Certificate of Medical Necessity for Ambulance Transfers
Recent CERT findings have identified concerns regarding the improper use of Certificates of Medical Necessity (CMN)/ Physician Certification Statement (PCS) and the Advanced Beneficiary Notice (ABN) to justify ambulance transport of Medicare beneficiaries. This issue has resulted in the denial of four ambulance claims processed by Highmark Medicare Services and recoupment of the associated payments. Furthermore, when extrapolated, these four errors alone will add approximately $30 million to this year’s national Medicare “fraud, waste, and abuse” figure to be reported in November 2010.
To address this problem, ambulance companies and physicians must be sure that the patient’s medical record clearly supports the need for ambulance transport and includes the specific information that render the ambulance transport medically necessary. Medical necessity is established when the patient’s condition is such that use of any other method of transportation is contraindicated. If another means of transportation could be used without endangering the individual’s health, whether or not such other transportation is actually available, no payment can be made for ambulance services. Please note that the supporting documentation needs to describe the patient’s condition at the time of transport, not what occurred years ago (as an outdated CMN/PCS may do). In addition, inclusion of a signed CMN/PCS in the medical record does not, by itself, establish the medical necessity of the transport; all other program criteria must be met
in order for payment to be rendered.
Medicare will not pay for transports that are not clearly medically necessary and reasonable. Emergency Medical Services providers should also be cognizant that the patient’s condition has not changed such that a CMN/PCS would no longer be valid. As a reminder, the physician’s order must be dated no earlier than 60 days before the date the service is furnished.
• A patient who is able to walk from the porch to the ambulance is likely not eligible for ambulance transfer in routine non-emergent settings.
• A patient whose CMN/PCS states that continuous oxygen is necessary, but whose trip sheet documents that no oxygen was needed or used, is likely not eligible for ambulance transfer in routine non-emergent settings.
As noted earlier, even if a physician writes an order for a patient to go by ambulance, that alone does not prove medical necessity. All other program criteria must be met in order for payment to be made. Transports that are not medically necessary should be brought to the attention of the provider signing the CMN/PCS and the billing company so the claim can be submitted to Medicare with the appropriate modifier for denial. The claim should be reported with the GA modifier if the patient signed an ABN which acknowledges that the patient was informed the transport would not be paid by Medicare. ABNs are rarely appropriate for ambulance services and are only appropriate for use in non-emergency situations. The GZ modifier should be reported on the claim if the beneficiary did not sign an ABN and is unaware that Medicare will not pay for the transport.