Checklist: Emergent ambulance services documentation
This checklist is intended to provide health care providers with a reference for use when responding to additional documentation requests for emergency ambulance transports. Health care providers retain responsibility to submit complete and accurate documentation. Providers should refer to the CMS official website for additional information regarding ambulance transports and Medicare coverage at https://www.cms.gov/center/ambulance.asp.
| Check | Emergent ambulance documentation description |
|---|---|
| Documentation includes the signature and credentials of the professional responsible for the transport and care of the beneficiary during the transport. | |
| Documentation to support the medical necessity for the emergent ambulance transport and why other means of transportation are contraindicated. | |
| Documentation supports the type of emergent ambulance transportation and appropriate qualified attendants. | |
| Check | Non-emergent ambulance documentation description |
| The Physician Certification Statement (PCS) is complete, legible, signed and dated with physician’s credentials. PCS needs to be renewed every 60 days for non-emergent repetitive services. | |
| Documentation to support the medical necessity for the non-emergent repetitive ambulance transport and why other means of transportation are contraindicated. | |
| For hospital-to-hospital transports, the record should clearly indicate precise treatment and/or procedure, date and legible identity of the observer, certification and rationale of necessity for non-emergent transfers. | |
| For non-emergency transport, the record should clearly indicate the reason for the transport, what medical monitoring was performed and why other means of transportation was contraindicated. | |
| Check | Important to both emergent and non-emergent documentation |
| Documentation is for the correct beneficiary and date of service. | |
| Documentation contains signature of beneficiary or their authorized representative. | |
| Documentation supports total, actual mileage and includes the origin to the destination street addresses | |
| Evidence that an advanced beneficiary notice of non-coverage was provided to the beneficiary, if applicable. | |
| Documentation supports necessity for transport to facility, other than nearest facility, if applicable. |
Disclaimer
This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or the CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.