Office of Workers' Compensation Programs (OWCP)

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Division of Coal Mine Workers' Compensation (DCMWC)

On This Page Ambulance Service Ambulance Modifiers Medical Documentation Ambulance Supplies Air Ambulance

Ambulance Service Billing Instruction

AMBULANCE SERVICE

Ambulance service (basic and advanced life support) is reimbursable by the Federal Black Lung Program when required for a beneficiary’s covered acute respiratory or pulmonary condition.

AMBULANCE MODIFIERS

Transportation in an ambulance is covered for the following ambulance (origin and destination) modifiers:

DH, NH, HD, HN, EH, PH, HE, RH, IH, HH AND HR.

The appropriate modifier listed above must be clearly defined on the bill in block 24-C and or block 24-D of the HCFA /OWCP-1500 billing form.  Bills that do not meet the above criteria will be denied.

MEDICAL DOCUMENTATION

Reimbursement for all ambulance transportation will only be approved if medical documentation is submitted with the bill. This documentation must be one of the following:

A hospital discharge summary, emergency room report, or a physician’s signed statement or a “physician’s certification for ambulance transport.” A signature by ANY of the following professionals is required: Physician, Physician Assistant, Nurse Practitioner, Registered Nurse or Discharge Planner. The documentation must certify that the ambulance service was required for a beneficiary's acute respiratory or pulmonary condition.

Without documentation that meets the above criteria, reimbursement for ambulance services will be denied.

AMBULANCE SUPPLIES

Ambulance supply codes A0382, A0392, A0394, A0396, A0398 and A0422 (e.g. disposable supplies, I.V. drug supplies, oxygen etc) are payable up to a dollar maximum but only in the presence of the “primary ambulance service (basic or advanced life support).

AIR AMBULANCE

*Ambulance codes: A0430, A0431, A0435 and A0436 are only payable for the treatment of Primary Lung Cancer (162.2-162.9) and will be referred to the DCMWC National Office for approval. Documentation for air ambulance must contain a treating physician’s signed statement or a “physician’s certification for ambulance transport,” indicating why this was the only available method of transport.

Without documentation that meets the above criteria, reimbursement for air ambulance services will be denied.

If you have any questions, please call the Federal Black Lung Program at 1-800-638-7072. You may also e-mail your comments to DCMWCPublic@dol.gov.