CMS 1500 – 24 G – days or units, 24 F – charges
Billing instruction for Ambulance Billing – Box 24e to 24g
| BlockNo. | Block Name | Block Code | Notes |
| 24e | Diagnosis Pointer | M | This block may contain up to four digits. If the service was provided for the primary diagnosis (in Block 21), enter 1. If provided for the secondary diagnosis, enter 2. If provided for the third diagnosis, enter 3, and for the fourth diagnosis, enter 4. |
| 24f | $Charges | M | Enter your usual charge to the general public for the service(s) provided. If billing for multiple units of service, multiply your usual charge by the number of units billed and enter that amount. For example, if your usual charge is sixty-five dollars, enter 6500. |
| 24g | Days or Units | M | Enter the number of units, services, or items provided. Note: Providers submitting claims for ambulance transport mileage reimbursement for more than one episode of transportation for a single recipient on the same date of service, and the same ambulance transport Procedure Code / Modifier combination applies to more than one episode of transportation, the episodes requiring the same Procedure Code / Modifier combination must be mulled on the same claim line indicating the total number of episodes provided in the Block 24G (Units). In instances of this nature it is important to document in the recipient’s file associated with these services the reason why it was necessary to bill the Procedure Code/Modifier combination for more than 1 unit. Billable mileage is paid beyond the first 20 loaded or unloaded miles of a round trip. Enter the number of miles of the round trip minus the first twenty miles (e.g., If the round trip was 100 miles, then enter 80 (miles) in block 24g). |
Please bill same services on one line item with the corresponding number of units.
Billing instruction for Ambulance Billing – Box 24e to 24g
| BlockNo. | Block Name | Block Code | Notes |
| 24e | Diagnosis Pointer | M | This block may contain up to four digits. If the service was provided for the primary diagnosis (in Block 21), enter 1. If provided for the secondary diagnosis, enter 2. If provided for the third diagnosis, enter 3, and for the fourth diagnosis, enter 4. |
| 24f | $Charges | M | Enter your usual charge to the general public for the service(s) provided. If billing for multiple units of service, multiply your usual charge by the number of units billed and enter that amount. For example, if your usual charge is sixty-five dollars, enter 6500. |
| 24g | Days or Units | M | Enter the number of units, services, or items provided. Note: Providers submitting claims for ambulance transport mileage reimbursement for more than one episode of transportation for a single recipient on the same date of service, and the same ambulance transport Procedure Code / Modifier combination applies to more than one episode of transportation, the episodes requiring the same Procedure Code / Modifier combination must be mulled on the same claim line indicating the total number of episodes provided in the Block 24G (Units). In instances of this nature it is important to document in the recipient’s file associated with these services the reason why it was necessary to bill the Procedure Code/Modifier combination for more than 1 unit. Billable mileage is paid beyond the first 20 loaded or unloaded miles of a round trip. Enter the number of miles of the round trip minus the first twenty miles (e.g., If the round trip was 100 miles, then enter 80 (miles) in block 24g). |