postprocedural pain
G89.29 Other chronic pain
I20.0 Unstable angina
I21.3 ST elevation (STEMI) myocardial infarction of unspecified site
I26.99 Other pulmonary embolism without acute cor pulmonale
I46.9 Cardiac arrest, cause unspecified
I48.91 Unspecified atrial fibrillation
I49.9 Cardiac arrhythmia, unspecified
I50.9 Heart failure, unspecified
I66.9 Occlusion and stenosis of unspecified cerebral artery
I67.848 Other cerebrovascular vasospasm and vasoconstriction
I67.89 Other cerebrovascular disease
I69.920 Aphasia following unspecified cerebrovascular disease
I69.949 Monoplegia of lower limb following unspecified cerebrovascular disease affecting unspecified side
I69.959 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side
I80.209 Phlebitis and thrombophlebitis of unspecified deep vessels of unspecified lower extremity
I95.9 Hypotension, unspecified
J18.8 Other pneumonia, unspecified organism
J18.9 Pneumonia, unspecified organism
J44.9 Chronic obstructive pulmonary disease, unspecified
J45.901 Unspecified asthma with (acute) exacerbation
J80 Acute respiratory distress syndrome
J81.0 Acute pulmonary edema
J95.00 Unspecified tracheostomy complication
J95.821 Acute postprocedural respiratory failure
J95.851 Ventilator associated pneumonia
J95.859 Other complication of respirator [ventilator]
J96.00 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia
J96.90 Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia
J98.4 Other disorders of lung
K29.00 Acute gastritis without bleeding
K29.01 Acute gastritis with bleeding
K29.70 Gastritis, unspecified, without bleeding
K29.90 Gastroduodenitis, unspecified, without bleeding
K56.699 Other intestinal obstruction unspecified as to partial versus complete obstruction
K92.2 Gastrointestinal hemorrhage, unspecified
L03.115 Cellulitis of right lower limb
L03.116 Cellulitis of left lower limb
L89.103 Pressure ulcer of unspecified part of back, stage 3
L89.104 Pressure ulcer of unspecified part of back, stage 4
L89.109 Pressure ulcer of unspecified part of back, unspecified stage
L89.153 Pressure ulcer of sacral region, stage 3
L89.154 Pressure ulcer of sacral region, stage 4
L89.203 Pressure ulcer of unspecified hip, stage 3
L89.204 Pressure ulcer of unspecified hip, stage 4
L89.209 Pressure ulcer of unspecified hip, unspecified stage
L89.303 Pressure ulcer of unspecified buttock, stage 3
L89.304 Pressure ulcer of unspecified buttock, stage 4
L89.309 Pressure ulcer of unspecified buttock, unspecified stage
L89.43 Pressure ulcer of contiguous site of back, buttock and hip, stage 3
L89.44 Pressure ulcer of contiguous site of back, buttock and hip, stage 4
M24.559 Contracture, unspecified hip
M24.569 Contracture, unspecified knee
M25.50 Pain in unspecified joint
M43.8X9 Other specified deforming dorsopathies, site unspecified
M53.9 Dorsopathy, unspecified
M54.50 Low back pain, unspecified
M54.51 Vertebrogenic low back pain
M54.89 Other dorsalgia
M54.9 Dorsalgia, unspecified
M79.601 Pain in right arm
M79.602 Pain in left arm
M79.604 Pain in right leg
M79.605 Pain in left leg
M79.609 Pain in unspecified limb
M79.89 Other specified soft tissue disorders
N17.9 Acute kidney failure, unspecified
N19 Unspecified kidney failure
O26.819 Pregnancy related exhaustion and fatigue, unspecified trimester
O26.899 Other specified pregnancy related conditions, unspecified trimester
O26.90 Pregnancy related conditions, unspecified, unspecified trimester
O75.9 Complication of labor and delivery, unspecified
O80 Encounter for full-term uncomplicated delivery
O99.891 Other specified diseases and conditions complicating pregnancy
O99.892 Other specified diseases and conditions complicating childbirth
O99.893 Other specified diseases and conditions complicating puerperium
R00.0 Tachycardia, unspecified
R00.2 Palpitations
R06.00 Dyspnea, unspecified
R06.02 Shortness of breath
R06.03 Acute respiratory distress
R06.3 Periodic breathing
R06.4 Hyperventilation
R06.82 Tachypnea, not elsewhere classified
R06.89 Other abnormalities of breathing
R06.9 Unspecified abnormalities of breathing
R07.1 Chest pain on breathing
R07.2 Precordial pain
R07.81 Pleurodynia
R07.82 Intercostal pain
R07.89 Other chest pain
R07.9 Chest pain, unspecified
R09.02 Hypoxemia
R09.1 Pleurisy
R09.2 Respiratory arrest
R09.89 Other specified symptoms and signs involving the circulatory and respiratory systems
R10.0 Acute abdomen
R10.10 Upper abdominal pain, unspecified
R10.11 Right upper quadrant pain
R10.12 Left upper quadrant pain
R10.13 Epigastric pain
R10.2 Pelvic and perineal pain
R10.30 Lower abdominal pain, unspecified
R10.31 Right lower quadrant pain
R10.32 Left lower quadrant pain
R10.33 Periumbilical pain
R10.817 Generalized abdominal tenderness
R10.819 Abdominal tenderness, unspecified site
R10.827 Generalized rebound abdominal tenderness
R10.829 Rebound abdominal tenderness, unspecified site
R10.84 Generalized abdominal pain
R10.9 Unspecified abdominal pain
R11.10 Vomiting, unspecified
R11.11 Vomiting without nausea
R11.2 Nausea with vomiting, unspecified
R19.00 Intra-abdominal and pelvic swelling, mass and lump, unspecified site
R19.07 Generalized intra-abdominal and pelvic swelling, mass and lump
R19.09 Other intra-abdominal and pelvic swelling, mass and lump
R19.30 Abdominal rigidity, unspecified site
R19.37 Generalized abdominal rigidity
R20.8 Other disturbances of skin sensation
R20.9 Unspecified disturbances of skin sensation
R23.0 Cyanosis
R23.1 Pallor
R25.0 Abnormal head movements
R26.1 Paralytic gait
R26.2 Difficulty in walking, not elsewhere classified
R27.0 Ataxia, unspecified
R27.8 Other lack of coordination
R27.9 Unspecified lack of coordination
R29.5 Transient paralysis
R29.810 Facial weakness
R29.818 Other symptoms and signs involving the nervous system
R40.0 Somnolence
R40.1 Stupor
R40.20 Unspecified coma
R40.2111 Coma scale, eyes open, never, in the field [EMT or ambulance]
R40.2121 Coma scale, eyes open, to pain, in the field [EMT or ambulance]
R40.2131 Coma scale, eyes open, to sound, in the field [EMT or ambulance]
R40.2141 Coma scale, eyes open, spontaneous, in the field [EMT or ambulance]
R40.2211 Coma scale, best verbal response, none, in the field [EMT or ambulance]
R40.2221 Coma scale, best verbal response, incomprehensible words, in the field [EMT or ambulance]
R40.2231 Coma scale, best verbal response, inappropriate words, in the field [EMT or ambulance]
R40.2241 Coma scale, best verbal response, confused conversation, in the field [EMT or ambulance]
R40.2251 Coma scale, best verbal response, oriented, in the field [EMT or ambulance]
R40.2311 Coma scale, best motor response, none, in the field [EMT or ambulance]
R40.2321 Coma scale, best motor response, extension, in the field [EMT or ambulance]
R40.2331 Coma scale, best motor response, abnormal flexion, in the field [EMT or ambulance]
R40.2341 Coma scale, best motor response, flexion withdrawal, in the field [EMT or ambulance]
R40.2351 Coma scale, best motor response, localizes pain, in the field [EMT or ambulance]
R40.2361 Coma scale, best motor response, obeys commands, in the field [EMT or ambulance]
R40.2410 Glasgow coma scale score 13-15, unspecified time
R40.2411 Glasgow coma scale score 13-15, in the field [EMT or ambulance]
R40.2412 Glasgow coma scale score 13-15, at arrival to emergency department
R40.2413 Glasgow coma scale score 13-15, at hospital admission
R40.2414 Glasgow coma scale score 13-15, 24 hours or more after hospital admission
R40.2420 Glasgow coma scale score 9-12, unspecified time
R40.2421 Glasgow coma scale score 9-12, in the field [EMT or ambulance]
R40.2422 Glasgow coma scale score 9-12, at arrival to emergency department
R40.2423 Glasgow coma scale score 9-12, at hospital admission
R40.2424 Glasgow coma scale score 9-12, 24 hours or more after hospital admission
R40.2430 Glasgow coma scale score 3-8, unspecified time
R40.2431 Glasgow coma scale score 3-8, in the field [EMT or ambulance]
R40.2432 Glasgow coma scale score 3-8, at arrival to emergency department
R40.2433 Glasgow coma scale score 3-8, at hospital admission
R40.2434 Glasgow coma scale score 3-8, 24 hours or more after hospital admission
R40.2440 Other coma, without documented Glasgow coma scale score, or with partial score reported, unspecified time
R40.2441 Other coma, without documented Glasgow coma scale score, or with partial score reported, in the field [EMT or ambulance]
R40.2442 Other coma, without documented Glasgow coma scale score, or with partial score reported, at arrival to emergency department
R40.2443 Other coma, without documented Glasgow coma scale score, or with partial score reported, at hospital admission
R40.2444 Other coma, without documented Glasgow coma scale score, or with partial score reported, 24 hours or more after hospital admission
R40.3 Persistent vegetative state
R40.4 Transient alteration of awareness
R41.0 Disorientation, unspecified
R41.2 Retrograde amnesia
R41.89 Other symptoms and signs involving cognitive functions and awareness
R42 Dizziness and giddiness
R44.2 Other hallucinations
R44.3 Hallucinations, unspecified
R45.89 Other symptoms and signs involving emotional state
R47.01 Aphasia
R47.02 Dysphasia
R47.81 Slurred speech
R47.89 Other speech disturbances
R50.81 Fever presenting with conditions classified elsewhere
R50.82 Postprocedural fever
R50.9 Fever, unspecified
R51.0 Headache with orthostatic component, not elsewhere classified
R52 Pain, unspecified
R53.1 Weakness
R53.2 Functional quadriplegia
R53.81 Other malaise
R53.83 Other fatigue
R55 Syncope and collapse
R56.9 Unspecified convulsions
R57.9 Shock, unspecified
R58 Hemorrhage, not elsewhere classified
R61 Generalized hyperhidrosis
R68.0 Hypothermia, not associated with low environmental temperature
R68.11 Excessive crying of infant (baby)
S05.90XA Unspecified injury of unspecified eye and orbit, initial encounter
S09.8XXA Other specified injuries of head, initial encounter
S09.90XA Unspecified injury of head, initial encounter
T07.XXXA Unspecified multiple injuries, initial encounter
T14.8XXA Other injury of unspecified body region, initial encounter
T14.90XA Injury, unspecified, initial encounter
T14.91XA Suicide attempt, initial encounter
T30.0 Burn of unspecified body region, unspecified degree
T50.901A Poisoning by unspecified drugs, medicaments and biological substances, accidental (unintentional), initial encounter
T50.902A Poisoning by unspecified drugs, medicaments and biological substances, intentional self-harm, initial encounter
T50.903A Poisoning by unspecified drugs, medicaments and biological substances, assault, initial encounter
T50.904A Poisoning by unspecified drugs, medicaments and biological substances, undetermined, initial encounter
T59.891A Toxic effect of other specified gases, fumes and vapors, accidental (unintentional), initial encounter
T59.91XA Toxic effect of unspecified gases, fumes and vapors, accidental (unintentional), initial encounter
T59.92XA Toxic effect of unspecified gases, fumes and vapors, intentional self-harm, initial encounter
T59.93XA Toxic effect of unspecified gases, fumes and vapors, assault, initial encounter
T59.94XA Toxic effect of unspecified gases, fumes and vapors, undetermined, initial encounter
T65.91XA Toxic effect of unspecified substance, accidental (unintentional), initial encounter
T65.92XA Toxic effect of unspecified substance, intentional self-harm, initial encounter
T65.93XA Toxic effect of unspecified substance, assault, initial encounter
T65.94XA Toxic effect of unspecified substance, undetermined, initial encounter
T67.2XXA Heat cramp, initial encounter
T67.5XXA Heat exhaustion, unspecified, initial encounter
T68.XXXA Hypothermia, initial encounter
T69.9XXA Effect of reduced temperature, unspecified, initial encounter
T74.21XA Adult sexual abuse, confirmed, initial encounter
T75.00XA Unspecified effects of lightning, initial encounter
T75.1XXA Unspecified effects of drowning and nonfatal submersion, initial encounter
T75.4XXA Electrocution, initial encounter
T76.21XA Adult sexual abuse, suspected, initial encounter
T78.2XXA Anaphylactic shock, unspecified, initial encounter
T78.40XA Allergy, unspecified, initial encounter
T81.89XA Other complications of procedures, not elsewhere classified, initial encounter
T81.9XXA Unspecified complication of procedure, initial encounter
T82.519A Breakdown (mechanical) of unspecified cardiac and vascular devices and implants, initial encounter
T82.529A Displacement of unspecified cardiac and vascular devices and implants, initial encounter
T82.539A Leakage of unspecified cardiac and vascular devices and implants, initial encounter
T82.599A Other mechanical complication of unspecified cardiac and vascular devices and implants, initial encounter
T83.198A Other mechanical complication of other urinary devices and implants, initial encounter
T83.498A Other mechanical complication of other prosthetic devices, implants and grafts of genital tract, initial encounter
T88.7XXA Unspecified adverse effect of drug or medicament, initial encounter
Y71.0 Diagnostic and monitoring cardiovascular devices associated with adverse incidents
Y82.8 Other medical devices associated with adverse incidents
Z20.818 Contact with and (suspected) exposure to other bacterial communicable diseases

Group 2

(90 Codes)
Group 2 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following is a list of suggested ICD-10 codes that may be used as a primary diagnosis for post treatment transfer (e.g. transfer to home, nursing facility, SNF, IRF, IPP).

Group 2 Codes
CodeDescription
C71.9 Malignant neoplasm of brain, unspecified
C80.1 Malignant (primary) neoplasm, unspecified
C80.2 Malignant neoplasm associated with transplanted organ
D49.0 Neoplasm of unspecified behavior of digestive system
D49.1 Neoplasm of unspecified behavior of respiratory system
D49.2 Neoplasm of unspecified behavior of bone, soft tissue, and skin
D49.3 Neoplasm of unspecified behavior of breast
D49.4 Neoplasm of unspecified behavior of bladder
D49.511 Neoplasm of unspecified behavior of right kidney
D49.512 Neoplasm of unspecified behavior of left kidney
D49.59 Neoplasm of unspecified behavior of other genitourinary organ
D49.6 Neoplasm of unspecified behavior of brain
D49.7 Neoplasm of unspecified behavior of endocrine glands and other parts of nervous system
D49.89 Neoplasm of unspecified behavior of other specified sites
F01.51 Vascular dementia with behavioral disturbance
F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance
F03.91 Unspecified dementia with behavioral disturbance
F63.3 Trichotillomania
F63.89 Other impulse disorders
G30.9 Alzheimer's disease, unspecified
G37.9 Demyelinating disease of central nervous system, unspecified
G89.29 Other chronic pain
G89.3 Neoplasm related pain (acute) (chronic)
I25.9 Chronic ischemic heart disease, unspecified
I42.9 Cardiomyopathy, unspecified
I50.9 Heart failure, unspecified
I67.89 Other cerebrovascular disease
I69.910 Attention and concentration deficit following unspecified cerebrovascular disease
I69.911 Memory deficit following unspecified cerebrovascular disease
I69.912 Visuospatial deficit and spatial neglect following unspecified cerebrovascular disease
I69.913 Psychomotor deficit following unspecified cerebrovascular disease
I69.914 Frontal lobe and executive function deficit following unspecified cerebrovascular disease
I69.915 Cognitive social or emotional deficit following unspecified cerebrovascular disease
I69.918 Other symptoms and signs involving cognitive functions following unspecified cerebrovascular disease
I69.941 Monoplegia of lower limb following unspecified cerebrovascular disease affecting right dominant side
I69.942 Monoplegia of lower limb following unspecified cerebrovascular disease affecting left dominant side
I69.943 Monoplegia of lower limb following unspecified cerebrovascular disease affecting right non-dominant side
I69.944 Monoplegia of lower limb following unspecified cerebrovascular disease affecting left non-dominant side
I69.949 Monoplegia of lower limb following unspecified cerebrovascular disease affecting unspecified side
I69.951 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side
I69.952 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side
I69.953 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right non-dominant side
I69.954 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side
I69.959 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side
J43.9 Emphysema, unspecified
J44.9 Chronic obstructive pulmonary disease, unspecified
L89.133 Pressure ulcer of right lower back, stage 3
L89.134 Pressure ulcer of right lower back, stage 4
L89.143 Pressure ulcer of left lower back, stage 3
L89.144 Pressure ulcer of left lower back, stage 4
L89.153 Pressure ulcer of sacral region, stage 3
L89.154 Pressure ulcer of sacral region, stage 4
L89.313 Pressure ulcer of right buttock, stage 3
L89.314 Pressure ulcer of right buttock, stage 4
L89.323 Pressure ulcer of left buttock, stage 3
L89.324 Pressure ulcer of left buttock, stage 4
L89.43 Pressure ulcer of contiguous site of back, buttock and hip, stage 3
L89.44 Pressure ulcer of contiguous site of back, buttock and hip, stage 4
M24.551 Contracture, right hip
M24.552 Contracture, left hip
M24.561 Contracture, right knee
M24.562 Contracture, left knee
M25.50 Pain in unspecified joint
R26.0 Ataxic gait
R26.1 Paralytic gait
R26.89 Other abnormalities of gait and mobility
R26.9 Unspecified abnormalities of gait and mobility
R27.0 Ataxia, unspecified
R27.8 Other lack of coordination
R27.9 Unspecified lack of coordination
R29.5 Transient paralysis
R40.0 Somnolence
R40.1 Stupor
R40.20 Unspecified coma
R40.3 Persistent vegetative state
R40.4 Transient alteration of awareness
R52 Pain, unspecified
R64 Cachexia
S12.9XXA Fracture of neck, unspecified, initial encounter
S13.29XA Dislocation of other parts of neck, initial encounter
S13.9XXA Sprain of joints and ligaments of unspecified parts of neck, initial encounter
S22.9XXA Fracture of bony thorax, part unspecified, initial encounter for closed fracture
S23.0XXA Traumatic rupture of thoracic intervertebral disc, initial encounter
S23.20XA Dislocation of unspecified part of thorax, initial encounter
S24.9XXA Injury of unspecified nerve of thorax, initial encounter
S32.9XXA Fracture of unspecified parts of lumbosacral spine and pelvis, initial encounter for closed fracture
S33.0XXA Traumatic rupture of lumbar intervertebral disc, initial encounter
S33.30XA Dislocation of unspecified parts of lumbar spine and pelvis, initial encounter
S72.91XA Unspecified fracture of right femur, initial encounter for closed fracture
S72.92XA Unspecified fracture of left femur, initial encounter for closed fracture

Group 3

(4 Codes)
Group 3 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following codes are secondary diagnosis codes that must be reported in addition to a primary diagnosis.

Group 3 Codes
CodeDescription
Z74.01 Bed confinement status
Z74.3* Need for continuous supervision
Z78.1* Physical restraint status
Z99.89* Dependence on other enabling machines and devices
Group 3 Medical Necessity ICD-10-CM Codes Asterisk Explanation

Note: Use code Z74.3 to denote cardiac/hemodynamic monitoring required en route.

Note: Use code Z78.1 to denote patient safety: danger to self and others - monitoring other and unspecified reactive psychosis.

Note: Use code Z99.89 to denote the need for continuous IV fluid(s), "active airway management", or the need for multiple machines/devices.

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

Note: Z76.89 should be reported for patients who were transported by ambulance, but did NOT require the services of an ambulance crew. Modifier GY should be appended.

Group 1 Codes
CodeDescription
Z76.89 Persons encountering health services in other specified circumstances

ICD-10-PCS Codes

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

CodeDescription
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
022x Skilled Nursing - Inpatient (Medicare Part B only)
023x Skilled Nursing - Outpatient
083x Ambulatory Surgery Center
085x Critical Access Hospital

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Note: The contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this Article. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS IOM, Publication 100-04, Medicare Claims Processing Manual, for further guidance.


CodeDescription
054X Ambulance - General Classification

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
10/01/2021 R9

Article revised and published on 10/14/2021 effective for dates of service on and after 10/01/2021 to reflect the Annual ICD-10-CM Code Updates.

The following ICD-10 code has been deleted and therefore has been removed from the article: M54.5 from Group 1 Codes.

The following ICD-10-CM codes have been added to the Article: M54.50 and M54.51 to Group 1 Codes. Minor formatting changes have been  made throughout the coding section.

10/01/2020 R8

Article revised and published on 10/01/2020 effective for dates of service on and after 10/01/2020 to reflect the Annual ICD-10-CM Code Updates. The following ICD-10-CM code(s) have been removed from the Group 1 Codes: O99.89 and R51. The following ICD-10-CM code(s) have been added to the Group 1 Codes: M79.602, O99.891, O99.892, O99.893 and R51.0. Minor formatting revisions have been made throughout the article.

11/14/2019 R7

Article revised and published on 11/14/2019. Consistent with CMS Change Request 10901, all coding information from the related LCD has been placed into this article. Due to system changes, the order of the Coding Section has been revised and new sections for CPT/HCPCS Modifiers and Other Coding Information have been added.

06/27/2019 R6

Revised and published on 6/27/2019 in response to a provider inquiry to add bill types 012x, 013x, 022x, 023x, 083x and 085x to the Coding and Billing Article: Ambulance Services A54574.

03/21/2019 R5

Article revised and published on 03/21/2019 to add secondary diagnosis codes and relevant coding and billing direction that was removed from LCD, L35162 Ambulance Services in response to Change Request 10901.

10/01/2018 R4

Article revised and published on 10/25/2018 effective for dates of service on and after 10/01/2018 to reflect the Annual ICD-10-CM Code Updates. The following ICD-10-CM code(s) have undergone a descriptor change: R40.2331.

10/01/2017 R3

Article revised and published on 10/05/2017 effective for dates of service on and after 10/01/2017 to reflect the Annual ICD-10-CM Code Updates.

The following ICD-10-CM code(s) have been deleted and therefore removed from the Article:
Group 1 Code Deletions: K56.69, T07, T14.8, T14.90, and T14.91.

The following ICD-10-CM code(s) have been added to the Article:
Group 1 Code Additions:
K56.699, R06.03, T07.XXXA, T14.8XXA, T14.90XA, and T14.91XA.

10/01/2016 R2 Article revised and published on 09/29/2016 effective for dates of service on and after 10/01/2016 to reflect the ICD-10 Annual Code Updates. The following ICD-10 code(s) have been deleted and therefore removed from the Article: Group 1 codes R40.241, R40.242, R40.243, and R40.244; Group 2 codes D49.5 and I69.91. The following ICD-10 code(s) have been added to the Article: Group 1 codes R40.2410, R40.2411, R40.2412, R40.2413, R40.2414, R40.2420, R40.2421, R40.2422, R40.2423, R40.2424, R40.2430, R40.2431, R40.2432, R40.2433, R40.2434, R40.2440, R40.2441, R40.2442, R40.2443, and R40.2444; Group 2 codes D49.511, D49.512, D49.59, I69.910, I69.911, I69.912, I69.913, I69.914, I69.915, and I69.918.
01/01/2016 R1 Article revised and published on 02/19/2016 effective for dates of service on and after 01/01/2016 to reflect the annual CPT/HCPCS code updates. For the following CPT/HCPCS code, either the short description and/or the long description was changed. Depending on which description is used in this Article, there may not be any change in how the code displays in the document: A0427.

Associated Documents

Related Local Coverage Documents
LCDs
L35162 - Ambulance Services (Ground Ambulance)
Related National Coverage Documents
N/A
Statutory Requirements URLs
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
N/A
Other URLs
N/A
Public Versions
Updated On Effective Dates Status
10/08/2021 10/01/2021 - N/A Currently in Effect You are here
09/25/2020 10/01/2020 - 09/30/2021 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

N/A