Modifier QM- Ambulance Service Provided Under Arrangement

Modifier QM identifies an ambulance service provided under arrangement by a provider of services and is used in applicable Medicare institutional ambulance billing.

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What Is Modifier QM?

Modifier QM is a HCPCS modifier used to indicate that an ambulance service was provided under arrangement by a provider of services.

In this situation, the institutional provider is responsible for the ambulance service but another ambulance entity furnishes the transportation under an arrangement with that provider.

QM distinguishes these services from ambulance services furnished directly by the provider. Modifier QN is used for the directly furnished situation.

The distinction is important because QM and QN describe how the ambulance service was furnished, rather than the patient's origin, destination, medical condition, or level of ambulance service.

When to Use Modifier QM

Service Provided Under Arrangement: Use QM when an institutional provider bills for an ambulance service that was furnished under an arrangement with another ambulance entity.

Institutional Ambulance Billing: QM applies to applicable institutional provider ambulance claims where Medicare requires identification of whether the service was furnished directly or under arrangement.

Ambulance HCPCS Service Is Reported: Append QM to the applicable ambulance HCPCS code when required by the claim-reporting rules.

Origin and Destination Are Also Reported: For a transported patient, the appropriate ambulance origin-and-destination modifier is generally reported in addition to QM.

QL Circumstances Apply: When a patient is pronounced dead after an ambulance is called and the applicable QL requirements are met, QM may also be required to identify that the ambulance response was provided under arrangement.

When NOT to Use Modifier QM

Provider Furnished the Ambulance Directly: Use Modifier QN when the ambulance service was furnished directly by the provider rather than under arrangement.

Independent Supplier Professional Claim: QM is associated with applicable institutional provider reporting and should not automatically be added to every ambulance claim.

To Identify Origin and Destination: QM does not identify where the ambulance trip began or ended. Separate ambulance origin-and-destination modifiers serve that purpose.

To Identify Medical Necessity: QM does not establish that ambulance transportation was medically necessary.

To Identify the Level of Service: QM does not distinguish BLS, ALS, specialty care transport, fixed-wing, or rotary-wing ambulance services.

Billing Example

A hospital arranges for an outside ambulance company to transport a Medicare beneficiary from the hospital to a skilled nursing facility.

The hospital bills the applicable ambulance service under the arrangement.

Because the ambulance transportation was provided under arrangement rather than furnished directly by the hospital, Modifier QM is reported with the applicable ambulance HCPCS code when required.

The appropriate origin-and-destination modifier would also be reported to identify the transportation route.

Documentation Requirements

Arrangement With Ambulance Entity: Documentation should support that the ambulance service was furnished under an arrangement rather than directly by the billing provider.

Ambulance Service Performed: Record the type and level of ambulance service actually provided.

Origin and Destination: Document where the patient was picked up and transported so the appropriate origin-and-destination modifier can be supported.

Medical Necessity: The record should establish why ambulance transportation and the level of service furnished were medically necessary.

Date of Service: Clearly document the date associated with each ambulance trip.

Mileage: When mileage is billed, documentation should support the applicable loaded mileage associated with the beneficiary's transport.

Billing and Claim Considerations

QM describes the relationship between the billing provider and the entity furnishing the ambulance service. It does not replace the other information required on an ambulance claim.

Applicable institutional ambulance claims generally require an ambulance HCPCS code, an appropriate origin-and-destination modifier, and QM or QN to identify how the ambulance service was furnished.

For example, ambulance base-service codes can include services such as BLS, ALS, specialty care transport, and air ambulance transportation. Mileage is separately reported with the appropriate ambulance mileage code when applicable.

The reported level of service must correspond to the service actually furnished and supported by the patient's condition and documentation.

Modifier QM vs. QN

QM and QN distinguish whether an ambulance service was furnished under arrangement or directly by the provider.

Modifier QM: Ambulance service provided under arrangement by a provider of services.

Modifier QN: Ambulance service furnished directly by a provider of services.

The modifiers should not be selected based on the patient's condition, destination, or ambulance level. Selection depends on the relationship under which the ambulance service was furnished.

Modifier QM and Origin/Destination Modifiers

QM does not replace the standard ambulance origin-and-destination modifier.

Ambulance transportation generally uses a two-character modifier identifying the patient's point of origin and destination. Examples can represent transportation between a residence, hospital, skilled nursing facility, dialysis facility, physician office, or other qualifying locations.

QM provides different information. It tells the payer that the ambulance service was furnished under arrangement.

Both pieces of information may therefore be required on the same ambulance claim.

Common Billing Mistakes

Using QM for Directly Furnished Services: A directly furnished provider ambulance service is identified with QN rather than QM.

Omitting the Origin/Destination Modifier: QM does not replace the modifier identifying the ambulance trip's origin and destination.

Using QM on Every Ambulance Claim: QM applies to the under-arrangement situation and should not be automatically appended to unrelated ambulance claims.

Incorrect Ambulance HCPCS Code: The base-service code must accurately represent the level and type of ambulance service furnished.

Unsupported Mileage: Mileage should correspond to the loaded miles associated with the beneficiary's actual transportation.

Confusing QM With Medical Necessity: QM identifies how the service was furnished. It does not demonstrate that ambulance transportation itself was medically necessary.

Common Denial Reasons

Incorrect QM/QN Selection: The modifier reported does not correspond to whether the service was furnished directly or under arrangement.

Missing Required Modifier Information: The claim is missing an applicable origin/destination or service-arrangement modifier.

Incorrect Ambulance HCPCS Code: The billed level of ambulance service is inconsistent with the documented service.

Medical Necessity Not Supported: Documentation does not establish the need for ambulance transportation or the reported level of service.

Origin or Destination Not Supported: The reported transportation modifier does not match the documented trip.

Incomplete Mileage Documentation: The mileage billed cannot be supported by the transportation record.

Frequently Asked Questions

Can Modifier QM and an ambulance origin-and-destination modifier be reported together?
Yes. They communicate different information. The origin-and-destination modifier identifies the ambulance transportation route, while QM indicates that the ambulance service was provided under arrangement.

What determines whether Modifier QM or QN should be reported?
The determining factor is how the institutional provider furnished the ambulance service. QM identifies a service provided under arrangement, while QN identifies an ambulance service furnished directly by the provider.