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Ambulance Documentation Requirements
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Ambulance Documentation Basics
Medical Necessity for Ambulance Services
Elements of Ambulance Documentation
Physician Certification Statement (PCS) for Ambulance Services
Air Ambulance Documentation After Death Pronouncement
Prior Authorization for Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT)
Hospital to Hospital Transports
Skilled Nursing Facility Patients
Additional Ambulance Resources
Ambulance Documentation Basics
Document all ambulance trips. The documentation must stand alone. This means it must tell the patient's story in a clear and concise manner. Medicare only considers what is in the documentation.
The basis for the ambulance dispatch is the complaint given. The dispatch does not drive medical necessity.
The ambulance trip documentation must support
- Medical necessity
- Billable loaded mileage
When documentation does not support medical necessity, Medicare does not pay for the base rate or mileage. The entire bill is the patient’s responsibility.
Ambulance suppliers develop their own way of gathering information. The most common way is the run sheet. The documented information must support the billable procedure code, modifiers, and diagnosis.
Two separate trips occur when transport to and from a single location occurs on the same day. Medicare Part A considers round trips when a beneficiary is inpatient in a facility. If the pick-up ZIP codes are different, then submit the trips on separate claims. Document the following to support the medical necessity of the ambulance trip:
- Details of the patient's condition
- Services rendered
- Times of both transports
- Loaded mileage
- Why the receiving facility is not within the patient’s locality
Medicare considers complete and legible documentation.
Medical Necessity for Ambulance Services
Medical necessity requires documentation that supports the patient’s condition requiring an ambulance for transport. Medicare considers ambulance transport medically necessary if any other means of transport could jeopardize the patient’s health. The law refers to this as contraindicated. This is not a limitation of liability situation. This is a coverage issue defined in the patient’s Medicare & You Guidebook. Medicare sends the guidebook yearly to each beneficiary or household.
The HCFA Ruling 95-1 contains the above information as well.
Bed-Confinement and Medical Necessity for Ambulance Services
Terms such as "bedridden," "bed-confined," "stretcher patient," or "required restraints" do not, by themselves, support medical necessity. The term "bed-confined" is not synonymous with "bed rest" or "non-ambulatory." It is simply one element of the beneficiary's condition to consider in determining medical necessity for ambulance transport. Contractor's determination will always use “contraindicated” for medical necessity of an ambulance transport.
CMS indicates a beneficiary is bed-confined if they are:
- Unable to get up from bed without assistance
- Unable to ambulate
- Unable to sit in a chair or wheelchair
Situations Medicare may consider bed-confined:
- Contractures creating non-ambulatory status in a patient who cannot sit
- Severe generalized weakness
- Immobility of lower extremities issues causing a patient to be unsafe sitting in a wheelchair
- Patient in spica cast, fixed hip joints, or lower extremity paralysis
Refer to the CMS Internet-Only Manual (IOM) for the “Medicare Policy Concerning Bed-Confinement." This policy is in the IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 10 – Ambulance Services , Section 10.2.3.
Oxygen Dependent and Ambulance Transports
Medicare may consider patients who need ambulance transport due to oxygen dependency. The patient must need Emergency Medical Technicians (EMTs) monitoring or placement of the oxygen. The Physician Certification Statement (PCS) must support that ambulance is the only safe means of transport. EMT’s evaluation must explain the why the patient needs transport in the run report. Items not supporting oxygen dependency for ambulance transports include:
- Patient requires oxygen monitoring without a further explanation in the PCS
- Patient can place the oxygen themselves, without assistance
Elements of Ambulance Documentation
It is best when the patient provides the documentation information. Medicare recognizes this is not always possible. Document any information gathered from
- Relatives
- Bystander
- Emergency Medical Technician (EMT) observations
Required elements of ambulance documentation:
- Patient name
- As it appears in the Medicare system
- Patient’s Medicare Beneficiary Identifier (MBI)
- Date and time of transport
- Date of transport over a midnight
- The date of pick-up
- The date of drop-off
- Document time
- Military hours
- With an AM and/or PM
- Date of transport over a midnight
- Point of pick-up (PoP) address
- ZIP code at a minimum
- If no ZIP code exists, document the closest to the PoP
- Point of drop-off address (PoD)
- Facility name
- Must be street address
- Nine-digit ZIP code
- Mileage information
- Loaded mileage or patient on board mileage
- Document mileage from the odometer.
- If an odometer reading is not available, use electronic mapping software or trip odometers. Provide a brief explanation of why you are using the alternate source.
- Name and credentials of the EMT treating the patient
- Legible signature(s)
- State licensed credentials
- Transports medical necessity
- The need for the EMT’s medical training
- Patient’s complaint
- Reason for dispatch
- On-scene
- On-site EMT observations includes what he/she
- Saw
- Smelled
- Felt
- Heard
- EMT’s assessment
- Why the transport requires the EMT’s medical training
- Relevant history of present illness, include
- Location of the patient before dispatch
- Observations by bystanders
- Method of transportation
- Basic Life Support (BLS)
- Advance Life Support (ALS)
- Specialty Care Transport (SCT)
- Treatments, including
- Monitoring and adjusting oxygen
- Interventions
- Medication administered and route
- Patient's condition and treatment response during transport
- Improvement
- Decline
- Stable, no change
- Point of Drop-off information
- Staff receiving the patient
- Condition at time of care transfer
- Dispatch report/method
- Level of transport
- Method of complaint
- 911 or other call
- Rig identifier
- Patient’s signature
- Legible or identifiable
- Before billing, not necessarily at time of transport
- Beneficiaries refusing to sign for claim submission to Medicare for payment are responsible for the full bill. Suppliers must document the beneficiary's refusal to sign.
- If the patient is unable to sign, the signature documentation must include:
- The reason the patient is unable to sign
- The representative’s
- Name
- Address
- Relationship to the patient
- If the patient signs by mark, documentation must include a witness’ name and address.
- Crew members can sign when no one else is available. Documentation must indicate:
- The reason the patient is unable to sign
- No one else is available
- Name, address, and company
- Legible signature of the crew member
- Other health insurance information
- Primary or secondary
- Type of insurance
Include the following, if known:
- Medications
- Allergies
- Family history
- Social history
- Name of person initiating the call
- Relationship of caller to patient
- Advance Beneficiary Notice of Noncoverage (ABN)
- Physician Certification Statement (PCS)
- Treating facilities records (showing treatment within 24 hours of pick-up or drop-off)
- This does not prove medical necessity
Physician Certification Statement (PCS) for Ambulance Services
Refer to the Code of Federals (CFR) for physician certification and recertification of services. This information is 42 CFR 410.40(d)(2) and 410.40(d)(3) .
A PCS is a statement by physician or non-physician practitioner stating why an ambulance transport is medically necessary. An ambulance supplier develops a form or information to gather. CMS does not require a specific form.
We have a sample PCS to help you create one meeting the Medicare requirements. Our sample PCS is for informational purposes only.
A PCS alone does not prove medical necessity. The evaluation before the transport proves medical necessity. The PCS helps the ambulance staff know what to evaluate today.
Medicare requires a PCS when the beneficiary is under a physician’s care. The date on the order cannot be more than 60 days before the transport. The situation is non-emergent and must meet one of the following:
- Scheduled, repetitive ambulance services
- Examples:
- Dialysis
- Chemotherapy
- Scheduled 24 hours or more in advance of the transport
- Examples:
- Unscheduled, ambulance services
- Examples:
- MRI scheduled on the morning of transport
- Scheduled under 24 hours before the transport
- Examples:
- Non-repetitive scheduled basis
- One-time transport
- From a facility to higher level of care
Situations Not Requiring a PCS for Ambulance Services
The following ambulance services do not require a PCS:
- Emergency transports
- Patient is under duress
- Patient’s not under the direct care of a physician
Unable to Obtain a PCS for Ambulance Services
Scheduled repetitive transports require a PCS. A physician must sign the PCS.
Physician signatures can occur up to 48 hours after a non-scheduled, non-repetitive, or one-time transports. When physicians are not available or 48 hours passes, Medicare accepts signatures from certain non-physician medical professionals. The medical professionals must have knowledge of the patient’s medical condition at the time of transport.
Non-physician medical professionals include:
- Physician assistant
- Nurse practitioner
- Registered nurse
- Clinical nurse specialist
- Discharge planner
Employment for the non-physician signing the PCS must be by:
- The beneficiary's attending physician
- The treating facility which is the transport origin
If not receiving a PCS within 21 days after the initial attempt, document your attempts to receive a PCS.
Document any verbal attempts to receive a PCS. Also, document any written attempts to receive a PCS with one of the following:
- A certified letter with a return receipt
- Other proof of mailing
- Fax
Ambulance Mileage
Medicare allows payment for loaded mileage or patient on board mileage. This is in the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 15 - Payment Rules , Section 20.1.4.
WPS Government Health Administrators recommends mileage reports are from vehicle odometers. If documentation does not contain mileage, we do accept alternate sources. Alternate source may include:
- Trip mileage odometer
- Mapping software
Payable mileage is to an appropriate facility with the bed, staff, and equipment available to treat the patient. The facility must be in the patient’s locality.
For destination information see the IOM Publication 100-02 Medicare Benefit Policy Manual, Chapter 10 – Ambulance Services , Section 10.3.
Prior Authorization for Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT)
Ambulance documentation requirements apply to the RSNAT program. To learn about this program, view the following:
- CMS Prior Authorization for Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) web page
- Our Prior Authorization for Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) resource
Air Ambulance Documentation After Death Pronouncement
The supplier’s documentation must show all the following:
- The air ambulance dispatch occurred to pick up a patient;
- The aircraft actually took off to make the pickup
- The patient’s pronouncement of death occurred before loading them onto the ambulance for transport
- An individual authorized by state law pronounces the patient’s death
- The dispatcher did not receive pronouncement notice in time to abort the flight
Providers do not need to submit documentation unless requested.
Hospital to Hospital Transports
Medicare covers air and ground transport from one hospital to another hospital. The documentation must contain why there is a medical need for the transport. Examples of reasons Medicare will consider the transport include:
- There is no bed available at the first facility
- The patient needs services not available at first hospital, examples include:
- A larger hospital
- A better equipped hospital
- A higher-level facility
- The treatment requires a burn unit
- The patient requires a general hospital and psychiatric care
- The patient requires a psychiatric ward
- The need for special diagnostic studies
Medicare does not consider patient or provider preference in this decision. Base the decision on medically necessity of the ambulance transport.
Hospice Patients
Ambulance suppliers must determine if the transport medical reason is the same or relates to the hospice medical reason. This determination must be in the documentation and determines who to bill for the transport.
See our Ambulance Statutory and Billing Requirements for billing information.
Skilled Nursing Facility (SNF) Patients
Medicare pays for some transports when a patient is an inpatient in a SNF. Document the following to determine if you bill Medicare or the SNF:
- Reason for transport
- Destination
- Service at the destination
Medicare may also consider a return trip to the SNF. This service requires separately identifiable information in the patient’s documentation. Medicare considers the trip to and from a destination as two separate trips. Each trip must meet the documentation requirements.
Additional Ambulance Resources
See our Ambulance Statutory and Billing Requirements for billing information.
See our Ambulance Enrollment page for enrollment information.
See our Ambulance Reimbursement page for an reimbursement information.
global-tags: J8A,J5A,Ambulance,J8B,J5B,Claims,Documentation
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- Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association web site, http://www.ADA.org/.
- Applicable Federal Acquisition Regulation Clauses (FARS)\Department of restrictions apply to Government Use. Please click here to see all U.S. Government Rights Provisions.
- ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT IS PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND, EITHER EXPRESSED OR IMPLIED, INCLUDING BUT NOT LIMITED TO, THE IMPLIED WARRANTIES O F MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE. NO FEE SCHEDULES, BASIC UNIT, RELATIVE VALUES OR RELATED LISTINGS ARE INCLUDED IN CDT. THE ADA DOES NOT DIRECTLY OR INDIRECTLY PRACTICE MEDICINE OR DISPENSE DENTAL SERVICES. THE SOLE RESPONSIBILITY FOR THE SOFTWARE, INCLUDING ANY CDT AND OTHER CONTENT CONTAINED THEREIN, IS WITH (INSERT NAME OF APPLICABLE ENTITY) OR THE CMS; AND NO ENDORSEMENT BY THE ADA IS INTENDED OR IMPLIED. THE ADA EXPRESSLY DISCLAIMS RESPONSIBILITY FOR ANY CONSEQUENCES OR LIABILITY ATTRIBUTABLE TO OR RELATED TO ANY USE, NON-USE, OR INTERPRETATION OF INFORMATION CONTAINED OR NOT CONTAINED IN THIS FILE/PRODUCT. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third party beneficiary to this Agreement.
- CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT should be addressed to the ADA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. IN NO EVENT SHALL CMS BE LIABLE FOR DIRECT, INDIRECT, SPECIAL, INCIDENTAL, OR CONSEQUENTIAL DAMAGES ARISING OUT OF THE USE OF SUCH INFORMATION OR MATERIAL.