Billing instruction for Ambulance Billing – Box 24a to 24b
| BlockNo. | Block Name | Block Code | Notes |
| 24a | Dates of Service | M/M | Enter the applicable date(s) of service. If billing for a service that was provided on one day only, complete either the From or the To column (but not both.). If the same service was provided on consecutive days, enter the first day of the service in the From column and the last day of service in the To column. Use an eight-digit (MMDDCCYY) format to record the From and To dates, (e.g. 03012004). If the dates are not consecutive, separate claim lines must be used. |
| 24b | Place of Service | M | Enter the 2-digit place of service code that indicates where the recipient was transported (i.e., destination). 12 – Patient’s Home 21 – Inpatient Hospital 22 – Outpatient Hospital 23 – Emergency Room 24 – Ambulatory Surgical Center (ASC)/ Hospital Short Procedure Unit (SPU) 32 – Nursing Facility 49 – Independent Clinic 50 – Federally Qualified Health Center 54 – Intermediate Care Facility/Mentally Retarded 55 – Residential Substance Abuse Treatment Facility 65 – End Stage Renal Disease Treatment Facility 72 – Rural Health Clinic 99 – Other Unlisted Facility |
| BlockNo. | Block Name | Block Code | Notes |
| 24a | Dates of Service | M/M | Enter the applicable date(s) of service. If billing for a service that was provided on one day only, complete either the From or the To column (but not both.). If the same service was provided on consecutive days, enter the first day of the service in the From column and the last day of service in the To column. Use an eight-digit (MMDDCCYY) format to record the From and To dates, (e.g. 03012004). If the dates are not consecutive, separate claim lines must be used. |
| 24b | Place of Service | M | Enter the 2-digit place of service code that indicates where the recipient was transported (i.e., destination). 12 – Patient’s Home 21 – Inpatient Hospital 22 – Outpatient Hospital 23 – Emergency Room 24 – Ambulatory Surgical Center (ASC)/ Hospital Short Procedure Unit (SPU) 32 – Nursing Facility 49 – Independent Clinic 50 – Federally Qualified Health Center 54 – Intermediate Care Facility/Mentally Retarded 55 – Residential Substance Abuse Treatment Facility 65 – End Stage Renal Disease Treatment Facility 72 – Rural Health Clinic 99 – Other Unlisted Facility |