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.

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.