When ambulance services are covered? (Part II Documentation Requirements)

Documentation Requirements

It is the responsibility of the ambulance supplier to maintain (and furnish upon request) complete and accurate documentation of the beneficiary's condition to demonstrate the ambulance service being furnished meets the medical necessity criteria. Documentation must be legible. The documents required for this purpose include the following:

1. Physician Certification Statement (PCS)

For scheduled and non-scheduled non-emergency ambulance transports, providers of ambulance transportation must obtain a written statement (PCS) from the patient’s attending physician, PA, NP, CNS, RN or discharge planner certifying that medical necessity requirements for ambulance transportation are met. The signature of the medical professional completing the PCS must be legible (or accompanied by a typed or printed name) and include credentials. Furthermore, signatures on the PCS must be dated at the time they are completed. A PCS is not required for emergency transports or for non-scheduled non-emergency transports of patients residing at home or in facilities where they are not under the direct care of a physician. It is important to note that the mere presence of the signed provider certification statement does not, by itself, demonstrate that the transport was medically necessary and does not absolve the ambulance provider from meeting all other coverage and documentation criteria.

For non-repetitive non-emergency transports, the following apply:

• If the ambulance provider is unable to obtain the PCS from the attending physician within 48 hours of transport, the ambulance provider may submit a claim if a certification has been obtained from a Physician Assistant (PA), Nurse Practitioner (NP), Clinical Nurse Specialist (CNS), Registered Nurse (RN) or discharge planner who is knowledgeable about the patient’s condition and who is employed by either the attending physician or the facility in which the patient is admitted. (Please note, that the term admitted does not necessarily mean admission to inpatient status. It also includes acceptance for care at an Emergency Room, ESRD Facility, etc., implying transfer of care).

• Alternatively, the provider may submit the claim after 21 days if there is documentation of attempt(s) to obtain the order and certification. The ambulance supplier must document efforts to obtain certification. When the PCS cannot be obtained the provider/supplier may send a letter via U.S. Postal Service certified mail with return receipt and/OR proof of mailing and/OR other similar service (FedEx, UPS) demonstrating delivery of the letter as evidence of the attempt to obtain the PCS.

For repetitive non-emergency transports, the following apply:

• A PCS for repetitive transports must be signed by the patient’s attending provider.

• The PCS must be dated no earlier than 60 days in advance of the transport for those patients who require repetitive ambulance services and whose transportation is scheduled in advance.

Additional PCS requirements

• A particular form or format is not required for the certification. Suppliers and physicians may develop their own certification form.

• Ambulance company employees should not complete forms on behalf of these individuals.

• Signature of the medical professional completing the PCS must also be legible (or accompanied by a typed or printed name) and include credentials.

• Signatures on the PCS must be dated at the time they are completed.

2. Trip record must include:

• A detailed description of the patient’s condition at the time of transport. Coverage will not be allowed if the trip record contains an insufficient description of the patient's condition at the time of transfer for the insurance to reasonably determine that other means of transportation are contraindicated. If the description of the patient’s condition is limited to conclusory statements and/or opinions, such as the following, the Contractor may base reimbursement on the supporting medical record documentation instead:

"Patient is non-ambulatory."

"Patient moved by drawsheet."

"Patient could only be moved by stretcher."

"Patient is bed-confined."

"Patient is unable to sit, stand or walk."

• The trip record must "paint a picture" of the patient's condition and must be consistent with documentation found in other supporting medical record documentation (including the physician's certification). The trip record must include the following, where possible:

• A concise explanation of symptoms reported by the patient and/or other observers and details of the patient's physical assessments that clearly demonstrate that the patient requires ambulance transportation and cannot be safely transported by an alternate mode.

• An objective description of the patient's physical condition in sufficient detail to demonstrate that the patient’s condition or functional status at the time of transport meets Medicare limitation of coverage for ambulance services.

• Description of the traumatic event when trauma is the basis for suspected injuries.

• A detailed description of existing safety issues.

• A detailed description of special precautions taken (if any) and explanation of the need for such precautions.

• A description of specific monitoring and treatments required, ordered and performed/administered. That a treatment (such as oxygen) and/or monitoring (such as cardiac rhythm monitoring) were performed absent sufficient description of the patient's condition (to demonstrate that the treatment and/or monitoring was medically necessary) is inadequate on its own merit to justify payment for the ambulance service. For example, when oxygen is supplied as a basis for ambulance transportation, the patient’s pretreatment capillary blood oxygen saturation and clinical respiratory description must be recorded. The two must be consistent with oxygen need.

• Statements such as the following, absent supporting information in relevant bullets above, are insufficient to justify payment for ambulance services:

Patient complained of shortness of breath.

History of stroke.

Past history of knee replacement.

Hypertension.

Chest pain.

Generalized weakness.

Is bed-confined.

• Signatures, including credentials, from the provider(s) who renders the services documented:

• Services provided/ordered must be authenticated by the author. The method used must be a handwritten or electronic signature.

• If the signature is found to be illegible or missing from the medical documentation, a signature log or attestation statement to determine the identity of the author may be requested.

• A signature log includes the typed or printed name and usual signature of the author associated with initials or an illegible signature.

• An attestation statement is required when a signature is missing from the documentation; it must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary, date of service and be specific to the service documented.

• Providers should not add late signatures to the documentation.

• Point of pick-up/destination (identify place and complete address).
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• For hospital-to-hospital transports, the trip record must clearly indicate the precise treatment or procedure (or medical specialist) that is available only at the receiving hospital. Non-specific or vague statements such as "needs cardiac care" or "needs higher level of care" are insufficient.

3. Any additional available documentation

• Documentation that supports medical necessity of ambulance transport (for example, emergency room report, SNF record, End Stage Renal Disease (ESRD) facility record, hospital record).

• Documentation supporting the number of loaded miles billed.

• Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.

• All documentation must be maintained in the patient's medical record and available upon request.

Source CMS National And Local coverage determinations.