Failure to demonstrate medical necessity represents the number one reason for improper Medicare payments. But the problem isn’t limited just to hospitals and physicians. Medical necessity requirements are also a concern for emergency medical services. That’s why it’s important for first responders to understand the circumstances and supporting documentation necessary to properly bill Medicare for a patient transport.

The rules surrounding the emergency transport of Medicare beneficiaries are strict and specific: In simplest terms, Medicare will reimburse only if the patient’s health is in danger and if they couldn’t have traveled by any other means. In other words, if the patient is not facing an imminent health emergency, and if they could have ridden in an automobile, taxi, wheel-chair van or other vehicle, then the transport will not be paid by Medicare.

The key to establishing that a patient’s health is in danger, or meeting the medical necessity requirement, is the detail provided in the patient care report, according Mauricio Chavez, vice president of EMS operations for web2pro Business Performance Services (web2pro). The documentation must reflect the first responder’s objective findings, the patient’s condition and the treatment required and administered.

“Whether the information is included in the narrative portion or in the vitals, signs and symptoms, our certified coders will read every bit of the patient care report to determine the appropriate diagnoses codes that support transport by ambulance,” Chavez said. “The key is to document accurately, completely, consistently and honestly.”

A basic rule of thumb when it comes to EMS documentation, Chavez said, is the more detail, the better. Conversely, if something is not clearly stated in the report, then it didn’t happen from a documentation standpoint. “A Medicare auditor will never assume anything, even if it is so obvious that it would seem to be unnecessary to include,” he said. “That’s why you’ve got to capture it all.”

Documentation elements

First responders need to provide a full but concise explanation of symptoms reported by the patient and/or other observers that demonstrate why the patient requires ambulance transportation and cannot be safely transported by an alternate mode. Among the specific documentation elements to include:

  • Relevant patient history (when available).
  • Observations and findings (patient’s condition at the time of transfer).
  • A detailed description of existing safety issues.
  • Description of the traumatic event if trauma is the basis for suspected injuries.
  • A detailed description of special precautions taken (if any) and an explanation regarding the need for such precautions.
  • Assessment and clinical evaluations, including:
  • Vital signs
  • Neurological assessment
  • Cardiac information
  • Documentation of procedures and supplies provided, including:
  • IV therapy
  • Respiratory therapy
  • Intubation
  • Cardiopulmonary resuscitation (CPR)
  • Oxygen administered
  • Drug therapy
  • Restraints
  • Patient’s progress and response to treatment.
  • Point of pickup (including complete address and zip code).
  • Precise treatment or procedure (or medical specialist) that is available only at the receiving hospital.

Chavez said it is essential to remember that describing treatments or monitoring without enough information about the patient’s condition to show that the care was medically necessary is inadequate for justifying transport payment. Below are some examples of general statements that, without supporting information, are insufficient to support medical necessity:

  • Patient complained of shortness of breath
  • History of stroke
  • Past history of knee replacement
  • Hypertension
  • Chest pain
  • Generalized weakness
  • Is bed-confined

ICD-10 cometh

Beyond the importance of clear documentation in demonstrating medical necessity, patient and treatment details also will be essential for supporting the ICD-10 code set, which goes into effect October 1, Chavez said. That’s because considerably more anatomical and treatment specificity is required to select the appropriate ICD-10 code.

“You can’t just say, `laceration to the face,’” Chavez said. “It’s more like, `laceration approximately an inch under the left eye; two-inch gash.’ The more detail the coder gets, the better the chance of being paid.”

Chavez said the assumption among some EMS agencies that ICD-10 will not affect them is erroneous; emergency medical services are not exempt from the new code set. At the same time, ambulance providers must be sure that their billing partner is prepared to code in ICD-10, and that their payers are ready to receive and adjudicate ICD-10 claims.

“You can’t afford to take anything for granted when it comes to ICD-10,” he said. “That means being sure that first responders understand the way they need to document and that your billing vendor has tested ICD-10 claims submissions with clearinghouses and payers. That’s the best way to avoid nasty surprises on October 1.”


About the author

web2pro Business Performance Services offers services and consulting to help hospitals, health systems, and physician practices improve business performance, boost margins and transition successfully to value-based care.