| Program Name: | BadgerCare Plus and Medicaid | Handbook Area: | Ambulance | | 05/09/2024 | Covered and Noncovered Services : CodesTopic #1045 Ambulance Disposable Medical Supplies and Services
The following table lists allowable HCPCS codes for DMS and services that may or may not be billed separately for ambulance services. For both DMS and ambulance services with no listed national HCPCS procedure codes, providers may use HCPCS procedure code A0999 (Unlisted ambulance service).
| Included in Ambulance Base Rate - Do Not Bill These Supplies and Services Separately |
| The following DMS and services are included
in the reimbursement for the ambulance base rate: |
- Additional time Emergency Medical Technician (EMT)*
- Air splint
- Alcohol preps
- Alcohol
- Ambulance bag, nondisposable
- Application of equipment
- Backboards
- Blood draw for chemostrip
- Blood pressure cuff
- Blood pressure monitoring
- Blood sample draw
- Blood tubes, green, red, purple
- Canister, nondisposable
- Cassette tape
- Cervical collar, nondisposable
- Cervical Immobilization Systems (CIDS)
- Chair stretcher
- Charges for reusable devices and equipment
- Charges for
vehicle sterilization
- Chemstrips/Dextrose Stix**
- Cloth
- Code blue
- Cot
cover
- Counter shock automatic
- Cardiopulmonary Resuscitation (CPR)
- CPR/CPR board
- Defibrillator monitor
-
Defibrillator, inverter
- Demand valve resuscitator
- Disposable face mask,
not an oxygen mask
- Dopplers
- Drugs used in transit or for starting IV
solutions
- Egg crate mattress
- Electrocardiogram (EKG) monitoring for infection control
-
Geriatric chairs
- Gloves, disposable or sterile
- Glucose stix
- Glucometer
supplies
- Glucometer
|
- Glucose monitoring
- Goggles
- Gowns, including disposable
- Graph paper
- Hazardous materials collection bags
- Heart monitor
- Infection control kit
- Infusion pump
- Inhalant
- Intravenous infusion
- Intubation
- Isolation kits
- Intermediate skills, I-Skills, D-Skills
- IV
pump
- IV therapy
- K-Y jelly
- Kendrick Extrication Device (KED)
- Lancets
-
Laryngoscope blades, nondisposable
- Linens
- Loading assist
- Long board
-
Major and minor bandaging
- Mast trousers
- Monitoring cassette
- Needles
- Nose
clip
- Para-med scissors
- Peak flow meter
- Perfusion monitoring
-
Pillow/pillowcases
- Probe cover, thermoscan
- Propaq monitor
- Protective
clothing
- Pulmonary resuscitation
- Pulse oximetry
- Razor
- Recording tape
|
- Resuscitator, equipment charge
- Sand bags
- Scoop stretcher
- Sharps container
- Sheets
- Splints, nondisposable
- Stair chair
- Straps
- Stretcher
- Suction
- Surgical masks
- Syringes
- Tape
- Telemetry
- Temperature strip
-
Thermometer
- Thermoscan
- Towel
- Traction splints bare treatment
- Ventilator
-
Vita trac
- Voice tape
- Washcloth
|
* Includes additional charges for services provided during nights, weekends,
or holidays.
** Includes charges for carrying a member with a contagious disease.
| A0384 or A0392 - Bill Only One Unit of
Service Per Transport |
| The following DMS are included in the
reimbursement when billing procedure codes A0384 (BLS specialized service
disposable supplies; defibrillation) or A0392 (ALS specialized service
disposable supplies; defibrillation): |
- Defibrillator electrodes
- Defibrillator pads
|
- Defibrillator supplies
- Defibrillator pads
|
|
| A0382 or A0398 - Bill Only One Unit of
Service Per Transport |
| The following DMS are included in the
reimbursement when billing procedure codes A0382 (BLS routine disposable
supplies) or A0398 (ALS routine disposable supplies): |
- Albuterol dispenser
- Bandage/cravat
- Bedpan, disposable
- Bite stix
- Blankets, disposable
- Blood pressure cuff, disposable
- Bloodstopper dressing
- Bulb aspirator
- Bulb aspirator tip
- Burn sheets
- Burn wraps
- Canister, disposable
- Cervical collar, disposable
- Chux
- CO2 detector
- Cold pack
- Convenience bag
- Disposable pads
- Disposable V-block
- Dressing
- ECG electrodes
- Emesis bag
- Emesis basin
- Fracture pan
|
- Gauze
- Glucose
- Glucose gel
- Glucose instant
- Glucose tube
- Head bed spine immobilizer,
disposable
- Head immobilizer, disposable
- Head on system
- Heart monitor pads
- Hot pack
- Insta glucose
- Jamshidi aspiration needle
- Kerlix dressing
- Lancer tip
- Portex tip
- Proventil dispenser
- Slings, disposable
- Small trauma dressings
- Sodium chloride, non-IV
solution
- Splints, disposable
- Sterile saline, non-IV
- Sterile water, non-IV
- Straps head/chin,
disposable
- Suction cartridge
|
- Suction canister, disposable
- Suction catheters
- Suction tip
- Suction tip and tubing
- Suction tubing
- Trauma dressing
- Trauma pack
- Triangle bandage
- Tube of glucose
- Tube, salem sump
- Underpad
- Urinal
- Vaseline gauze
- Veni dress
- V-vac cartridge
- Whistle tip, suction tip
- Yankhauer catheter
- Yankhauer tip
- Yankhauer tip with tubing
- Yankhauer tubing
|
| A0394 - May Be Billed for More Than
One Unit of Service Per Transport |
| The following DMS are included in the
reimbursement when billing procedure code A0394 (ALS specialized service
disposable supplies; IV drug therapy): |
- Angiocath needle
- Angio set
- Backcheck venoset
- Backcheck vent
- Catheter, IV
- Dial a flow or IV flow
- Disposable arm pad
- Disposable arm boards
- Extension
- Extension set, tubing
- IV administration sets
- IV antiseptic wipes
- IV armboard
- IV blood tubing
|
- IV cassette
- IV cath
- IV cath protector
- IV equipment
- IV medical tubing or IV tubing
- IV micro tubing
- IV prep pack
- IV pump ext set
- IV pump ext tubing set
- IV select 3 tubing
- IV start pack
- IV supplies
- IV tape
|
- IV three-way stop-cock
extension
- IV trauma set
- IV Y-site tubing
- IV 2x2
- Luer lock adapter
- Pump tubing IV supplies
- Regular drip set, tubing
- Tourniquet
- Twin site extension
- Twin ext set
- Venaguard cath
- Vena guard
- Y-site tubing
|
| A0396 - Bill Only One Unit of Service
Per Transport |
| The following DMS are included in the
reimbursement when billing procedure code A0396 (ALS specialized service
disposable supplies; esophageal intubation): |
- Adult stylette, disposable
- Airway
- Airway valve
- Catheter guide for airways
- Combi tube
- Endotracheal tube guides
- Endotracheal tubes, ET tube
|
- Esophageal gastric tube
airway (EGTA)
- EGTA mask
- TGTA tube
- Esophageal Obturator Airway
(EOA)
- EOA mask
- EOA tube
- Intubation tubing
|
- Laryngoscope blades,
disposable
- Pharyngeal Tracheal Lumen (PTL)
airway
- PTL airway
- Revive easy airway, PTL
- Secure easy ET holder
- Stylette
|
| A0422 - Bill Only
One Unit of Service Per Transport |
| The following DMS and services are
included in the reimbursement when billing procedure code A0422 (Ambulance [ALS
or BLS] oxygen and oxygen supplies, life sustaining situation): |
- Autovent with bag mask
- Ambu disposable
resuscitator
- Ambu SPUR
- Bag easy resuscitator
- Bag valve, one-way valve
- Blob seal, seal easy mask
- Cannula, nasal cannula
- Humidified oxygen
- Humidifiers
- LSP disposable resuscitator
- Mouth to mask resuscitation
- Mouth to mask valve
- Nasal airway, disposable
|
- Nasal cannula
- Nasopharyngeal
- Nebulizer dispenser
- Nebulizer setup
- Nebulizer
- Non-rebreathing masks
- Non- or partial-rebreather
- Oxygen delivery
- Oxygen masks
- Oxygen mask with tubing
- One-way valve
- Oral pharyngeal
|
- Oxygen tubing
- Oxygen connection tube
- PEEP Valve
- Pocket mask
- Pulse oximeter sensor,
disposable
- Rebreathing mask
- Resuscitation kit
- Resuscitator mask
- Simple mask
- Tracheostomy mask or collar
- Venturi mask
- WPR
|
| A0999* - Bill Only
One Unit of Service Per Transport |
| The following disposable supplies are
included in the reimbursement when billing procedure code A0999 (Unlisted
ambulance service): |
- Burn blanket
- IV nitro tubing
- Pacing pads/pacing
electrodes
|
- Pressure infuser,
disposable
- Ob-Gyn supplies or kit
|
- OB/3 stage kit
- Zoll pacing pad
|
* Providers should use procedure code A0999 for any DMS or service not
listed. |