“Coverage of ambulance services guidelines”, the medical documentation must substantiate the following:
Reasons for transport |
Supporting documentation includes |
|---|---|
Bed-confined |
The beneficiary is unable to get up from bed without assistance, unable to ambulate AND unable to sit in chair (including 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 such as: • History of condition, and/or reason why beneficiary is unable to get up from bed without assistance • Muscle strength scale assessment, trunk strength • Physical mobility assessment with transfer ability inclusive of activities of daily living (ADLs) • Any and all applicable clinical data supporting beneficiary condition Clinical assessment data, with objective findings such as: • History of condition, and/or reason why beneficiary is unable to sit in a chair (including wheelchair) • Muscle strength scale assessment, trunk strength • Physical mobility assessment with transfer ability, ADLs • Any and all applicable clinical data supporting condition Clinical assessment data, with objective findings such as: • History of condition, and/or reason why beneficiary is unable to ambulate • Muscle strength scale assessment, trunk strength • Physical mobility assessment with transfer ability, ADLs • All applicable clinical data supporting condition |
Unable to maintain erect sitting position in a chair for time needed to transport |
To support inability to maintain erect sitting position the record should include, but is not limited to: • History of condition, and/or reason why beneficiary is unable to maintain erect sitting position for time needed to transport • Muscle strength scale assessment including trunk strength and upper body strength • Physical mobility assessment with transfer ability, ADLs • Any and all applicable clinical data supporting condition |
Unable to sit in a chair or wheelchair due to Grade II or greater decubitus ulcers |
To support inability to sit in wheelchair due to wounds/ulcer the record should include, but is not limited to clinical assessment data, with objective findings such as: • Muscle strength scale/physical assessment including transfer ability • Wound assessment including history, location, stage, and wound vac status • Off-loading requirements, or special handling instructions that contraindicate any other means of transportation other than ambulance • All applicable clinical data supporting condition |
Third party assistance/attendant required to apply, administer, or regulate or adjust oxygen en route |
To support third party assistance needed, the record should include, but is not limited to, the following: • Clinical assessment data, with objective findings of why the beneficiary is not able to self-administer oxygen • Oxygen flow rate, and way of administration • Physical assessment and reasons why the beneficiary requires oxygen • Any and all applicable clinical data supporting condition |
Airway management |
To support beneficiary’s need for Airway Management the record should include, but is not limited to, the following clinical assessment data with objective findings related to: • Physical assessment and medical history supporting presence of tracheostomy and reasons why • Ventilation requirements while in transport • Quantity/quality of secretions and ability to suction • Deep suctioning needed it must be indicated in the assessment |
IV medications/fluids required during transport |
To support beneficiary’s required IV medication/fluids needed while in transport the record should include, but is not limited to, the following: • Clinical assessment data, with objective findings related to the type of fluids being administered and why • Level of assistance needed to maintain IV status while in transport • IV site assessment data |
Special handling en route – isolation |
To support beneficiary’s need for special handling related to isolation while in transport the record should include, but is not limited to, the following: • Level of isolation required • Reason for isolation • Clinical assessment data, with objective findings related to the medical history supporting isolation |
Contractures that impair mobility and result in bed confinement |
To support beneficiary’s need for special handling related to contractures the record should include, but is not limited to, the following clinical assessment data, with objective findings such as: • Muscle strength scale of all extremities • Location of contracture • Degree of contraction • Range of motion assessment • Reason why the contracture would prevent beneficiary’s from being transported by any means other than ambulance |
Non-healed fractures that impair mobility |
To support beneficiary’s need for special handling related to non-healed fractures the record should include, but is not limited to, the following clinical assessment data, with objective findings such as: • Location and history of non-healed fracture • Functional mobility assessment including muscle strength scales supporting fracture status • Weight bearing status • Reason why the beneficiary cannot be transported by any means other than ambulance • Any and all applicable clinical data supporting condition |
Moderate to severe pain on movement that impairs mobility |
To support beneficiary’s need for special handling related to non-healed fractures the record should include, but is not limited to, the following clinical assessment data, with objective findings such as: • Location, duration, and rate of pain must be present in the documentation • Medications associate with pain treatment • Why the beneficiary cannot be transported by any means other than ambulance • Any and all application clinical data supporting the need pain management |
DVT requiring elevation of one or both lower extremities |
To support beneficiary’s need for special handling related to Deep Vein Thrombosis (DVT) diagnosis the record should include, but is not limited to, the following clinical assessment data, with objective findings such as: • Diagnosis, location, and assessment of DVT • Weight bearing status |
Morbid obesity impairing mobility and requiring additional personnel/equipment to handle |
To support beneficiary’s need for special handling related to morbid obesity the record should include, but is not limited to, the following clinical assessment data, with objective findings such as: • BMI supporting morbid obesity • Functional mobility assessment including transfer status supporting need for additional personnel/equipment |
Orthopedic device (e.g., backboard, halo, use of pins in traction, etc.) requiring special handling |
To support beneficiary’s need orthopedic devices the record should include, but is not limited to, the following clinical assessment data, with objective findings such as: • Medical history including reason for orthopedic device • Identification of device, location, and duration of use • Physical assessment including transfer ability, muscle strength scale and level of assist required while in transport |
Severe muscular weakness and de-conditioned state precludes any significant mobility related physical activity |
To support beneficiary’s severe muscular weakness and deconditioned state the record should include, but is not limited to, the following clinical assessment data, with objective findings such as: • Medical history indicating reason why the beneficiary has severe weakness and deconditioning • Physical assessment including transfer ability, muscle strength scale, trunk strength, ADLs, and level of assist required while in transport |
Restraints (physical or chemical) anticipated or used during transport |
To support beneficiary’s need for restraints the record should include, but is not limited to, the following clinical assessment data, with objective findings such as: • Medical history supporting reason for restraints • Type and location of restraints • Physical assessment supporting need for restraints including cognitive assessment |
Danger to self or others – monitoring/seclusion |
To support beneficiary’s need for monitoring the record should include, but is not limited to, the following clinical assessment data, with objective findings such as: • Assessment of cognition with examples of current behaviors requiring additional monitoring while in transport • If the beneficiary is able to follow simple commands, has decreased safety awareness, presents with aggression, and/or is a flight risk |
Risk of falling off wheelchair or stretcher while in motion (not related to obesity) |
To support beneficiary’s fall risk the record should include, but is not limited to, the following clinical assessment data, with objective findings such as: • Physical assessment supporting why the beneficiary is a fall risk • Muscle strength scales and trunk strength signifying fall risks • Medical history including previous falls with or without injury |
