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Provider documentation tool for non-emergent ambulance transportation

This article is designed to assist medical providers with documenting the beneficiary’s medical condition supporting coverage for non-emergent ambulance transportation. This resource is to be used as an educational tool and does not guarantee medical necessity is met, Medicare coverage or reimbursement.

Bed-confinement definition:

  • Per 42CFR §410.40(d)(1) “Coverage of ambulance services guidelines”, the medical documentation must substantiate the following:
    • The beneficiary is “bed-confined”; and
    • The beneficiary’s condition is such that other methods of transportation are contraindicated; or,
    • The beneficiary’s medical condition, regardless of bed confinement, is such that transportation by ambulance is medically required.

Reasons for transport

  • Bed-confined
  • Unable to maintain erect sitting position in a chair
  • Grade II or greater decubitus ulcers
  • Oxygen use
  • Airway management
  • IV during transport
  • Isolation
  • Contractures
  • Fractures
  • Pain
  • Deep vein thrombosis
  • Morbid obesity
  • Orthopedic device for handling
  • Weakness
  • Restraints
  • Danger to self or others
  • Risk of falling off wheelchair/stretcher

Documentation tips

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

Documentation tips

Qualifying documentation 

  • Beneficiary’s medical record
  • Face-to-face assessment performed by a medical provider current and clearly dated
  • Includes beneficiary’s condition(s) supporting the level of need for non-emergent ambulance transportation
  • The record is legible and includes appropriate beneficiary identification
  • Signed by the medical professional with a handwritten or electronic signature and includes credentials
  • In addition to medical documentation indicating the level of medical necessity records must also support the reasons indicated on the PCS (physicians statement certification) 

Examples of qualifying documentation includes but is not limited to the following:

  • Emergency room report
  • Skilled nursing facility (SNF) record
  • Hospital record
  • Doctor's progress note
  • Nurse's note
  • Plan of care
  • Minimum Data Set (MDS)
  • Interdisciplinary note
  • Physical or occupational therapy progress note

Medical records should include objective findings and/or medical reasons for supporting conditions that require non-emergent ambulance transportation. 

Blanket statements, addendums, and attestations, including letters of medical necessity will not stand alone and require the original documentation from the beneficiary’s medical record as support.