PROCEDURE MODIFIER MODIFIER MODIFIER SERVICE DESCRIPTION RATE CODE 1 2 3 MEDICAL CODES S0209 RD WHEELCHAIR VAN, MEDICAL, MILEAGE, PER MILE $1.26 S0209 RD CG WHEELCHAIR VAN, MEDICAL, MILEAGE, PER MILE PER CONTRACT S0209 TP RD WHEELCHAIR VAN, MEDICAL, UNLOADED MILEAGE, PER MILE $0.46 TP RD CG WHEELCHAIR VAN, MEDICAL, UNLOADED MILEAGE, PER MILE PER CONTRACT S0215 RD NON-EMERGENCY TRANSPORTATION; MILEAGE, PER MILE $1.55 S0215 RD CG NON-EMERGENCY TRANSPORTATION; MILEAGE, PER MILE PER CONTRACT T2049 RD NON-EMERGENCY TRANSPORTATION; STRETCHER VAN, MILEAGE; PER MILE $1.46 T2049 RD CG NON-EMERGENCY TRANSPORTATION; STRETCHER VAN, MILEAGE; PER MILE PER CONTRACT NON-EMERGENCY TRANSPORTATION; STRETCHER VAN, UNLOADED MILEAGE; T2049 TP RD $1.25 PER MILE NON-MEDICAL CODES S0209 RI WHEELCHAIR VAN, NON MEDICAL, MILEAGE, PER MILE PER CONTRACT S0209 TP RI WHEELCHAIR VAN, NON MEDICAL, UNLOADED MILEAGE, PER MILE PER CONTRACT S0215 RI NON-EMERGENCY, NON-MEDICAL, TRANSPORTATION: MILEAGE, PER MILE PER CONTRACT NON-EMERGENCY, NON-MEDICAL, TRANSPORTATION, UNLOADED MILEAGE, PER S0215 TP RI PER CONTRACT MILE S0215 U1 RI NON-EMERGENCY, NON-MEDICAL, TRANSPORTATION, MILEAGE, PER MILE PER CONTRACT RD=MEDICAL RI=NON-MEDICAL CG=PAYS OVER THE MA RATE **RATES ARE SUBJECT TO CHANGE PER MEDICAID MAX FEE SCHEDULE** **PROVIDER IS RESPONSIBLE FOR BILLING CORRECT RATES** UPDATED 01.16.17 TZ
PROCEDURE CODE MODIFIER 1 MODIFIER 2 MODIFIER 3 SERVICE DESCRIPTION RATE MEDICAL CODES S0209 RD WHEELCHAIR VAN, MEDICAL, MILEAGE, PER MILE $1.26 S0209 RD CG WHEELCHAIR VAN, MEDICAL, MILEAGE, PER MILE PER CONTRACT S0209 TP RD WHEELCHAIR VAN, MEDICAL, UNLOADED MILEAGE, PER MILE $0.46 TP RD CG WHEELCHAIR VAN, MEDICAL, UNLOADED MILEAGE, PER MILE PER CONTRACT S0215 RD NON-EMERGENCY TRANSPORTATION; MILEAGE, PER MILE $1.55 S0215 RD CG NON-EMERGENCY TRANSPORTATION; MILEAGE, PER MILE PER CONTRACT T2049 RD NON-EMERGENCY TRANSPORTATION; STRETCHER VAN, MILEAGE; PER MILE $1.46 T2049 RD CG NON-EMERGENCY TRANSPORTATION; STRETCHER VAN, MILEAGE; PER MILE PER CONTRACT T2049 TP RD NON-EMERGENCY TRANSPORTATION; STRETCHER VAN, UNLOADED MILEAGE; PER MILE $1.25 NON-MEDICAL CODES S0209 RI WHEELCHAIR VAN, NON MEDICAL, MILEAGE, PER MILE PER CONTRACT S0209 TP RI WHEELCHAIR VAN, NON MEDICAL, UNLOADED MILEAGE, PER MILE PER CONTRACT S0215 RI NON-EMERGENCY, NON-MEDICAL, TRANSPORTATION: MILEAGE, PER MILE PER CONTRACT S0215 TP RI NON-EMERGENCY, NON-MEDICAL, TRANSPORTATION, UNLOADED MILEAGE, PER MILE PER CONTRACT S0215 U1 RI NON-EMERGENCY, NON-MEDICAL, TRANSPORTATION, MILEAGE, PER MILE PER CONTRACT RD=MEDICAL RI=NON-MEDICAL CG=PAYS OVER THE MA RATE **RATES ARE SUBJECT TO CHANGE PER MEDICAID MAX FEE SCHEDULE** **PROVIDER IS RESPONSIBLE FOR BILLING CORRECT RATES** UPDATED 01.16.17 TZ
TRANSPORTATION-Ancillary-Codes-for-Providers-1.16.17.docx