Last Modified: 6/4/2024
Location: FL, PR, USVI
Business: Part A, Part B
Ambulance transportation is a covered service under Medicare when the patient’s condition is such that the use of any other method of transportation would endanger the patient’s health.
The ambulance provider must have full documentary evidence to support the Medicare claim for ambulance services. Without documentation that would establish the medical necessity of a service, the service may be non-covered by Medicare, either as a denial prior to payment or a request for refund after an incorrect payment has been made.
It is the responsibility of the ambulance supplier to maintain (and furnish to Medicare upon request) complete and accurate documentation of the beneficiary's condition to demonstrate the ambulance service being furnished meets the medical necessity criteria.
The trip/run sheet of the patient's encounter is used as a medical record for ambulance services and should include the following:
• Complete and legible information. Every page of the record must be legible and include the appropriate patient information (e.g., complete name, dates of service).
• 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 statement).
• The trip record must include the reason for the transport:
• A concise explanation of symptoms reported by the patient and/or other observers.
• 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.
• 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.
• Relevant history. (when available)
• Observations and findings. (patient’s condition at the time of transfer)
• Detailed description of existing safety issues.
• Description of the traumatic event when trauma is the basis for suspected injuries.
• Any special precautions taken and explanation of the need for such precautions.
• Assessment and clinical evaluations that should include:
• Vital signs
• Neurological assessment
• Cardiac information
• Documentation of procedures and supplies provided such as:
• IV therapy
• Respiratory therapy
• Intubation
• Cardiopulmonary Resuscitation
• Oxygen administered
• Drug therapy
• Restraints
• Description of specific monitoring and treatments required, ordered and performed/administered. (needs to demonstrate that the treatment and/or monitoring was medically necessary)
• Point of pickup/destination. (identify place and complete address)
• 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.
• Signatures, including credentials, and date to identify the provider of services.
• If multiple person(s) provide care/services to the beneficiary during the transport, they must all authenticate the record.
• 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.
• Documentation supporting the number of loaded miles billed which may include:
• Odometer reading,
• Trip odometer reading,
• GPS system,
• Navigation computer,
• Mapping programs
• Be sure to include:
• Any additional available documentation that supports medical necessity of ambulance transport.
• A separate run sheet for each transport. (e.g., two run sheets for round trips)
• Dispatch record.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.
