Priority Medical Claims – Ambulance Documentation Guidelines
Ambulance Documentation Guide – Section One
Medicare and many other insurance programs cover ground and air ambulance both. Ground ambulance refers to land and water born vehicles both. Air ambulance service can apply to specially equipped helicopters and airplanes both. Ambulance coverage is further broken down into emergency and non-emergency response coverage. In this article, we will discuss documentation requirements for both emergency and non-emergency land ambulance.
Medicare coverage for ambulance service is limited to situations where the transport is both medically necessary and reasonable, based on the patient’s medical condition, as recorded in the Patient Care Report and physician’s medical records when applicable. Reasonableness and necessity are both determined by careful review of the patient care report and any required attachments. Ambulance PCR attachments usually include a Patient Signature Form, Physician Certification Statement and in some situations, an Advanced Beneficiary Notice. Prior authorizations for repetitive patients require supplemental medical records from the ordering physician to support his/her decision to order ambulance transport. Some coverage guidelines create differences based on destination, situation and frequency of transport as well.
Ambulance Documentation Quick Tips
- Most ambulance documentation problems can be corrected by a review of the patient care process. A thorough assessment and interview should yield as much information as needed to prove medical necessity for an ambulance transport, even a non-emergent transport.
- Use medical terminology, at least up to the level of your training as an EMS provider. Do not use lay person or street terms to describe your patient’s medical condition.
- Adopt, use and enforce a set of standard abbreviations and symbols company wide. EMS documentation can be difficult to interpret for billers and Medicare staff. If abbreviations are not standardized and defined by a legend or key, Medicare could disregard the thought or observation being expressed. This can lead to denied claims, lost money and patient care mistakes.
- Use the same approach with routine, non-emergent patients as you would with a medical emergency patient. EMTs tend to be far too accepting of unknown facts in their non-emergency patients. If you do not know why your patient requires a stretcher and medical supervision during transport, ask questions until you do…then document what you learned. When in doubt about medical necessity, use the same investigative determination that you would use with an an unknown problem patient.
- Do not use copy and paste narratives for non-emergency transports, especially repetitive patients. They are easy to spot when charts are compared to one another, which is common in the billing and payer office. The shortcut is tempting we know, computers make it much easier, but this isn’t a good idea. Patient care reports should record the patient’s condition at the time of transport. Copy and paste narratives undermine confidence in your medical record and increase the likelihood of payment denials.
- PCS forms, even when filled out and signed by a physician, do not prove medical necessity. Medicare & Medicaid rules insist that EMT documentation stand alone to prove the patient needed the ambulance. The PCS may be a required formality for the trip, but you still have to perform a thorough interview and assessment, then document the results. The PCS can not replace any portion of the EMT’s Patient Care Report.
- The “chief complaint” field is one of the most commonly misused fields in non-emergency transport scenarios. The C/C should be the primary emergency complaint or in the case of routine transport, the reason for stretcher. The medical history item than contributes the most to the need for stretcher. “Hemodialysis treatment for ESRD” and “Doctor’s Appointment” should be in the reason for transport field or narrative.
- It actually IS important to document the reason for the patient’s visit to the destination or pickup facility. Medicare (and other payers) require that transports be provided “for the purpose of receiving covered medical care”. However, this information does not belong in the chief complaint field. Use fields such as “Reason for Transport” or the HPI narrative to describe this information.
- Include supply usage report forms with your PCR attachments. In some situations PMC can bill and collect for supplies and services beyond the mileage and load fee. Tracking supplies also aids in loss prevention and inventory management which saves money too.
Requirements for Staffing, Vehicles, Equipment and Supplies
Ambulances must be staffed by the minimum necessary personnel required to satisfy state and local laws for ambulance providers. In most communities this means that a certified EMT basic must attend the patient while the driver may have some less training. It is imperative that crews meet local requirements for the procedures they are providing and the equipment they are using. The same requirements exist for the vehicles themselves and the equipment and stock inside. State and local requirements must be met for the transport before it is a Medicare covered service.
Documenting to meet this requirement means the PCR should accurately record items such as agency name, agency ID number, ambulance vehicle ID numbers, crew member names, certification numbers and credentials. Ambulance patient care reports should be signed, either with ink or electronically, whichever is appropriate for your system. Electronic signatures are valid in today’s world, as long the ePCR system employs administrative and technical safeguards to protect the integrity of the user. This is one reason HIPAA and the HITECH act require password policies to be in place.
Medical Necessity for Ambulance Transportation
For Medicare and most other payers, the transport and the procedures performed during the transport, must be necessary and reasonable, based on the patient’s medical condition. Medical necessity is established when the patient’s medical condition prevents them from using any other type of vehicle safely. Medicare regulations state that a patient must be “bed confined” or suffer from some other medical condition that contraindicates transportation before the service can be considered medically necessary.
“Bed-confined” should not be used as a slang or catch all term in EMT documentation. The term has a technical and legal definition that should be kept in mind when the term is used. “Bed-confined” does not mean the same thing as “bed ridden”, “non-ambulatory” or “bed rest”. Those terms do not interchange well with “bed-confined”. According to Medicare and Medicaid guidelines, a patient is “Bed-Confined” when they are:
- Unable to get up from bed without assistance; and
- Unable to walk or ambulate; and
- Unable to sit in a chair or wheelchair.
The patient’s medical condition should be described using as precise terms as possible. Conditions such as stroke, ESRD, hypertension or Diabetes are common medical conditions for ambulance patients, but they must be followed up with a description of how those illnesses affect the patient or contribute to the need for movement by stretcher. Medical history items rarely justify the need for an ambulance on their own. City buses are used every day by people who have diseases such as ESRD, HTN and IDDM. It is the effect of those diseases that will describe why your patient needs an ambulance. Without that type of explanation, Medicare draws the conclusion that the patient did not have a true medical necessity for the ambulance.
Reasonableness for Ambulance Transportation
Ambulance transports are reimbursed for the level of service actually provided to the patient, as long as that level of service was necessary to treat the patient’s documented condition. ALS transports pay a higher rate, but the ALS procedures must be necessary due to the patient’s medical condition. Providing ALS services, simply because local ordinance requires an ALS response or a written protocol calls for it, are not sufficient. When documenting an ALS intervention or procedure, a brief mention of the reason for that procedure will be helpful to the billing office. This can be usually be done quickly with the activity log entry for the intervention.
Ambulance Patient Condition
To be covered, the ambulance patient must be suffering from a condition that makes other forms of transportation unsafe for the patient. Examples include:
- Transported in an emergency situation (accident, injury or acute illness)
- Exhibits signs and symptoms of respiratory or cardiac distress (chest pain or dyspnea)
- Exhibits signs and symptoms that could indicate an acute stroke
- Requires emergency treatment during transport to the nearest facility
- Severe bleeding
- Needed to be restrained to prevent injury to self or others
- Was unconscious or in shock
- Patient unable to self-regulate and administer oxygen (oxygen dependent patients)
- Immobilization due to spinal or other orthopedic concerns after an injury
- Could only be moved by stretcher
- Bed confined before and after the ambulance transport
Remember, always describe the reasons or circumstances surrounding observations like the ones above. It may not be enough to simply say that a patient is “bed confined”. The EMT should qualify those statements with an explanation of the circumstances surrounding the patient’s condition. An example might read…”Patient had to be moved by stretcher due to altered level of consciousness, paresis and pain at AV shunt site”. The EMT would then further qualify the observations with a statement such as “Family interview reported history of CVA in 2009 and again in 2012 with resulting paresis and mental status changes. Usual GCS is 446 or 436. Observed poor trunk control due to severe weakness and altered LOC. Also noted guarding of right arm AV shunt. Family reports surgical implant was done less than one week ago.”
Ambulance Documentation Guidelines – Section Two
Patient Signature Requirements for Ambulance Claims
There are at least two billing forms that require patient signatures. The Advance Beneficiary Notice (ABN) and the standard Billing Authorization form. The ABN is used for transports that Medicare is not likely to cover and the Billing Authorization form is to be signed by every transport patient.
Advance Beneficiary Notice of Non-coverage
The ABN is to notify an ambulance transport patient that a service is not likely to be covered by Medicare. Because some ambulance transports are covered, it is easy for patients to say that they were confused or uninformed. Medicare regulations require an ABN for these situations, if the form was not obtained, the patient is not liable for any provider charges. The patient can even request a refund later if they did not sign a valid ABN prior to transport. The ABN form is provided by CMS, it cannot be altered by the provider except for the name and contact info that appears in the header. You must enter estimated charges, record the patient’s decision to receive or reject the service, help them read it and retain a signed copy. The patient must be given a copy as well. The Ambulance ABN should not be used with emergency or unstable patients and it should not be used for every patient. The ABN is not a valid substitute for the Billing Authorization. Like all signature forms, if the form is not filled out completely, it is not valid. Do not leave relevant blanks empty, the patient signature is not valid in that case. More detailed instructions are available on our website at //prioritymedicalclaims.com/blog/.
Ambulance Signature & Claim Submission Authorization Form
This form allows ambulance suppliers to bill Medicare and other insurance, share and obtain medical records and it includes permission to appeal denials and receive payments directly from the insurance.
EMS suppliers may want to include a receipt for a “Notice of Privacy Practices” as part of their HIPAA compliance efforts in section one. This can be done with a few words added to the end of the paragraph in section one.
Hospital based “providers” have some additional considerations to confront with patient signatures, for that reason, we suggest contacting PMC or an attorney before using this form for your purposes. This information is only meant for use by ambulance suppliers who are not hospital owned and operated.
NOTE: Priority Medical Claims, Inc. (PMC) recommends EMS providers use the signature form provided by Page Wolfberg & Wirth (PWW), EMS Attorneys. The form can downloaded for free at their website, www.pwwemslaw.com. The PWW signature form and instructions are copyrighted works and included here for educational and reference purposes only. The following commentary and critique is offered by PMC for the EMS Provider’s educational purposes only. Any use of PWW’s copyrighted work by an EMS provider is at that provider’s discretion and may be subject to PWW’s free use policy.
Section One: Patient Signature
Section one should be signed and dated by the patient, if they are mentally and physically stable. If the EMT forgets to do this, it is fatal to the billing process. Section one patient signatures only require the EMT to witness them in the following situations.
- REFUSAL TO SIGN: If the patient refuses to permit billing of their insurance by refusing to sign, AND THEY ARE MENTALLY AND PHYSICALLY STABLE, the EMT should write “REFUSED TO SIGN” on the signature line and sign and date as a witness. The billing office will bill the patient directly. In a refusal situation with a stable patient, DO NOT go on to section two and three. If a stable patient exercises their right to NOT have their insurance billed, do not try to override that choice.
- UNABLE TO SIGN: If the patient is mentally or physically unable to sign, the EMT should write “UNABLE TO SIGN” and witness section one.
- PATIENT SIGNS WITH A MARK OR AN “X”: If the patient signs with a mark or an “X”, the EMT should witness and date section one.
When a patient is unable to sign and date the form due to their medical or mental condition, move on to section two.
Section Two: Authorized Representative
NOTE: Section two and three both begin with a field to write in a reason for the patient’s inability to sign in section one. Section two and three can only be used if there is valid medical or mental condition preventing them from signing. Emotional duress in a medical emergency is one example. Another would be a mental status change resulting in a reduced GCS score. Section one MUST be used when the patient is stable and calm. Failing to so is usually fatal to the billing process.
Section two is for representatives to sign on the patient’s behalf. They are listed on the form in order of legal preference. The law prefers a legal guardian over a facility representative. The EMT should ask and look for these people, in the order they are listed on the form.
Be sure to have them sign, write their name and date in a legible manner. These fields are required by law to be legally defensible.
Representatives who sign, do not accept financial responsibility for any provider fees. This is spelled out on the form.
Acceptable representatives include:
- Legal guardian of the patient.
- Relative or other person who receives payments or benefits from social security or public assistance on the patient’s behalf. Representative payee.
- Relative or other person who arranges patient’s medical treatment or exercises other responsibility for the patient’s affairs.
- Representative of an agency or institution that did not furnish the ambulance service being billed, but furnished other care, service or assistance to the patient. (Home health, SNF Staff, Dr. Office Staff)
Section Three: Ambulance Crew & Receiving Facility Signatures
This section is for use when the patient is physically or mentally unable to sign section one and there is no representative available or willing to sign section two on the patient’s behalf at the time of service. Like section two, you must list the medical condition that makes it impractical for the patient to sign. You must also list the name and location of the facility. Ambulance crew member statement must be completed at the time of transport ALONG WITH the receiving facility representative signature. Both parties MUST write their names and dates beside their signatures.
Physician Certification Statement
Medicare Part B’s billing rules require a “Physician Certification Statement” for the following nonemergency ambulance transport patient types.
- Inter-facility transfers (emergency and non-emergency response).
- Non-emergency, repetitive, pre-scheduled transport patients.
- Non-emergency transport patients (non-repetitive)
Ambulance PCS forms are required for virtually all inter-facility transfers and non-emergency transports. The PCS form must include patient name, HICN, origin and destination, and filled out for medical necessity. Finally, the form must be signed and the printed name, credentials and date included. The information below will address the different requirements for “inter-facility”, “repetitive” and “non-repetitive” patients.
Inter-Facility Patient Ambulance PCS
“Inter-facility” is a term that refers to ambulance transports between two SNFs or two Hospitals. To be covered by Medicare Part B, the patient has to be:
- Discharged from the first facility and admitted to the second.
- Require a higher level of care than available at first facility, and;
- that care must not be available at the first facility.
The above information should appear in the PCS form for an inter-facility patient. However, this does not relieve the EMT of the need to cover this information in their narrative too. Medicare gives considerable weight to the observations and findings of the transporting EMT. When the EMT documentation is missing critical elements, Medicare assumes that nothing was found or noted and that the service should not be covered. EMT findings and lack of findings are equally significant. The EMT must be mindful of their interview and assessment skills, using them for every call, even the non-emergency and inter-facility. Ideally, the EMT should include a statement such as; “Patient was discharged from ABC Hospital ER and transported to XYZ Hospital – CCU for direct admit. Patient was diagnosed with an inferior wall MI and required a cardio-thoracic surgical consult that was not available at first hospital.” This statement addresses the core coverage requirements for Medicare.
The patient must be discharged from the first facility, admitted to the second, and must need a service that is not available at the first. When the patient returns to the first facility after receiving tests or treatments, the first facility is responsible for the transport costs. If the EMT does not explain the circumstances of the transfer, as described above, the trip may not be billable at all.
The PCS and the EMT Patient Care Report must stand alone as independent eye witnesses to the patient’s condition and circumstances of transport. Both the PCS and the PCR must contain enough information to determine that Medicare coverage criteria have been met. Otherwise, payment will be denied at billing or during an audit later. EMTs who understand this and study their responsibilities to their patient and employer are among the most successful men and women in the industry.
Repetitive Patient Ambulance PCS
“Repetitive Patients” need dialysis, wound care and cancer treatment one, three or even five times per week. They are transported to the same destination over and over. Medicare PCS rules are very different for these patients.
- The “Repetitive” PCS can only be signed by the ordering/referring “physician”. An RN or discharge planner signature is not acceptable.
- The PCS can only be used to bill service dates equal to the date the PCS was obtained by the ambulance provider. This is usually evidenced by the physician’s signature date but can be much later. A repetitive patient’s PCS form must be “on file” before the crew is dispatched. The date the PCS is received by the provider is the first service date that can be billed.
- A repetitive patient PCS form is valid for transports provided up to 60 days beyond the date of physician signature.
- The PCS form is specific to form’s listed origin and destination(s). A PCS written up for dialysis transports cannot be used to cover a transport home from the ER.
- The first three transports provided to these patients are not considered “repetitive”. The patient must be transported three times in ten days or once per week for three weeks before the definition of “repetitive” applies. It is that fourth transport that makes the patient “repetitive” and triggers the requirement that the PCS be on file prior to transport. If you transport the patient without the PCS on file, those transports are not covered, even if you obtain the PCS later and even if the physician signature date was prior to those service dates. The rule that a PCS be on file prior to transport is absolute, there is no workaround.
Nonemergency, Non-Repetitive Ambulance PCS
The occasional patient requires a PCS for each trip or round trip. These PCS forms can be obtained up to 48 hours after transport. They must be complete with patient name, origin and destination, HICN, medical necessity information, provider signature, printed name, credentials and date. If any of this information is missing, the PCS could be rejected by the patient’s insurance.
If the patient is NOT repetitive, the PCS can be signed by the MD, DO, PA, FNP, RN or Discharge Planner with personal knowledge of the patient. This is not like the “repetitive” patient which must be signed by only the referring physician.
If the ambulance service can’t obtain the PCS at the time of transport, Medicare billing rules permit providers to use certified mail to request the PCS in writing. If the PCS does not arrive within 21 days, and the ambulance service has a signed, return mail receipt, the return receipt can be attached to the chart in lieu of the PCS and billed to Medicare. The patient must not be “repetitive” on the service date, and the ambulance provider must wait 21 days for the PCs to be mailed back to them.
Payment is available for service that is required for patients who pass away. Even if the patient is pronounced on scene by EMS. The only time there is no payment available is when the patient is pronounced prior to the ambulance being requested and dispatched. In all cases, record the following information for deceased patients.
- Date and time that death was pronounced, not the same as estimated time of death.
- Name & credentials of the professional who pronounced death
Other information needed is the same as for any other patient. If the patient is pronounced by EMS at the scene, we need to know what was done for the patient, if anything, up to the point of being pronounced dead. We also must be able to tell if the patient was pronounced after loading into ambulance and where the patient was ultimately taken to. This can all be extrapolated by recording the date and time of death, name and credentials of professional who pronounced.
Specialty Care Transport
Medicare and many other payers allow higher payment levels for Critical Care Transport. The key to getting this reimbursement level is to clearly document the supplies, services, procedures and interventions performed and or monitored. Indicate in your chart that service level was not just ALS, or ALS 2, be sure to indicate the call was an SCT or Critical Care level of service.
The SCT level of care, must contain some intervention that cannot be performed by a Paramedic. It must require the services of a specially trained Paramedic such as a CCT Medic. If this can be clearly seen in the Patient Care Report, we can bill that at the higher level of payment.
Keith A. Waycaster, CEO
Priority Medical Claims, Inc.
EMS & Ambulance billing since 1995
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