Medicare Coverage Requirements for

Medically Necessary Non-emergency and

Emergency transports
The Why
 This education is required as part of Cone
Health Compliance for ambulance
services.
 Medicare Ambulance Coverage
 Medicare covers ambulance services via ground
transportation only if they are provided to a patient
whose medical condition is such that other means of
transportation is contraindicated. The patient’s condition
requires both the ambulance transportation and the level
of service provided for the billed service to be
considered medically necessary.
 Eligibility Requirements
To be eligible for Medicare ambulance services:
 An approved supplier of ambulance services transported
the patient to and/or from a proper location
 The patient suffered from an illness or injury, which
contraindicated transportation by other means, and
medically required ambulance services.
 Bed confinement is not the sole criterion in determining
the medical necessity of ambulance transportation.
 Scenarios where Medicare would presume medical
necessity for both emergent & non-emergent
ambulance services
 You transported the patient in an emergency, i.e., as a result of an
accident, injury, or acute illness
 You needed to restrain the patient to prevent injury to the patient or
others
 Patient required oxygen or other emergency treatment during
transport to the nearest proper facility
 Patient was unconscious or in shock
 Patient showed signs and symptoms of acute respiratory distress or
cardiac distress, such as shortness of breath or chest pain
 Patient showed signs and symptoms that show the possibility of
acute stroke
 Patient needed to stay immobile due to fracture that had not been
set or the possibility of a fracture
 Patient experienced severe hemorrhage
 Patient could only be moved by stretcher
 Patient was bed-confined before and after the ambulance trip
Reasons for Denial for Ambulance
Service in the 2020 reporting period
– 23.5% related to errors in medical
necessity documentation
 Medicare Learning Network

 Medicare Fee-for-Service improper

payment rate for ambulance services for
the 2020 reporting period is 7.2%, a
projected improper payment amount of
$349 million.
 Medical Necessity/Physician
Certification Statement (PCS)
 All transports being billed to Medicare for
payment must meet medical necessity and be
reasonable and necessary.
 Medical Necessity/PCS forms must be obtained on all
transports in which the patient is under the direct
supervision of a physician.
 This includes transports to and from a hospital, SNF, or ECF
when the patient is under the direct supervision of a
physician.
 “Emergency” transports are excluded from the
medical necessity/PCS requirement.
 Note: Most interfacility hospital-to-hospital transports
are considered non-emergent transports.
 Medical Necessity Forms
 May be signed by and RN, NP/PA, MD, or
case manager/MSW.
 Must be signed by a physician if the
transport is repetitive (or a medical
necessity form must be completed for
each leg of the transport).
 Repetitive scheduled services are regularly
provided transportation for the diagnosis or
treatment of a pt’s medical condition, e.g.,
transportation for dialysis or radiation.
 Medical Necessity (Con’t)
 Bed confinement
 Is not synonymous with “bed rest,” “non-
ambulatory,” or “stretcher-bound.”
 A patient’s bed confinement status may change.
 Transports must also include a reason for transport (Why
are you transporting this patient)…bed confinement is
not an automatic qualifier for payment under the
Medicare Fee Schedule.
 A patient need not be bed confined in order to for a
provider to bill the Medicare program…the transport
notes must include the reason(s) for ambulance
transport. What makes it medically necessary?
 Bed confinement criteria
 The patient can’t get up from bed without
help.
 The patient can’t ambulate.
 The patient can’t sit in a chair or
wheelchair.
 ALL three must be met to determine bed
confinement.
 Note: Bed confinement is 1 factor in medical
necessity determinations.
 Billing Levels

BLS Non-emergent BLS-Emergency

ALS 1 Non-emergent ALS 1-Emergency

ALS 2 SCT
 Responses (Emergency)
 An emergency response is an immediate response at
the BLS or ALS 1 level of service in response to a 911 or
equivalent call.
 An immediate response is one in which the ambulance
provider begins as quickly as possible to take the steps
necessary to respond to the call.
 IMPORTANT: Interfacility transports are mostly non-
emergent. (Exceptions include, but not limited to:
STEMI, acute stroke to tertiary care center, acute trauma
or surgical need). Your PCR documentation is key.
 Responses (Non-emergency)
 Responses to a call that do not require an
immediate response.
 If a call could otherwise be scheduled.
 Transport returns, to SNF or LTACH, etc.
 Most interfacility transports.
 BLS Non-emergent

 Basic Life Support given as determined by

state laws by an EMT-Basic (minimum).
 These calls can generally be delayed to
handle another call.
 Examples: patients on oxygen, no IV drips, no
cardiac monitor
 BLS-Emergency

 The provisions of BLS services in the

context of an emergency response
 Examples: patients on oxygen, no IV
drips, no cardiac monitor
 ALS 1 Non-emergent

 Transportation by an ALS ambulance

(EMT-I or EMT-P), medically necessary
supplies and services and an ALS
assessment by ALS personnel or the
provision of at least one ALS intervention
(i.e. cardiac monitor). These are NOT
immediate responses.
 ALS 1 Emergent
 The Advanced Life Support, Level 1…in
the presence of an emergency response.
 Ex. Response for Code STEMI transport to
the cath lab or Code Stroke transport to
interventional radiology
 ALS is used for patients on the cardiac
monitor, for example.
 ALS 2
 Does not require an emergency response.
 Must have either at least one (1) of the
following ALS2 procedures OR at least
three (3) separate administrations of one
or more medications by intravenous (IV)
push/bolus or by continuous infusion.
 Medications do not include D5W, NS, or
LR.
 IM, PO, SL, or nebulized meds do not
qualify for ALS 2.
 ALS 2 (Procedures)
 Manual defibrillation/Cardioversion.
 Endotracheal intubation
 Central Venous Line
 Cardiac pacing
 Chest decompression
 Surgical airway
 Intraosseous line.
 Endotracheal Intubation is covered at the ALS-2 level
even if we just monitor during transport.
Specialty Care Transport (SCT)
 Specialty Care Transport means interfacility
transportation of a critically injured or ill beneficiary by
a ground ambulance, including medically necessary
supplies and services, at a level of service beyond
the scope of an EMT-Paramedic.
 This is state specific.
 SCT is necessary when a beneficiary’s condition
requires ongoing care that must be furnished by one
or more health professionals in an appropriate
specialty area, for example, nursing, emergency
medicine, respiratory care, cardiovascular care, or a
paramedic with additional training.
 Examples of SCT: Managing ventilator settings,
monitored arterial lines, IABP use
 Signature Requirements
 The signature of the patient, or that of a person
authorized to sign on behalf of the patient, is
REQUIRED for every transport.
 If the patient can’t sign because of a mental or
physical condition, the following individuals may sign
on behalf of the patient.
 Patient’s legal guardian
 A relative or other person who receives social security or
other governmental benefits on behalf of the patient
 A relative or other person who arranges for the patient’s
treatment or exercises other responsibility for their affairs
 A representative of an agency or institution that didn’t
provide the services for which claims payment, but provided
other care, services, or help to the patient.
 A representative of the provider or of the nonparticipation
hospital claiming payment for services it has provided.
 Signature Requirements
 In Zoll Tablet PCR:
 Go to the “Outcomes” tab, then click the “Signatures” tab on
the left column.
 Click “Add” in the lower left of the screen.
 Select a signature type:
 For the patient to sign: choose the “Patient Signature” form.
 For a relative or other patient representative: choose the
“Representative Signature” form.
 If the patient is unable to sign and there is no relative or other
patient representative, then a CareLink crew member may sign.
 Select the “Crew Signature-Patient Incapable of Signing”
form.
 Note: If the patient is unable to sign, you must document the
reason why in your PCR.
 What does this mean for you?
 Obtain a medical necessity/PCS form for each transport.
 For transports between Cone Health facilities, obtain a copy of
the medical necessity form that was completed in Epic.
 For transports from non-Cone Health facilities, complete the
paper CareLink medical necessity form.
 IMPORTANT: Return all medical necessity forms to the
CareLink mail room bin to the left of the copier by end of
shift.
 Your PCR documentation is a key component!
 Document the reason why the patient is being transported to
their destination.
 Document the reason why ambulance transport is necessary.
 Document this information in your narrative.
 Obtain the signature of the patient, or that of a person
authorized to sign the claim form on behalf of the patient.
 Document with the appropriate signature form in Tablet
PCR.
 Certification of Medical Necessity of Ambulance Transport

Patient Name: ________________________________ Transport Number: ______________________

Paper CareLink Medical Necessity Form Referring Facility: ______________________________ Receiving Facility: _______________________

Referring Physician: ____________________________ Receiving Physician: _____________________

Transport Status:
 Emergency-Responding immediately to prepare for transport
 Non-emergency
Condition/Situation Necessitating Transport by Stretcher (Check all that apply):
 Bed confined--Inability to:
 Get up from bed without assistance
and
 Ambulate and
 Sit in a chair or wheelchair
 Transport a result of acute injury, illness, or 
accident
 Patient requires restraint/close observation
by professional care giver to prevent injury to
self or others
 Unconscious, unresponsive
 Hemorrhage and/or shock
Hemodynamically unstable
 Chest pain and/or continued cardiac
monitoring
 Respiratory distress, hypoxemia or other
respiratory condition requiring acute use of
oxygen
 Continued mechanical ventilation/airway
management, potential for acute airway
deterioration
 The receiving facility is the closest facility
providing appropriate care required by
patient’s condition/illness
 Beds unavailable or treatment unavailable at 
closest facility
 Severe vertigo/dizziness causing inability to 
remain upright
 Immobilization for:
 Stabilization of suspected/confirmed
fractures
 Spinal immobilization for suspected or
confirmed spinal injury
Signs and symptoms of an acute neurological
event: CVA, ICH, Seizure
 Pain management requiring administration of
medications, positioning, etc.
 Continuation of invasive monitoring
 Continuation of level of care currently receiving
 Management of intravenous lines and
medications; blood and blood product
administration
 Recent diagnostic or surgical procedure
prohibiting sitting in an upright position; patient
remains sedated following procedure
 Active and/or pre-term labor requiring continuous
monitor of mother and/or fetus
 Immobility of lower extremities and unable to be
moved by wheelchair: fixed hip joints, spica cast
Severe generalized weakness
Other ___________________________

Signature of person completing form: ________________________________ Date: ___________

 MD  NP/PA  RN  Case Manager/MSW
For non-emergency transports only:

As the attending physician/direct care provider, I verify that the above named patient requires transport by
ambulance related to the condition(s)/situation(s) checked above.

Signature: _____________________________________ Date: __________________

 MD  NP/PA  RN  Case Manager/MSW
 Expectations for
Documentation and Paperwork
 All CareLink PCRs are expected to be completed and
saved to the server by the end of your shift.
 Note: If you have IT issues preventing you from completing
your PCR, please notify the Director via email with the
specific issue(s).
 Medical necessity forms are expected to be placed
in the bin to the left of the copier in the CareLink
mail room by the end of your shift.
 Patient records that are no longer needed for your
PCR documentation must be placed in the shred bin
by the end of your shift.
 References
 Medicare Learning Network, Provider
Compliance Tips for Ambulance Services,
MLN909409 December 2020
Provider Compliance Tips for Ambulance Se
rvices (cms.gov)
 Medicare Learning Network, MLN Matters
Number MM9761 Revised, 9/12/2016