HCPCS Code A0428

Official Description

Ambulance service, basic life support, non-emergency transport, (bls)

Short Descr	Bls
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	2
MUE	Not applicable/unspecified.
OTS Orthotic	No
CCS Clinical Classification	239 - Transportation - patient, provider, equipment

HN	Bachelors degree level
HR	Family/couple with client present
HH	Integrated mental health/substance abuse program
HE	Mental health program
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
GW	Service not related to the hospice patient's terminal condition
PN	Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital
NR	New when rented (use the 'nr' modifier when dme which was new at the time of rental is subsequently purchased)
JE	Administered via dialysate
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.
GN	Services delivered under an outpatient speech language pathology plan of care
EJ	Subsequent claims for a defined course of therapy, e.g., epo, sodium hyaluronate, infliximab
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
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.
QN	Ambulance service furnished directly by a provider of services
HD	Pregnant/parenting women's program
HI	Integrated mental health and intellectual disability/developmental disabilities program
QL	Patient pronounced dead after ambulance called
SH	Second concurrently administered infusion therapy
HS	Family/couple without client present
RD	Drug provided to beneficiary, but not administered "incident-to"
HJ	Employee assistance program
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
GZ	Item or service expected to be denied as not reasonable and necessary
HP	Doctoral level
RE	Furnished in full compliance with fda-mandated risk evaluation and mitigation strategy (rems)
KX	Requirements specified in the medical policy have been met
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
GA	Waiver of liability statement issued as required by payer policy, individual case
GE	This service has been performed by a resident without the presence of a teaching physician under the primary care exception
GV	Attending physician not employed or paid under arrangement by the patient's hospice provider
RR	Rental (use the 'rr' modifier when dme is to be rented)
SN	Third surgical opinion
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.
CC	Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
CR	Catastrophe/disaster related
EX	Expatriate beneficiary
FY	X-ray taken using computed radiography technology/cassette-based imaging
GB	Claim being re-submitted for payment because it is no longer covered under a global payment demonstration
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
GM	Multiple patients on one ambulance trip
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
HC	Adult program, geriatric
HG	Opioid addiction treatment program
HL	Intern
HM	Less than bachelor degree level
HO	Masters degree level
HV	Funded state addictions agency
HW	Funded by state mental health agency
HX	Funded by county/local 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
PB	Surgical or other invasive procedure on wrong 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
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
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)
QM	Ambulance service provided under arrangement by a provider of services
QW	Clia waived test
RI	Ramus intermedius coronary artery
SD	Services provided by registered nurse with specialized, highly technical home infusion training
SE	State and/or federally-funded programs/services
SJ	Third or more concurrently administered infusion therapy
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)
TK	Extra patient or passenger, non-ambulance
TP	Medical transport, unloaded vehicle
TW	Back-up equipment
U1	Medicaid level of care 1, as defined by each state
U2	Medicaid level of care 2, as defined by each state
U3	Medicaid level of care 3, as defined by each state
U8	Medicaid level of care 8, as defined by each state
UA	Medicaid level of care 10, as defined by each state
UD	Medicaid level of care 13, as defined by each state
UJ	Services provided at night
XE	Separate encounter, a service that is distinct because it occurred during a separate encounter