Last Modified: 3/22/2024
Location: FL, PR, USVI
Business: Part B
Accessible from the CMS
ambulance prior authorization webpage 
, the
CMS letter to physicians states 
, "As the ordering physician/practitioner, you are required to supply the ambulance supplier or beneficiary the physician certification statement (PCS) as well as any other documentation that supports medical necessity for the repetitive scheduled non-emergent ambulance transports."
The medical records must meet certain criteria to be considered and to support the
medical necessity of the requested transports.
For a complete description of record requirements, refer to the following resources:
The following is a checklist that itemizes the medical record criteria. Print and refer to the list to ensure the records you submit to the ambulance service supplier are acceptable and contain clinical assessment data that supports the medical necessity of the requested ambulance transports.
NOTE: Completion of the list does not guarantee prior authorization of the request.
The record is specific to and regards a date of service that contains objective observations from a patient encounter. For example, the record is an emergency room report, SNF record, dialysis facility record, hospital record, doctor's progress note, nurse's note, plan of care, interdisciplinary notes, physical or occupational therapy progress note.
The record is current. The date of service for the record is on, or prior to, the signature date on the PCS.
The record is legible. Every page of the record is readable.
Every page of the record includes the appropriate patient identification information (e.g., complete name, dates of service).
The record includes the physician or non-physician practitioner responsible for and providing the care of the patient.
The record is signed by the medical professional with a handwritten or electronic signature and should include credentials.
The record supports the medical conditions itemized or checked on the PCS.
The record paints a comprehensive picture of the medical conditions itemized or listed on the PCS.
Statements such as the following, absent supporting clinical assessment data with objective findings, are insufficient to justify Medicare payment for ambulance services:
• Patient complained of shortness of breath
• History of stroke
• Contractures
• Hypertension
• Amputations
• Chest pain
• Paralysis
• Generalized weakness
• Ulcers
• Is bed-confined or bedbound
• A list of diagnoses
• A list of treatments or medications to treat the diagnoses
Medical records that indicate conditions such as the above should include objective findings and/or medical reasons on or for those conditions, such as bed-confinement.
"Bed-confined" means the patient is:
• Unable to get up from bed without assistance,
• Unable to ambulate, and
• Unable to sit in a chair (including a wheelchair).
To support bedbound status, all three elements of the definition must be adequately addressed in the medical records. The records must contain:
• Clinical assessment data, with objective findings, that reveals that the patient cannot get out of bed without assistance, and why.
• Clinical assessment data, with objective findings, that reveals that the patient is unable to ambulate, and why.
• Clinical assessment data, with objective findings, that reveals that the patient is unable to sit in a chair, and why.
The clinical assessment data includes objective findings on each condition, including but not limited to:
• Measurements
• Degrees of magnitude or scale
• Exact body location of condition
• The origin or history of the condition
• Timeframes and dates, such as upcoming treatment dates, expected duration of condition, or dates when treatment goals are anticipated to be attained
To support that the patient has a mobility status issue/condition that necessitates ambulance transport, the issue/condition, and the reason why it mandates an ambulance transport must be described with clinical assessment data that includes objective findings. The medical records must contain:
• Clinical assessment data with objective findings that comprehensively describes the mobility status issue or condition.
• Clinical assessment data with objective findings that comprehensively explains why the condition/issue contraindicates transport by any means other than ambulance.
• The clinical assessment data includes objective findings on each condition, including but not limited to:
• Measurements
• Degrees of magnitude or scale
• Exact body location of condition
• The origin or history of the condition
• Timeframes and dates, such as upcoming treatment dates, expected duration of condition, or dates when treatment goals are anticipated to be attained
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.
