Friday, September 5, 2014

EMS Patient Care Report Writing | Documentation 101 | Part 9 - Medical Necessity

The “Best” of the Ambulance Billing Services blog
Two years ago we put together a “Documentation 101” series of eleven educational blogs, covering what we determined to be the fine points of writing an effective Patient Care Report. Since then, the series has been read by dozens of patient care providers all across the Country. The series is posted on our website at It has been used for crew training and as a point of reference across our clients and friends in the EMS industry.

The Centers for Medicare and Medicaid Services Sets the Rules
This week we’ll stray a bit from the actual nuts and bolts of the PCR and drop behind the scenes a bit by explaining the concept of documenting the all-important concept of Medical Necessity.

CMS National Payment Policy
The Centers for Medicare and Medicaid Services (CMS) sets all of the policy rules and regulations that “drive the bus,” so to speak, when it comes to paying for healthcare under the Medicare and Medicaid programs across the United States. As we all are aware, Medicare and Medicaid rules at the national level are then often copied into other health insurance payers and extend to all sorts of payment policies pertaining to the pre-hospital world of EMS.

The CMS National Payment Policy is…
“Medicare covers ambulance services only if furnished to a beneficiary whose medical condition at the time of transport is such that transportation by any other means would endanger the patient’s health. A patient whose condition permits transport in any type of vehicle other than an ambulance does not qualify for Medicare payment. Medicare payment for ambulance transportation depends on the patient’s condition at the actual time of the transport, regardless of the patient’s diagnosis. To be deemed medically necessary for payment, the patient must require both the transportation and the level of service provided.”
Take special notice of the key sections above. Our PCR must always attempt to provide an explanation showing why transportation of the patient by any other means (private vehicle, taxi, bus, wheelchair van, etc.) would endanger the patient’s health. CMS is clear in their direction stating that they will review each claim submitted for payment to Medicare and, by extension, Medicaid as to whether or not the patient could have been safely transporting in a vehicle other than an ambulance.

Medical Necessity Defined

CMS further defines a patient’s medical necessity in the following manner.
“Ambulance transportation is covered when the patient’s condition required the vehicle itself and/or the specialized services of the trained ambulance personnel. A requirement of coverage is that the needed services of the ambulance personnel were provided and clear clinical documentation in the patient’s medical record validates their need and their provision. The patient’s condition, as well as changes in that condition and the treatment provided, must be in the record of the ambulance service (usually the run sheet).”
Probably the most important instruction in the above definition is the CMS expectation expecting “clear clinical documentation” to support the medical necessity of your patient. This includes documentation for emergency and non-emergency trips alike.

Medical Necessity cannot be explained in your PCR using only vague terms. For example, broad statements with no concrete documented evidence of a condition ruling out all other safe means of transportation are not recommended to be used in your PCR.

We cannot stress enough the importance of being specific and as clinical in nature as possible. Include all the numbers that we talked about over the past two previous blog postings (check them out again if you need to be reminded.) Specifics are the name of the game.

Often we see PCR’s come into our office using very broad and vague phrases. Phrases such as “ill person”, “sick person”, or documenting using explanation phrases that include “Patient complained of…” or “Patient has a past history of…” while failing to support those phrases with specific concrete medical necessity evidence. As providers and the authors of our PCR’S, we MUST provide a full explanation of the history of present illness and specifics of the patient’s condition RIGHT NOW as part of your CURRENT scenario. Failing to achieve this effectively is usually where PCR’s become problematic in meeting the needs as described in the above CMS Payment and Medical Necessity policies.

Grasp the Concept

There you have it. Another piece to the PCR puzzle has been provided to you. Over the past weeks we have been dissecting important elements that must be recorded as part of the PCR you write and turn into the billing office for billing of the claim for payment.

This weeks’ blog posting is more about the theory of writing a PCR to justify payment of the claim by Medicare, Medicaid and other insurance payers. If you grasp these very basic but hugely important concepts, then each time you write a PCR you will find yourself defining what the medical necessity of your patient was for this incident and every scenario that follows by using clear clinical, detailed and specific and descriptive wording.

Thanks for reading
Thanks for reading while we took this trip down the blogging memory lane. We hope you enjoyed our re-visit of the documentation series. You’re now well on your way to mastering the techniques necessary to author an effective Patient Care Report. Plus, you’re helping to support your billing office!

This support and more awaits current clients and EMS agencies that want to be Enhanced clients. Talk to us about your needs. Current clients can use Enhanced Pulsepoint™ to connect to Client Services. Agencies interested in the services to offer can contact Chuck Humphrey at or by phone at (800) 369-7544, Extension 108.
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