016.06.06 Ark. Code R. 076

Current through Register Vol. 49, No. 10, October, 2024

Rule 016.06.06-076 - Transportation Update Transmittal #86

252.100 Ambulance Procedure Codes

93041*	A0380	A0382	A0390	A0398	A0422	A0426	A0427
A0429	J0150*	J0170*	J0280*	J0460*	J1094*	J1100*	J1160*
J1200*	J1940*	J2060*	J2175*	J2270*	J2310*	J2550*	J2560*
J3360*	J3410*	J3475*	J3480*	J3490*	Q4076*

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

Procedure Code	Required Modifier	Description
A0436	Emergency, per mile, loaded, helicopter air ambulance
A0422	U1	Emergency, oxygen, helicopter air ambulance
A0431	Ambulance service, emergency, basic pick-up, helicopter, one unit per day
A0428	Ambulance service, ILS intermediate transport, mileage and disposable supplies billed separately
A0380	TF	ILS mileage (per mile)
T2002**	Non-emergency ground ambulance transportation, hospital to nursing facility
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.)
A0434	Air Ventilator/Respiratory Therapist, one unit equals one hour (Round to the nearest hour.)

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

016.06.06 Ark. Code R. 076

11/3/2006