`A0021` Outside state ambulance serv

Ambulance service, outside state per mile, transport (medicaid only)

Medicare coverage: Not payable by Medicare
Status: active (October 2026 file)

Medically Unlikely Edits (effective October 1, 2026)

Practitioner: max 0 units per day (clinical), rationale: CMS Policy
Outpatient hospital: max 0 units per day (clinical), rationale: CMS Policy

Medicare pricing for A0021

Physician Fee Schedule (CY 2026, RVU26D)

Status I: not valid for Medicare (Medicare uses another code).

Payer policies and prior authorization for A0021

Payer coverage policies that name A0021

A0021 appears in 1 coverage policy from Blue Cross & Blue Shield of Mississippi.

Payer	Policy	Role in policy	Reviewed	Document
Blue Cross & Blue Shield of Mississippi	Ambulance And Medical Transport Services (L.9.01.400)	covered if criteria are met		payer document

Medicaid fee-for-service

Prior authorization required or conditional in IN.

VT: $2.35 (outpatient_hospital_opps), effective Feb 1, 2026
WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), effective Apr 1, 2026

From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.

A0021 Outside state ambulance serv