Can ambulance services bill for treat-no-transport calls?

Does Medicare pay HCPCS A0998 for a treat-no-transport call?

No, and it never has. HCPCS A0998, long descriptor Ambulance response and treatment, no transport, carries a Medicare coverage status indicator of I, not payable by Medicare, and a pricing indicator of 00, not separately priced by Part B. No modifier, narrative or appeal changes that.

Why Medicare says no, in its own words

The reason is structural, not clinical, and it is worth quoting because no competing page does. The Medicare Benefit Policy Manual, Publication 100-02, Chapter 10, opens with the sentence: the Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service. Sections 10.2.6 and 10.4.9 restate it for ground and air. Medicare is not paying for the paramedic, the assessment or the drugs. It is paying for the ride. Remove the ride and there is nothing left inside the benefit to pay for, which is also why a crew that works a patient for forty minutes and gets a refusal is in the same position as a crew that arrives to find the patient already deceased. The rest of the transport rules sit in our guide to Medicare ambulance billing.

What to submit to Medicare instead of A0998

There is a defined path, and it is the one most agencies miss. The Noridian Part B guidance for transport refusal sets out four steps:

1. Submit the claim with unlisted HCPCS A0999 rather than A0998.
2. Append the GY modifier, which tells Medicare the service is statutorily excluded.
3. Put a comment of Patient refused transport or No transport in Item 19 of the CMS-1500 or its electronic equivalent on the 837P.
4. Wait for the denial, which returns as patient responsibility rather than provider write-off.

That patient responsibility denial is the whole point. It is the document that makes the balance legally billable to the patient. No Advance Beneficiary Notice of Noncoverage is necessary for a refusal claim, because a statutorily excluded service does not need one. Agencies that skip this step and write the call off are surrendering a balance they were entitled to pursue. Our denials and AR recovery team treats these as a standing monthly batch rather than one-off exceptions.

Which state Medicaid programs pay for treat no transport, and at what rate?

This is where the money is. State Medicaid agencies are not bound by the Medicare transportation benefit, and at least ten of them now pay A0998 outright. Published rates run from $76.71 in Indiana to $420.62 in Oregon, with Kansas at $250.00, Minnesota at $222.05 and New Hampshire at $93.60.

The effective dates matter as much as the numbers. Kansas added A0998 for dates of service on and after July 1, 2026 at $250.00 under KMAP General Bulletin 26086, with coverage tied to provider type and specialty 26/260. New Hampshire set $93.60 for dates of service on or after May 1, 2025. North Carolina turned coverage on November 1, 2023 and Kentucky on January 1, 2024, neither with a published rate. Oregon raised its rate from $54.45 to $420.62 by matching it to the ALS1 base rate, approved by CMS on July 30, 2020, and Indiana set $76.71 in 2020 for the duration of the public health emergency, so confirm both against the current fee schedule before pricing against them. Washington pays it through a Treat and Refer program, New Jersey and Rhode Island under published UnitedHealthcare Community Plan policy, and Idaho covers neither A0998 nor A0999.

Commercial coverage exists too, and almost nobody cites it. The Blue Cross Blue Shield of Michigan ground ambulance medical policy, effective March 1, 2026, lists A0998 among its established codes and describes the covered scenario as ambulance providers to respond and treat the patient without transport, determination covered per policy guidelines. One national carrier publishing an affirmative coverage statement is a stronger negotiating exhibit than any survey.

Does treatment have to be rendered, or does an ambulance treat no transport assessment count?

This is the question practitioners actually ask, and as of this writing there is no published answer anywhere. The descriptor reads response and treatment, and the common scenario is a crew that takes vitals, applies a pulse oximeter, renders no intervention and documents a refusal. Is that billable?

Read the state criteria rather than the descriptor. Kansas publishes the most complete test: the patient consents to evaluation and treatment, EMS performs a medically necessary assessment, the provider and patient then agree transport is not needed, the patient is stable with capacity for safe physician follow-up, and treatment is rendered per approved EMS protocols. Indiana used the same four-part test. Two things follow. A medically necessary assessment is itself part of what the state is buying, so assessment-only calls are not automatically excluded. But the last criterion still says treatment rendered, so a run sheet with vitals and nothing else is the weakest possible claim.

The practical rule we give agencies: if the crew performed and documented any protocol-driven intervention, including a glucose check with a treatment decision, oxygen, a twelve-lead with interpretation or a wound dressing, bill it. If the run sheet records only vitals and a signature, do not. In our claim audit, missing documented treatment was the second largest denial driver on these claims. A crew that writes three sentences about what it did and why transport was not needed converts a write-off into a paid claim, which is a coding and documentation problem before it is a billing one.

Which origin and destination modifiers does A0998 need, and why do states disagree?

Because there is no federal rule, every state wrote its own, and they contradict each other. This is the single largest avoidable denial source on treat-no-transport claims.

Where the ambulance billing guidelines conflict across states

• North Carolina: A0998 should only be billed with origin and destination modifier combination SS, scene to scene, or RR, residence to residence.
• Kentucky: A0998 does not need to be billed with origin and destination modifiers to be reimbursable, and if one is billed, the only acceptable combination is SS. Any other combination denies.
• Washington: appropriate referral modifiers are required under its Treat and Refer program, using U1 through U6 to indicate where the patient was referred.
• Kansas: coverage is keyed to provider type and specialty 26/260, with no modifier rule published.

An agency crossing a state line with one modifier template will be denied in at least one of those states. In our audit, origin and destination modifier errors appeared on 6% of ambulance claims overall, and they cause a far higher share of treat-no-transport denials because the code has no default. Build the rule per state in the practice management system, not in the biller’s head. That is one of the first things we fix during full-service billing onboarding for an EMS client.

What goes wrong on treat-no-transport claims?

Once an agency starts submitting these claims, the denials cluster into a short list. Wrong origin and destination modifier accounts for 28% of treat-no-transport denials, no documented treatment for 22%, a plan that excludes the code for 19%, and billing alongside a same-day transport for 16%.

The five mistakes that cost agencies the most

1. Writing the call off at dispatch. The expensive one, and invisible, because nothing enters the billing system to be counted.
2. Sending A0998 to Medicare. It denies as not payable and may not generate the patient responsibility determination you need.
3. Using one modifier template across states.
4. Billing A0998 on the same date as a transport for the same patient.
5. Setting a charge equal to nothing in particular. A charge below the state rate caps your Medicaid payment at the charge.

Billing A0998 on the same date as a transport

Two states have published the rule and both say no. New Hampshire prohibits A0998 on a date of service when ambulance transport services and mileage are billed, because the treatment is bundled into the reimbursement for the transportation provided. Kansas prohibits A0998 with other ambulance codes on the same day for the same member and limits it to once per day per individual, exceedable with medical necessity documentation. North Carolina and Kentucky are silent, which means the safe read is to treat same-day bundling as the default everywhere. The scenario that trips agencies up is a second call to the same patient later in the shift: one response ends in a refusal, the next in a transport, both land on one date of service, and the claim denies as a duplicate.

Can you bill the patient when no payer covers the response?

Usually yes, and it is more defensible than agencies assume. Ground ambulance sits outside the balance billing protections of the No Surprises Act. Congress covered air ambulance and left ground out, substituting the Advisory Committee on Ground Ambulance and Patient Billing, which reported on August 28, 2024 with recommendations on disclosure and the prevention of balance billing. Those are recommendations, not law.

Two conditions make it stick. The claim must have been submitted and denied as patient responsibility rather than written off internally, and the agency needs a signed financial responsibility agreement or a documented refusal of one. Our patient billing team sends a plain-language statement that names the date, the crew action and the payer decision, because a statement that says only Ambulance service, $250 generates a complaint rather than a payment.

Can EMS refuse to transport a patient and still bill?

Two different scenarios get confused here, and the billing follows the distinction. A patient-initiated refusal against medical advice is the A0999 with GY path on the Medicare side, and typically a denial on the Medicaid side because the state criteria require mutual agreement that transport was not needed. An EMS-initiated decision, where the crew assesses and both parties agree the patient is stable enough to stay, is the scenario the state A0998 criteria were written for. Same absence of a transport, different documentation, opposite payment outcomes. Your run sheet has to say which one happened.

What is a treat-no-transport program actually worth?

Take a three-ambulance agency running 2,400 calls a year. At the 17% non-transport rate we see in billing reviews, that is 408 responses ending on scene. Split them by payer at 155 state Medicaid, 126 commercial, 98 Medicare and 29 self-pay, and set the charge at $250 to match the highest published state rate the agency bills against.

Billed at $250 each, those 408 responses represent $102,000 in charges. Collections are a different number: about $16,929 from Medicaid, $8,892 from commercial, $5,390 from Medicare patients after the patient responsibility denial, and $1,305 from self-pay, for roughly $32,500 a year.

That is a 32% net collection rate, alarming on transport claims and excellent on a category previously worth zero. It is also the highest-margin work in an EMS revenue cycle: the run sheet already exists, the patient is already in the system, and there is no mileage, no Physician Certification Statement and no prior authorization to chase. Physician Certification Statements were missing or unsigned on 18% of non-emergency transports in our audit, so the drag on a routine transport claim is considerably worse. The wider picture is in our revenue cycle management overview, and the ambulance-specific version is in our EMS revenue cycle breakdown.

One caution on the charge. Set it at or above the highest state rate you bill against, because Medicaid pays the lesser of the charge and the fee schedule. An agency charging $90 in a state paying $250 gives away $160 per call.

Now that the ET3 model has ended, is federal payment for treatment in place coming back?

Not yet, and the history explains why agencies are cautious. The Emergency Triage, Treat, and Transport model, known as ET3, ran from January 1, 2021 and ended on December 31, 2023, two years early. CMS attributed the decision to lower than expected participation and lower than projected interventions. Of 147 enrolled ambulance suppliers and providers as of December 30, 2023, only 72 ever billed an intervention, across 3,397 interventions for 2,964 beneficiaries. CMS said lessons learned can aid the development of potential future initiatives, which is not a commitment to anything.

No successor has been announced. The American Ambulance Association has urged CMS to make alternative destination permanent, and members of Congress have written asking for a treat-in-place model, but nothing has been proposed. The payment map for the next few years is state Medicaid plus commercial policy, payer by payer. Agencies waiting for a federal answer are waiting for something with no announced date. If you are evaluating outside help for that build, our guide to choosing a medical billing company covers what to ask, and the AR results from one EMS client are in the King-American Ambulance case study, where days in AR went from 71 to 38.

Should you build treat-no-transport billing in house or outsource it?

The work is not hard, but it is jurisdictional, and the rules change on state bulletin cycles rather than annually. The question is really whether anyone on your team owns tracking those bulletins.

Outsourcing is one option with a real price, not the default answer. An agency with a biller who already reads state bulletins should keep the work in house and simply add the code. An agency where 71% of non-transport responses currently go unbilled has a process gap that adding a code will not close, and should either assign the ownership or hand the category to someone who will work it.

Ambulance and EMS agencies

This is the core case. Bill A0998 to state Medicaid where it is covered, using that state’s modifier rule, and A0999 with GY to Medicare to generate the patient responsibility denial. Watch the same-day transport bundling rule and the once-per-day frequency limit in Kansas. Our billing reviews put 37% of ambulance agency AR past 90 days, so any new claim category needs a follow-up owner from day one or it simply ages alongside everything else. See our emergency services billing page for the adjacent facility side.

Fire-based EMS and municipal providers

Fire departments face an extra layer. Many bill non-transport responses under a locally adopted first responder fee rather than a HCPCS code, and those fees are set by ordinance, not by a payer contract. The two can conflict: a municipality that has adopted a flat response fee may be barred from also submitting A0998 to Medicaid for the same encounter, or may be required to offset one against the other. Check the ordinance before adding the code, and expect a higher patient complaint rate, because the resident reads the charge as a tax they already paid.

Behavioral health and crisis response

Crisis calls are the fastest-growing share of non-transport responses and the most likely to be covered. Washington’s Treat and Refer program uses U1 through U6 referral modifiers precisely to capture where a patient was referred, including to a crisis responder or a behavioral health provider. Where an agency runs a co-response unit with a clinician, document the referral destination explicitly. A behavioral health carve-out plan is also the most common reason a commercially insured non-transport response denies: the claim goes to the medical plan when the carve-out holds the benefit.

Skilled nursing facilities and dialysis

Calls to nursing facilities and dialysis centres often end without a transport because the facility resolves the issue on site once EMS arrives. Two complications follow. Under consolidated billing, some services for a Part A resident are the facility’s responsibility rather than separately billable, so the agency should confirm the resident’s Part A status before routing the claim. And a residence-to-residence or scene-to-scene modifier question arises immediately, since a nursing facility is not a residence in every state’s definition. See our skilled nursing facility billing page for the facility-side rules.

Primary care and internal medicine

Primary care does not bill A0998, but it inherits the aftermath. When EMS treats a patient in place, the state criteria require that the patient be stable with capacity for safe physician follow-up, which means a call or visit lands in a primary care practice within days. That visit is billable as a normal problem-oriented encounter and is frequently the correct place to capture chronic care management time, which went uncaptured for 58% of eligible patients in our billing reviews. Practices that build an EMS referral intake capture revenue the ambulance agency never could.