Ambulance Documentation Requirements

It is expected that patient's medical records reflect the need for care/services provided. The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered. They may include:

Check Brief Description
  Legible handwritten physician and/or clinician signatures
  Valid electronic physician and/or clinician signatures
  • If an Electronic Health Record (EHR) is used, the Electronic Order Signature Process [PDF] should be submitted to verify provider's Electronic Ordering System is secure
  Legible physician and/or clinician certifications and credentials supporting advanced/special training of personnel
  Records of patient's condition before, during and after this billing period to support medical necessity and reason service was provided
  • Originating facility's physician progress notes, nursing records, and/or discharge summary, if applicable
  • Destination facility's emergency records, history and physical, physician progress notes and/or nursing records, if applicable
  Ambulance trip sheet, patient care report (PCR) and/or air ambulance flight record to support transportation to closest appropriate facility and need for type and level of ambulance service billed
  • Reason for transport by air ambulance instead of ground ambulance, if applicable
  Local 911 Ambulance Dispatch Protocols
  Total mileage documentation
  Itemization of services
  Documentation to support indications and/or criteria as specified in Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs) or coverage article for service(s) billed, if applicable
  Advance Beneficiary Notice of Noncoverage (ABN), if applicable

Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part A Claim Review for detailed information about each of these contractors.

Documentation Submission

Once a provider compiles all the necessary documentation, it is important to submit them to the appropriate contractor according to the request received. Select the request below to view the appropriate submission instructions.

View the Ambulance webpage for additional information and resources.

 

Last Updated Feb 08, 2019

Documentation Requirements Disclaimer

The documentation requirements contents/references provided within this section were prepared as educational tools and are not intended to grant rights or impose obligations. Use of these documents are not intended to take the place of either written law or regulations.

The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered.

Important that physician intent, physician decision and physician recommendation to provide services derived clearly from the medical record and properly authenticated.

The submission of these records shall not guarantee payment as all applicable coverage requirements must be met.