Documentation & Reimbursement

Documentation & Reimbursement
Documentation has many important uses besides reimbursement.  It is the legal record for your agency and for your patients, is shared with hospitals to provide continuity of care and is used for internal data collection and quality assurance.  Over the next few months, our newsletter will feature a series of articles on documentation from the billing perspective.  This second installment is focused on the medical necessity.

Part 2:  Medical Necessity

Medicare patients make up a substantial portion of ambulance transports so it is important to understand their documentation requirements. One of the big requirements to receive payment from Medicare is that transports must be "medically necessary". How Medicare defines medical necessity is narrower than most of us would think. The fact that someone called 911 does not make a transport medically necessary and does not guarantee payment.

The Medicare standard for medical necessity is this: "Transport by other means is contraindicated". In other words, if the patient can be safely transported by car, wheelchair van or some other method, an ambulance is not necessary and Medicare will not pay.
It is helpful to know what conditions are considered medically necessary and to always document them when those conditions are present. Here is the list of medically necessary conditions: 

The patient... 

  • was unconscious or in shock
  • required restraints - danger to self or others
  • showed signs of respiratory distress
  • was hemorrhaging
  • required IV or other emergency procedures
  • showed signs of stroke or myocardial infarction
  • required immobilization for a possible fracture
  • condition required they be moved by stretcher
  • was bed-confined
  • Each of these conditions needs some explanation-for instance, why restraints were required or a description of stroke symptoms. The definition of bed-confined is a patient who is unable to get up from bed without assistance, unable to ambulate and unable to sit in a chair or wheelchair. Rather than only documenting that the patient is bed-confined, the patient's condition should be fully described.

    The PCR is your main source to prove whether a transport is medically necessary. Always keep in mind, if it's not documented, it didn't happen.

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