HCPCS Code A0425

Official Description

Ground mileage, per statute mile

Short Descr	Ground mileage
Coverage	Carrier Priced
Pricing Indicator(s)	52 – Reasonable charge
MPI	A – Not applicable, as HCPCS priced under one methodology
BETOS	O1A – Ambulance
TOS Code(s)	D – Ambulance
Added Date	1/1/2001
Status Code	Statutory Exclusion (from MPFS, may be paid under other methodologies)
Global Days	XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC)	9 - Not Applicable
Multiple Procedures (51)	9 - Concept does not apply.
Bilateral Surgery (50)	9 - Concept does not apply.
Physician Supervisions	09 - Concept does not apply.
Assistant Surgeon (80, 82)	9 - Concept does not apply.
Co-Surgeons (62)	9 - Concept does not apply.
Team Surgery (66)	9 - Concept does not apply.
Diagnostic Imaging Family	99 - Concept Does Not Apply
APC Status Indicator	Service Paid under Fee Schedule or Payment System other than OPPS
MUE	250
MUE	Not applicable/unspecified.
OTS Orthotic	No
CCS Clinical Classification	239 - Transportation - patient, provider, equipment

HH	Integrated mental health/substance abuse program
HN	Bachelors degree level
SH	Second concurrently administered infusion therapy
HR	Family/couple with client present
HE	Mental health program
GW	Service not related to the hospice patient's terminal condition
GY	Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit
PN	Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital
QN	Ambulance service furnished directly by a provider of services
NR	New when rented (use the 'nr' modifier when dme which was new at the time of rental is subsequently purchased)
76	Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
RP	Replacement and repair -rp may be used to indicate replacement of dme, orthotic and prosthetic devices which have been in use for sometime. the claim shows the code for the part, followed by the 'rp' modifier and the charge for the part.
HI	Integrated mental health and intellectual disability/developmental disabilities program
HD	Pregnant/parenting women's program
HS	Family/couple without client present
GR	This service was performed in whole or in part by a resident in a department of veterans affairs medical center or clinic, supervised in accordance with va policy
HP	Doctoral level
RD	Drug provided to beneficiary, but not administered "incident-to"
EJ	Subsequent claims for a defined course of therapy, e.g., epo, sodium hyaluronate, infliximab
JE	Administered via dialysate
GN	Services delivered under an outpatient speech language pathology plan of care
RI	Ramus intermedius coronary artery
U1	Medicaid level of care 1, as defined by each state
CC	Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
EP	Service provided as part of medicaid early periodic screening diagnosis and treatment (epsdt) program
ER	Items and services furnished by a provider-based, off-campus emergency department
GA	Waiver of liability statement issued as required by payer policy, individual case
RE	Furnished in full compliance with fda-mandated risk evaluation and mitigation strategy (rems)
CR	Catastrophe/disaster related
ED	Hematocrit level has exceeded 39% (or hemoglobin level has exceeded 13.0 g/dl) for 3 or more consecutive billing cycles immediately prior to and including the current cycle
EE	Hematocrit level has not exceeded 39% (or hemoglobin level has not exceeded 13.0 g/dl) for 3 or more consecutive billing cycles immediately prior to and including the current cycle
GM	Multiple patients on one ambulance trip
GV	Attending physician not employed or paid under arrangement by the patient's hospice provider
GZ	Item or service expected to be denied as not reasonable and necessary
HG	Opioid addiction treatment program
HJ	Employee assistance program
HX	Funded by county/local agency
KX	Requirements specified in the medical policy have been met
QM	Ambulance service provided under arrangement by a provider of services
RR	Rental (use the 'rr' modifier when dme is to be rented)
SN	Third surgical opinion
U2	Medicaid level of care 2, as defined by each state
U8	Medicaid level of care 8, as defined by each state
22	Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service.
25	Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service: it may be necessary to indicate that on the day a procedure or service identified by a cpt code was performed, the patient's condition required a significant, separately identifiable e/m service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. a significant, separately identifiable e/m service is defined or substantiated by documentation that satisfies the relevant criteria for the respective e/m service to be reported (see evaluation and management services guidelines for instructions on determining level of e/m service). the e/m service may be prompted by the symptom or condition for which the procedure and/or service was provided. as such, different diagnoses are not required for reporting of the e/m services on the same date. this circumstance may be reported by adding modifier 25 to the appropriate level of e/m service. note: this modifier is not used to report an e/m service that resulted in a decision to perform surgery. see modifier 57 for significant, separately identifiable non-e/m services, see modifier 59.
47	Anesthesia by surgeon: regional or general anesthesia provided by the surgeon may be reported by adding modifier 47 to the basic service. (this does not include local anesthesia.) note: modifier 47 would not be used as a modifier for the anesthesia procedures.
51	Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
59	Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
77	Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
AM	Physician, team member service
EC	Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
ET	Emergency services
EX	Expatriate beneficiary
FY	X-ray taken using computed radiography technology/cassette-based imaging
GD	Units of service exceeds medically unlikely edit value and represents reasonable and necessary services
GE	This service has been performed by a resident without the presence of a teaching physician under the primary care exception
GF	Non-physician (e.g. nurse practitioner (np), certified registered nurse anesthetist (crna), certified registered nurse (crn), clinical nurse specialist (cns), physician assistant (pa)) services in a critical access hospital
GG	Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day
GH	Diagnostic mammogram converted from screening mammogram on same day
GJ	"opt out" physician or practitioner emergency or urgent service
GP	Services delivered under an outpatient physical therapy plan of care
GS	Dosage of erythropoietin stimulating agent has been reduced and maintained in response to hematocrit or hemoglobin level
GX	Notice of liability issued, voluntary under payer policy
HB	Adult program, non geriatric
HC	Adult program, geriatric
HF	Substance abuse program
HM	Less than bachelor degree level
HO	Masters degree level
HW	Funded by state mental health agency
HY	Funded by juvenile justice agency
JD	Skin substitute not used as a graft
JG	Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes
MC	Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of electronic health record or clinical decision support mechanism vendor issues
MH	Unknown if ordering professional consulted a clinical decision support mechanism for this service, related information was not provided to the furnishing professional or provider
PC	Wrong surgery or other invasive procedure on patient
PD	Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days
PI	Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing
PO	Excepted service provided at an off-campus, outpatient, provider-based department of a hospital
PS	Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy
PT	Colorectal cancer screening test; converted to diagnostic test or other procedure
Q3	Live kidney donor surgery and related services
QA	Prescribed amounts of stationary oxygen for daytime use while at rest and nighttime use differ and the average of the two amounts is less than 1 liter per minute (lpm)
QB	Prescribed amounts of stationary oxygen for daytime use while at rest and nighttime use differ and the average of the two amounts exceeds 4 liters per minute (lpm) and portable oxygen is prescribed
QJ	Services/items provided to a prisoner or patient in state or local custody, however the state or local government, as applicable, meets the requirements in 42 cfr 411.4 (b)
QL	Patient pronounced dead after ambulance called
QW	Clia waived test
RC	Right coronary artery
SC	Medically necessary service or supply
SD	Services provided by registered nurse with specialized, highly technical home infusion training
SE	State and/or federally-funded programs/services
SF	Second opinion ordered by a professional review organization (pro) per section 9401, p.l. 99-272 (100% reimbursement - no medicare deductible or coinsurance)
SG	Ambulatory surgical center (asc) facility service
SJ	Third or more concurrently administered infusion therapy
SL	State supplied vaccine
SS	Home infusion services provided in the infusion suite of the iv therapy provider
SU	Procedure performed in physician's office (to denote use of facility and equipment)
SW	Services provided by a certified diabetic educator
TF	Intermediate level of care
TH	Obstetrical treatment/services, prenatal or postpartum
TN	Rural/outside providers' customary service area
TW	Back-up equipment
U3	Medicaid level of care 3, as defined by each state
U4	Medicaid level of care 4, as defined by each state
UA	Medicaid level of care 10, as defined by each state
UB	Medicaid level of care 11, as defined by each state
UD	Medicaid level of care 13, as defined by each state
UH	Services provided in the evening
UJ	Services provided at night
XE	Separate encounter, a service that is distinct because it occurred during a separate encounter