Physician Certification Statement – Ambulance PCS
Medicare Ambulance Billing Rules – PCS
Medicare ambulance billing rules require providers to obtain a PCS (“Physician Certification Statement”) for most ‘non-emergency’ patient transports. Providers are not required to use a specific version of the PCS form but there are some rules that need to be followed. This could be new information so take your time.
Tips & Suggestions – Ambulance PCS Form
The first item we want to focus on is the title of your PCS form. The federal regulations require a “Physician Certification Statement”, so be sure that is the title or name of your form. Regardless of your form’s design, content or intent, “Physician Certification Statement” is the title you need on your PCS form. Other titles could cause your PCS form to be rejected by Medicare. The federal regulations governing the Ambulance PCS form can be found at 42 CFR 410.40(d).
Specific information that must be on the Ambulance PCS form:
- Patient name
- Medicare / Insurance ID#
- Date(s) of ambulance transport
- Signature of an authorized clinician, printed name and date of signature
- Patient’s medical problem/condition necessitating transport by ambulance, including specific explanation as to why other means of transportation would endanger the patient’s health
Non-emergency, Non-Repetitive Transports:
The PCS must be obtained prior to submitting a claim to medicare, but no more than 48 hours after the transport was provided. If the physician will not or can not sign the PCS, a signed certification statement may be obtained from one of the following clinicians.
- Physician’s Assistant (PA)
- Nurse Practitioner (NP)
- Clinical Nurse Specialist (CNS)
- Registered Nurse (RN)
- Discharge Planner who has personal knowledge of the patient’s condition at the time the ambulance service is ordered or furnished
Non-emergency, Repetitive Patients – Ambulance PCS form:
An ambulance patient becomes “repetitive” after providing the third non-emergency ambulance transport in a ten day period, or once per week for three weeks. The definition of “repetitive” is based on the quantity and frequency of transports only. These patients usually go to dialysis, wound care or cancer treatment centers.
Once a patient becomes “repetitive”, the PCS rules change in a very important way. At that point, the PCS has to be in the ambulance provider’s hands, prior to furnishing the transport. Transports provided while no PCS is on file with the ambulance provider are not covered by Medicare. Failure to have the PCS on hand prior to transport means that the transport is not covered by Medicare. Claims should not be submitted to Medicare for payment. If you want to do additional research on this subject, coverage details are spelled out in federal regulation at 42 CFR 410.40(d)(2).
Some additional things you need to know:
- Repetitive ambulance trips may be scheduled or unscheduled
- Repetitive means…three or more transports during a ten day period or at least once per week for three weeks (Repetitive rules begin to apply after the third transport)
- The term repetitive is based solely on the quantity of transports in the ten day / three week period (three transports in ten days or three weeks)
- Dialysis, Radiation Therapy & Wound Care are common examples of repetitive patient scenarios
- A repetitive patient PCS can be used to support claims for up to 60 days beyond the date of signature
- An Emergency Ambulance Response (BLS Emergency or ALS 1) does not require a PCS form to be signed
Ambulance PCS – Compliance Alert:
- Transports of repetitive patients are not covered until the PCS is in the provider’s hands. Services furnished before taking physican possession of the PCS are non-covered services. Providers should advise the billing office of the date the PCS is obtained to prevent inappropriate billing. Federal regulation & Medicare billing rules require providers to obtain the PCS before furnishing the transport, when the patient becomes “repetitive”. This happens after the third transport in ten days or the third week if transported once per week.
- PCS forms are reviewed by Medicare during prior auth requests, prepayment medical reviews and post-payment audits. Charts and their attachments are considered complete and accurate if they are advanced to the billing office. Missing medical information can not be presumed by our staff or the payer’s. Make sure you have a robust documentation quality improvement process. If you need help building this skill set into your company, call PMC today!!! 1-800-635-7577.
Billing Medicare Without the Required PCS:
A Physician Certification Statement (PCS) must be on file for all non-emergency transports before billing Medicare. If the transport is not repetitive, the provider has 48 hours to obtain the PCS from the ordering physician. If this is not possible, the provider can request a PCS by certified mail, returned signed receipt. If no PCS has been returned for 21 days after the date of service, and the provider has documentation of mailed requests, the provider can go ahead and bill Medicare. This exception does not apply to patients whose transports have qualified as a “repetitive” transport service. In those cases, transports are only covered by Medicare after the PCS is obtained by the provider. When a PCS is delayed for a repetitive patient, the service is not covered by Medicare. Proof of mailing must be a certified mail receipt from the US Postal Service or similar service. A PCS or proof of mailing do not alone prove that the transport was medically necessary.
Emergency Transports – PCS Forms:
Emergency ambulance responses that are provided in response to a 9-1-1 (or the equivalent) call, do not require a PCS form.
Additional Resources – Ambulance PCS
Palmetto GBA – Regional Medicare Administrative Contractor for NC, SC, VA & WV…CLICK HERE
Page Wolfberg & Wirth – Sample Medicare Billing Forms (Including Sample PCS)…CLICK HERE
We hope you found our Physician Certification Statement discussion helpful. For more information like this and other important issues, sign up for our newsletter at the bottom of our home page. We will never sell your information. Thank you for allowing us to serve you today, strong EMS agencies saves lives, and that is why we exist. Your success as an EMS provider is not an option…in fact, it is a requirement and a core value at PMC.
How can we help you further? Call today!!! 1-800-635-7577