Physician Certification Statement for Ambulance Services

Ambulance providers are required by federal regulations eCFR: 42 CFR 410.40 — Coverage of ambulance services to obtain a physician certification statement (PCS) from the attending physician for non-emergency ambulance trips (scheduled or non-scheduled) before submitting a claim to Medicare. A PCS is required in advance for non-emergency scheduled or repetitive ambulance services.

The information on the PCS is used to help establish the medical necessity for the ambulance transportation, although it is not the only criterion. Under Medicare guidelines, ambulance transportation must be medically necessary and reasonable. Medical necessity is established when the patient’s condition is such that use of any other method of transportation is contraindicated, meaning transportation by other means would endanger the individual’s health. Vague and general information is of little or no value. Past medical conditions may contribute to the need for the ambulance transportation but are not sufficient alone to justify that transport. Detailed information specific to the patient at the time the ambulance was ordered, or the transportation was furnished is needed to determine the medical necessity.

What Is a Physician Certification Statement?
The physician certification statement (PCS) is a statement signed and dated by the beneficiary's attending physician which certifies that the medical necessity provisions of paragraph (e)(1) of eCFR: 42 CFR 410.40 — Coverage of ambulance services are met. The statement need not be a stand-alone document and no specific format or title is required.

• While there is no specific Medicare-approved form for the PCS, the information on the form used must comply with Medicare guidelines.

What Information Must Be on the PCS?

• Patient’s name
• Date(s) of ambulance transport
• Patient’s medical problem/condition necessitating the ambulance transport. Information on the PCS must include a specific explanation as to why other means of transportation would endanger the patient’s health.
• Signature of an authorized individual and the date signed. Note: Medicare requires that services provided/ordered be authenticated by the author. The signature for each entry must be legible and should include the practitioner’s first and last name. For clarification purposes, we recommend you include your applicable credentials (e.g., D.O. or M.D.).

Who May Sign the PCS for Scheduled, Repetitive, Non-Emergent Transportation? 
The patient’s attending physician.

What Is a Nonphysician Certification Statement?
A nonphysician certification statement is a statement signed and dated by an individual which certifies that the medical necessity provisions of paragraph (e)(1) of eCFR: 42 CFR 410.40 — Coverage of ambulance services are met and who meets all of the criteria below for this definition. The statement need not be a stand-alone document and no specific format or title is required.

• Has personal knowledge of the beneficiary's condition at the time the ambulance transport is ordered or the service is furnished
• Who must be employed
  • By the beneficiary's attending physician; or
  • By the hospital or facility where the beneficiary is being treated and from which the beneficiary is transported
     
• Is among the following individuals if you are unable to obtain the attending physician’s signature, with respect to whom all Medicare regulations and all applicable State licensure laws apply:
  • Physician assistant (PA)
  • Nurse practitioner (NP)
  • Registered nurse (RN)
  • Clinical nurse specialist (CNS) 
  • Licensed practical nurse (LPN)
  • Social worker
  • Case manager
  • Discharge planner

What Else Should You Know About the PCS?

• In all cases, the ambulance supplier must keep appropriate documentation and present it upon request
• If upon request, the medical record does not contain a valid PCS or documentation of the attempt to obtain it, the ambulance service will be denied
• The presence of the signed certification statement or signed returned receipt does not alone demonstrate that the ambulance transport was medically necessary. All other program criteria must be met for payment to be made.

PCS Requirements and Types of Ambulance Transport

• Repetitive ambulance services
  • Repetitive trips may be scheduled or unscheduled
  • A repetitive ambulance service is defined as medically necessary ambulance transportation that is furnished three or more times during a 10-day period or at least once per week for at least three weeks
  • Dialysis and respiratory therapy are types of treatments for which repetitive ambulance services are often necessary
  • The requirement for obtaining a PCS for repetitive, scheduled, non-emergency ambulance services is based on the quantitative standard (three or more times during a 10-day period or at least once per week for at least three weeks). Regularly scheduled ambulance services for follow-up visits, whether routine or unexpected, are not considered 'repetitive' for purposes of this requirement unless one of the quantitative standards is met.
     
• Non-emergency, 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 physician certification statement dated no earlier than 60 days before the date the service is furnished
     
• Non-emergency unscheduled ambulance services and non-emergency scheduled, non-repetitive ambulance services
   
  • Ambulance suppliers must obtain a PCS before submitting claims for this type of ambulance transport
  • The PCS can be obtained from the patient’s attending physician up to 48 hours after the ambulance transport
  • If the ambulance supplier is unable to obtain a signed PCS from the patient’s attending physician, a signed nonphysician certification statement must be obtained from one of the authorized individuals listed in the definition above for nonphysician certification statement
  • If the ambulance supplier is unable to obtain the required certification within 21 calendar days following the date of the transport, the ambulance supplier must document its attempts to obtain the requested certification and may then submit the claim. Acceptable documentation includes a signed return receipt from the U.S. Postal Service or other similar mail service that demonstrates that the ambulance supplier attempted to obtain the required signature from the beneficiary’s attending physician or other authorized individual.
     
• Emergency transports
   
  • An emergency response is defined as a BLS or ALS-1 level of service provided in immediate response to a 911 call or the equivalent
  •  A PCS is not required if the transport is an emergency transport. The patient’s diagnosis and whether the transport is documented as an emergency due to the patient’s condition is not relevant to this determination

When Is a PCS required?

• When a PCS cannot be obtained in accordance with 42 CFR 410.40(d)(3)(iv), a supplier may send a letter via U.S. Postal Service (USPS) Certified Mail with a return receipt proof of mailing or other similar commercial service demonstrating delivery of the letter as evidence of the attempt to obtain the PCS
• Suppliers may also use the U.S. Postal Service Certificate of Mailing, Form 3817 as an acceptable alternative to certified mail

References

• eCFR: 42 CFR 410.40 — Coverage of ambulance services
• CMS MLN Matters article MM6698, Signature Guidelines for Medical Review Purposes (PDF)