EMG – BOX 24 C, filling instruction
Billing instruction for Ambulance Billing – Box 24a to 24d
| BlockNo. | Block Name | Block Code | Notes |
| 24c | EMG | A | Enter 1 if the service provided was in response to an emergency, 2 if urgent. Otherwise, leave this item blank. |
| 24d | Procedures, Services, or Supplies (CPT/HCPCS & Modifier) | M/M/A | List the procedure code(s) for the service(s) being rendered and any applicable modifier(s). In the first section of the block, enter the procedure code that describes the service provided. In the second and third sections of the block, enter up to four applicable modifiers. Note: There must be at least one modifier enter in the second section of this block for the service(s) provided. Ambulance procedure codes A0425 (Ground mileage, per statute mile) and A0430 (Ambulance service, conventional air services, transport, fixed wing) must have modifier U8 in the second section of this block. The modifiers applicable to ambulance services are: RH – Residence to Hospital HR – Hospital to Residence HE – Hospital to Residential, domiciliary, custodial facility (nursing home, not skilled nursing facility) RE – Residence to Residential, domiciliary, custodial facility (nursing home, not skilled nursing facility) HN – Hospital to Skilled Nursing Facility (SNF) PH – Physician’s Office (includes HMO non- hospital facility, clinic, etc) to Hospital RJ – Residence to Non-Hospital based dialysis facility JH – Non-Hospital based dialysis facility to Hospital JR – Non-Hospital based dialysis facility to Residence RG – Residence to Hospital based dialysis facility (hospital or hospital-related) GR – Hospital based dialysis facility (hospital or hospital-related to Residence SD – Scene of accident or acute event to Diagnostic or therapeutic site other than “P” (physician) or “H” (hospital) SH – Scene of accident or acute event to Hospital SI – Scene of accident or acute event to Site of transfer (for example, airport or helicopter) between types of ambulance IH – Site of transfer (for example, airport or helicopter) between types of ambulance to Hospital HH – Hospital to Hospital HI – Hospital to Site of transfer (for example, airport or helicopter) between types of ambulance NH – Skilled Nursing Facility to Hospital EH – Residential, domiciliary, custodial facility (nursing home, not skilled nursing facility) to Hospital RD – Residence to Diagnostic or therapeutic site other than “P” (physician) or “H” (hospital) II – Site of transfer (for example, airport or helicopter) between types of ambulance to Site of transfer (for example, airport or helicopter) between types of ambulance RN – Residence to Skilled Nursing Facility (SNF) HD – Hospital to Diagnostic or therapeutic site other than “P” (physician) or “H” (hospital) |