| Program Name: | BadgerCare Plus and Medicaid | Handbook Area: | Ambulance | | 05/01/2024 | Covered and Noncovered Services : CodesTopic #1036 Procedure Codes and Modifiers
The following table lists allowable HCPCS codes and modifiers for ambulance services. These codes are updated on a quarterly basis. Consult the maximum allowable fee schedule
or call Provider Services for the most current procedure codes and allowable modifier combinations.
| Procedure Code |
Description |
Multiple Carry Modifier |
| A0225 |
Ambulance service, neonatal transport, base rate, emergency transport, one way |
|
| A0380 |
BLS mileage (per mile) |
|
| A0382 |
BLS1 routine disposable supplies |
|
| A0384 |
BLS specialized service disposable supplies; defibrillation (used by ALS2 ambulances and BLS ambulances in jurisdictions where defibrillation is permitted in BLS ambulances) |
|
| A0390 |
ALS mileage (per mile) |
|
| A0392 |
ALS specialized service disposable supplies; defibrillation (to be used only in jurisdictions where defibrillation cannot be performed by BLS ambulances) |
|
| A0394 |
ALS specialized service disposable supplies; IV drug therapy |
|
| A0396 |
ALS specialized service disposable supplies; esophageal intubation |
|
| A0398 |
ALS routine disposable supplies |
|
| A0420 |
Ambulance waiting time (ALS or BLS), one half (1/2) hour increments |
|
| A0422 |
Ambulance (ALS or BLS) oxygen and oxygen supplies, life sustaining situation |
|
| A0424 |
Extra ambulance attendant, ground (ALS or BLS) or air (fixed or rotary winged); (requires medical review) |
|
| A04253 |
Ground mileage, per statute mile |
|
| A04253 |
Ground mileage, per statute mile |
GM |
| A0426 |
Ambulance service, advanced life support, non-emergency transport, Level 1 (ALS1) |
|
| A0426 |
Ambulance service, advanced life support, non-emergency transport, Level 1 (ALS1) |
GM |
| A0427 |
Ambulance service, advanced life support, emergency transport, Level 1 (ALS1-Emergency) |
|
| A0427 |
Ambulance service, advanced life support, emergency transport, Level 1 (ALS1-Emergency) |
GM |
| A0428 |
Ambulance service, basic life support, non-emergency transport (BLS) | |
| A0428 |
Ambulance service, basic life support, non-emergency transport (BLS) |
GM |
| A0429 |
Ambulance service, basic life support, emergency transport (BLS-Emergency) |
|
| A0429 |
Ambulance service, basic life support, emergency transport (BLS-Emergency) |
GM |
| A0430 |
Ambulance service, conventional air services, transport, one way (fixed wing) |
|
| A0431 |
Ambulance service, conventional air services, transport, one way (rotary wing) |
|
| A0433 |
Advanced life support, Level 2 (ALS2) |
|
| A0433 |
Advanced life support, Level 2 (ALS2) |
GM |
| A0434 |
Specialty care transport (SCT) |
|
| A0434 |
Specialty care transport (SCT) |
GM |
| A0435 |
Fixed wing air mileage, per statute mile |
|
| A0436 |
Rotary wing air mileage, per statute mile |
|
| A0998 |
Ambulance response and treatment, no transport |
|
| A09994 |
Unlisted ambulance service |
|
| T2003 |
Non-emergency transportation; encounter/trip |
|
| T2003 |
Non-emergency transportation; encounter/trip |
GM |
1 BadgerCare Plus assigns BLS status to all land ambulance providers with a Wisconsin DHS ambulance service provider license at the basic level.
2 BadgerCare Plus assigns ALS status to all land ambulance providers with a DHS ambulance service provider license at the intermediate or paramedic level.
3 A0425 will only be reimbursed by BadgerCare Plus and Wisconsin Medicaid when it appears on a Medicare crossover claim for a dual eligible or when it is used to bill for NEMT provided by an ambulance to a member who is not eligible to receive NEMT through the NEMT manager contracted with DHS.
4 This code may be used for both DMS and ambulance services if a more specific code is unavailable. |