Ambulance Documentation Requirements - JF Part B
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 box if submitted | Brief Description |
|---|---|
| Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation | |
| Practitioner, nurse, and ancillary progress notes | |
| Ambulance records for the billed date of service including run sheets, Physician Certification Statements (PCS), procedures and supplies used, base rate and cost per mile and any other documentation to warrant transport | |
| Documentation that provides detailed medical information, including but not limited to objective description of the patient’s signs/symptoms, relevant history, medical condition, mobility, functional, and mental status before and after the ambulance trip, as well as other on-scene information, assessment/exam, treatment/specific monitoring, patient’s response to interventions, change in patient’s condition, and any other special circumstances | |
| Medical justification for transport and/or transfer. | |
| Transfer sheet | |
| Local 911 Ambulance Dispatch Protocols | |
| In hospital to hospital transfers, medical reason beneficiary could not be treated at first or initial hospital | |
| Documentation to support reason not transporting to nearest Facility | |
| Total number of beneficiaries transported by ambulance together | |
| Forms containing Beneficiary/Authorized representative signature | |
| Emergency Room records | |
| All records that justify and support the level of care received | |
| Documentation supporting the diagnosis code(s) required for the item(s) billed | |
| Documentation to support the code(s) and modifier(s) billed | |
| List of all non-standard abbreviations or acronyms used, including definitions | |
| Other pertinent information | |
| Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Policy article | |
| Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services) | |
| Signature attestation and credentials of all personnel providing services | |
| If an electronic health record is utilized, include your facility’s process of how the electronic signature is created. Include an example of how the electronic signature displays once signed by the physician | |
| Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC) |
Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part B Claim Review for detailed information about each of these contractors.
Documentation Submission
Once a provider/supplier 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.
- Noridian Medical Review - Automated Development System (ADS) Letter
- Comprehensive Error Rate Testing (CERT) - CID Request
- Level One Appeal - Redetermination Request
View the Ambulance webpage for additional information and resources.
Last Updated Tue, 26 Oct 2021 15:11:27 +0000
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.