Ambulance Transports – Repetitive vs. Non-Repetitive, Scheduled vs. Unscheduled
Repetitive vs. Non-Repetitive Transports
Medicare requirements for obtaining a Physician Certification Statement (PCS) for ambulance transportation differ depending upon whether the service is considered repetitive or non-repetitive.
- A repetitive ambulance service is defined as medically necessary ambulance transportation that is furnished either:
- Three or more times during a 10-day period
- At least once per week for at least three weeks
- Ambulance services that do not meet the definition of repetitive are considered non-repetitive
- These definitions were published in the CMS Program Memorandum AB-03-106 available on the CMS Web site (PDF, 174 KB)
Scheduled vs. Unscheduled Transports
The Centers for Medicare & Medicaid Services (CMS) has recently clarified the definition of scheduled ambulance transports.
- The term scheduled means that the ambulance transports were already established/ordered (e.g., scheduled for the beneficiary). The issue of scheduled vs. unscheduled does not refer to the timeframe in which the provider was contacted about the need for ambulance transportation.
- Based on this definition of scheduled ambulance services, if a physician has certified the need for repetitive ambulance transports via PCS, all ambulance transports that fall under the umbrella of this PCS are considered scheduled. This is true even if the ambulance company that normally provides the services for the beneficiary asks another ambulance company to provide the ambulance service on a given day.
- As an ambulance supplier, if you agree to provide ambulance transportation on a one-time basis for a beneficiary for whom a physician has certified the need for repetitive ambulance transports, you may obtain a separate PCS for this service or you may work with the ambulance company that normally provides services for that beneficiary to obtain a copy of the original PCS. Remember, the requirement to obtain a PCS has not changed, regardless of whether Palmetto GBA requests a copy of the PCS. Although you may call Palmetto GBA to verify whether the patient has a parent claim and coverage decision on file, each ambulance supplier that provides ambulance transportation to Medicare beneficiaries must also maintain copies of all required documentation, including PCS.
Example:
Betty A. receives dialysis three times a week. Because of other medical conditions, Betty must be transported from her residence to dialysis via ambulance. Ambulance Company X normally provides this service, and they have a PCS from Betty's attending physician. On Friday, all of Company X's vehicles are either out of service for maintenance or are providing services to other patients. Company X calls Company J for assistance, and Company J agrees to take Betty to dialysis on Friday.
- This is a scheduled, repetitive transport because treatment has already been established for Betty
- Company J must also have a current PCS on file prior to transport. Company J can obtain its own PCS from Betty's attending physician, or Company J can request a copy of the PCS from Company X.
- Company J must determine if the Friday transport is a parent claim, by working with Company X or calling Palmetto GBA at (866) 332-7025. Remember: even though Company J can verify the patient's parent claim status with Palmetto GBA, Company J is still required to maintain a copy of the PCS as part of their records and must be able to provide a copy of the PCS upon request.
- If Company J's transport is not a parent claim for Palmetto GBA purposes, Company J must maintain a copy of the PCS in their files. Palmetto GBA will make a coverage decision on the claim based on information submitted with Betty's parent claim.
- If Company J's transport is considered a parent claim for Palmetto GBA purposes, Company J may submit a copy of the PCS and other relevant information with the claim, or they may submit their claim without the documentation and Palmetto GBA will request the information from them
CMS Requirements: Reminder
As a reminder, the CMS requirements for obtaining a PCS for nonemergency, scheduled, repetitive ambulance services are contained in the Code of Federal Regulations, section 410.40(d)(2), Vol. 67, dated February 27, 2002. The Code of Federal Regulations states:
"(2) Special rule for nonemergency, scheduled, repetitive ambulance services.
Medicare covers medically necessary nonemergency, scheduled, repetitive ambulance services if the ambulance provider or supplier, before furnishing the service to the beneficiary, obtains a written order from the beneficiary's attending physician certifying that the medical necessity requirements of paragraph (d)(1) of this section are met. The physician's order must be dated no earlier than 60 days before the date the service is furnished."
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