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State-Administered Transportation Procedure Codes, Modifiers and Payment Rates

Effective 7/1/2016

Revised: 09-21-2016

For Mode 4 – Assisted Transport see Local county or tribal agency procedure codes, modifiers and payment rates.

Procedure
Code

Description

Modifier Indicator

Payment Rate

A0130
Wheelchair;
Lift-equipped, ramp transport

Nonemergency transportation; wheelchair van;
Mode 5 – Lift-equipped, ramp transport base rate

Transport location modifier required; reverse modifier for return trip

$18.00

S0209
Wheelchair mileage;
lift-equipped, ramp transport mileage

Nonemergency transportation; wheelchair van, mileage per mile;
Mode 5 mileage

Modifier required

$1.55 per loaded mile

T2003 UA
Protected transport

Nonemergency transportation; protected transport; Mode 6 – protected transport base rate

Transport modifier required; reverse modifier for return trip

$75.00 per loaded mile
(must include an attendant)

S0215 UA
Protected transport mileage

Nonemergency transportation; protected transport mileage

Modifier required

$2.40 per loaded mile

T2005
Stretcher

Nonemergency transportation; non-ambulatory stretcher van;
Mode 7 – stretcher transport base rate

Transport modifier required; reverse modifier for return trip

$60.00

T2049
Stretcher mileage

Nonemergency transportation; non-ambulatory stretcher van mileage;
Mode 7 mileage

Modifier required

$2.40 per loaded mile

T2001
Extra Attendant

Nonemergency transportation; patient attendant or escort;
Mode 7 only

Transport modifier required; reverse modifier for return trip

$9.00

Bill each procedure code by the number of units.

When requesting a level-of-service assessment, contact KEPRO at 844-681-8144. If you need an assessment for protected transport, contact the county mental health crisis team.

Place of Service Codes:
41 – Ambulance Land
42 – Ambulance Air or Water
99 – Place of service for special transportation

HCPCS origin and destination codes (for more than one modifier on the same line item, the first position indicates the origin and the second position indicates the destination):

Code

Description

D

Diagnostic or therapeutic site other than P or H when these are used as origin codes

E

Residential, domiciliary, custodial facility (other than an 1819 facility)

G

Hospital-based ESRD facility

H

Hospital

I

Site of transfer (e.g., airport or helicopter pad) between modes of ambulance transport

J

Freestanding ESRD facility

N

Skilled nursing facility (SNF)

P

Physician’s office

QM

Institutional based providers only. Ambulance service provided under arrangement by a provider of services

QN

Institutional based providers only. Ambulance service furnished directly by a provider of services

R

Residence

S

Scene of accident or acute event

X

Intermediate stop at physician’s office en route to the hospital (destination code only)

76

Repeat procedure by same provider

77

Repeat procedure by another provider

Multiple Rider Reduction

Reduce the percentage of the base rate and the percentage of the mileage based on the number of riders. See the table for percentage calculations.

Percentage of reduction

# of Riders

% of Base

% of Mileage

1

100

100

2

80

50

3

70

34

4

60

25

5-9

50

20

10 or more

40

10

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