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25 <br /> NC Medicaid Medicaid and Health Choice <br /> Ambulance Services Clinical Coverage Policy No: 15 <br /> Effective Date:January 15,2020 <br /> Revenue Codes <br /> Institutional providers must report revenue code(RC) 540 and one of the HCPCS codes listed <br /> above for each ambulance trip provided. Institutional providers must report RC 540 and a mileage <br /> code,when applicable, on a separate detail line. <br /> Revenue Code <br /> RC540 <br /> Condition Codes <br /> Institutional providers must report one of the condition codes listed below: <br /> Condition Code <br /> AK Air Ambulance Required <br /> AL Specialized Treatment/Bed Unavailable(transported to alternate facility) <br /> AM Non-Emergency Medically Necessary Stretcher Transport Required <br /> Medical Conditions List <br /> Refer to the Medicare Claims Processing Manual, Chapter 15-Ambulance, Section 40-Medical <br /> Conditions List and Instructions located at <br /> http://www.cros. og v/Regulations-and-Guidance/Guidance/Manuals/Downloads/clml04c15.pdf <br /> Unlisted Procedure or Service <br /> CPT: The provider(s) shall refer to and comply with the Instructions for Use of the CPT <br /> Codebook,Unlisted Procedure or Service, and Special Report as documented in the current CPT in <br /> effect at the time of service. <br /> HCPCS: The provider(s) shall refer to and comply with the Instructions For Use of HCPCS <br /> National Level 1I codes,Unlisted Procedure or Service and Special Report as documented in the <br /> current HCPCS edition in effect at the time of service. <br /> A Modifiers <br /> Provider(s) shall follow applicable modifier guidelines. <br /> Providers must report an origin and destination modifier for each ambulance trip provided. Origin <br /> and destination modifiers used for ambulance services are created by combining two alpha <br /> characters.Each alpha character,with the exception of"x,"represents an origin code or a <br /> destination code. The pair of alpha codes creates one modifier. The first position alpha code equals <br /> origin;the second position alpha code equals destination. The modifier description is listed in the <br /> Health Care Procedure Coding System(HCPCS). Provider(s) shall refer to the applicable edition <br /> for the code description as it is no longer documented in the policy. <br /> Alpha Codes <br /> D I R <br /> E J S <br /> G N X <br /> H P <br /> 20A13 19 <br />