Last Modified: 4/25/2024
Location: FL, PR, USVI
Business: Part B
Physician certification statements (PCS) are required for patients who are under the direct care of a physician and are required for:
• Scheduled non-emergency ambulance transports
• Unscheduled non-emergency ambulance transports
Ambulance suppliers must obtain certification from the patient’s attending physician verifying the medical necessity of ambulance transportation in certain circumstances. The physician certification must be accurate and timely as it is essential to the billing of Medicare for ambulance services.
The attending physician is responsible for supervising the medical care of the patient by:
• Reviewing the patient’s program of care
• Ordering medications
• Monitoring changes in the patient’s medical status
• Signing and dating all orders
Note: The signed PCS does not, by itself, demonstrate the transport was medically necessary and does not absolve the ambulance provider from meeting all other coverage and documentation criteria.
PCS requirements for non-emergency scheduled repetitive ambulance transportation include the following:
• The PCS for repetitive transports must be signed and dated by the attending physician before furnishing the services to the patient
• The PCS must be dated no earlier than 60 days in advance of the transport for those patients who require repetitive ambulance services and whose transportation is scheduled in advance
• The PCS may include the expected length of time ambulance transport would be required but may not exceed 60 days
A repetitive ambulance service is defined as a medically necessary ambulance transportation furnished in three or more round trips during a ten-day period; or at least one round trip per week for at least three weeks.
Repetitive ambulance services are often needed by beneficiaries receiving dialysis or cancer treatment.
• PCS requirements for non-emergency unscheduled or scheduled on a non-repetitive basis ambulance transportation must be obtained from the attending physician within 48 hours after transport.
If the ambulance provider is unable to obtain the PCS from the attending physician within 48 hours of transport, the provider may submit a claim if a certification has been obtained from one of the following who is knowledgeable about the patient’s condition and who is employed by either the attending physician or the facility to which the patient is admitted:
• Physician assistant
• Nurse practitioner
• Clinical nurse specialist
• Registered nurse
• Discharge planner
• Licensed practical nurse (LPN) or licensed vocational nurse (LVN)
• Social workers; and
• Case managers
As with the other non-physician staff currently permitted to sign non-repetitive, unscheduled PCS forms, LPNs, LVNs, social workers, and case managers need to be employed by the beneficiary’s attending physician or the hospital or facility where the beneficiary is being treated and from which the beneficiary is transported and have personal knowledge of the beneficiary’s condition at the time the ambulance transport is ordered, or the service is furnished.
If unable to obtain the written order within the 48-hour limit, the supplier may submit the claim after 21 days if there is documentation of attempts to obtain the order and certification. When the PCS cannot be obtained in accordance with 42 CFR 410.40, the ambulance supplier may send a letter via U.S. Postal Service certified mail using the return receipt and/or proof of mailing or other similar service, demonstrating delivery of the letter as evidence of the attempt to obtain the PCS.
CMS does not require a particular form or format for the certification, and it can be simply a written statement that supports the need for ambulance services.
First Coast recommends the form:
• Contain a section that allows the physician to provide a narrative description of the patient’s physical condition at the time of the transport
• Be a patient-specific form that is signed and dated by authorized personnel
• Contain pertinent medical information in the narrative portion that will assist Medicare in making medical necessity determinations
• Confirm or support the medical information submitted on the trip sheet and the diagnosis information submitted on the claim form
Note: A PCS is not required for emergency transports or for non-scheduled, non-emergency transports of patients residing at home or in facilities where they are not under the direct care of a physician.
The PCS must:
• Be signed and dated by the patient’s attending physician.
• The signature of the medical professional completing the PCS must be legible/ readable (or accompanied by a typed or printed name name) and include credentials.
• The prefix “Dr.” is a title and not a credential.
• Stamped signatures or file signatures are not acceptable.
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.
