Palmetto GBA (Medicare) covers ambulance transportation only when transportation by any other means would endanger the patient’s health. A patient whose medical condition permits transport in any type of vehicle other than an ambulance does not qualify for ambulance coverage. It is the responsibility of the ambulance supplier to maintain (and furnish to Medicare upon request) complete and accurate documentation of the beneficiary's condition to demonstrate the ambulance service being furnished meets the medical necessity criteria. The run report should 'paint a picture' of the patient's condition at the time of transport. All documentation must be complete and legible.

The Prior Authorization Demonstration for South Carolina began on December 1, 2014 and expanded to North Carolina, Virginia and West Virginia on January 1, 2016. Ambulance suppliers that are not institutionally (hospital) based that provide Part B Medicare covered ambulance services and are enrolled as an independent ambulance suppliers will be participants. Prior authorization is a process through which a request for affirmation of coverage is submitted for review before a service is rendered to a beneficiary and before a claim is submitted for payment. Prior authorization helps ensure that applicable coverage, payment and coding rules are met before services are rendered .Please visit the Palmetto GBA website for more information regarding the Prior Authorization model.

Painting a picture of the patient’s condition begins with the run report.

Run reports must document each patient encounter. We strongly recommend that each run sheet include the following information:

  • Reason for the transport
  • Explanation as to why the patient requires ambulance transportation and cannot be safely transported by an alternate mode
  • Any relevant history provided by patient and/or observers
  • A description of patient’s condition and functional status at the time of transfer
  • Assessment and clinical evaluations that should include:
    • Vital signs
    • Presence of any cardiac issues
    • Neurological status
    • Respiratory status
    • Wound or other skin issues
    • Amputations
    • Casts, braces or immobilizers
  • Documentation of procedures and supplies provided such as:
    • Drug therapy
    • Emergency oxygen administered
    • IV therapy
    • Restraints
    • CPR
    • Intubation
    • Cardiac monitoring
  • A description of specific monitoring and treatments ordered and performed/administered. The fact that a treatment (i.e., oxygen) or monitoring (i.e., cardiac rhythm monitoring) was performed, absent sufficient description of the patient’s condition (to demonstrate that the treatment and/or monitoring were medically necessary) is inadequate on its own merit to justify payment for the ambulance service.
  • The patient’s progress, responses to treatment and changes as treatment is given (e.g., monitoring of vital signs after medication has been given)
  • Point of pick-up (e.g., identify place and complete address)
  • Mileage associated with transport
  • For hospital-to-hospital transports, the trip record must clearly indicate the precise treatment, procedure or medical specialist that is available only at the receiving hospital. Non-specific or vague statements (i.e., needs cardiac care or needs higher level of care) are insufficient.
  • Any additional available documentation that supports medical necessity of ambulance transport (e.g., Physician Certification Statement (PCS))
  • A separate run sheet for each transport (e.g., two run sheets for round trips)
  • For hospital to hospital transports, documentation must indicate the patient was discharged from the origin hospital and admitted to the destination hospital. The specific services that were not available at the first hospital must also be documented.
  • Date and legible identity of the observer

Note: The HCPCS codes and diagnosis codes submitted on Medicare claims must be supported by the documentation on the run sheet.

Documentation that must be in the medical record and be made available to Medicare upon request:

  • Patient’s medical record - The patient’s medical record must indicate the medical necessity of services for each date of service submitted on a claim
  • Non-scheduled non-emergency ambulance services - The ambulance supplier must obtain a physician’s order, also called a PCS, certifying the need for an ambulance and retain the certificate on file, unless the beneficiary resides at home or in facilities in which he or she is not under the direct care of a physician. In some cases, it is acceptable to obtain the signed certification statement from physician’s assistants, nurse practitioners, clinical nurse specialists or registered nurses when they are furnishing professional services to the beneficiary and all applicable state licensure or certification requirements are met. Anyone different a MD or DO can only sign in limited circumstances .This certification must be dated no more than 60 days prior to the date the service is provided. In cases where a beneficiary requires non-emergency unscheduled transportation, this certification can be dated up to 48 hours after the ambulance service has been provided. This certificate must be obtained before the claim may be submitted to Medicare.
  • Repetitive Scheduled Non emergency Ambulance stretcher transport ( The Prior Authorization Model ) - Requires that the PCS be signed and dated by the patient’s attending physician  and must not be more than 60 days prior to the requested start date. A signed and dated PCS does not, by itself, demonstrate that the repetitive scheduled transports are medically necessary. Under this model, an ambulance supplier or beneficiary is encouraged to submit to their MAC a request for prior authorization along with all relevant documentation to support Medicare coverage of a repetitive scheduled non-emergent ambulance transport. Prior authorization allows ambulance suppliers to address issues with claims prior to rendering services and to avoid an appeal process.

Medical Necessity
Medical necessity is established when the patient's condition is such that use of any other method of transportation is contraindicated. 

  • When a bed-confined beneficiary was transported, the record must clearly document that the beneficiary was unable to get up from bed without assistance, was unable to ambulate, and was unable to sit in a wheelchair before and after the ambulance trip
  • When a beneficiary was transported because of the need to remain immobile due to the possibility of a fracture or a fracture that had not been set, the involved bone and the date and time of the fracture or injury must be clearly documented
  • When a beneficiary who could be moved only by stretcher was transported, the specific condition necessitating the stretcher must be clearly documented

In general, Palmetto GBA will cover non-emergency ambulance services when it is documented that the beneficiary: 

  • Was bed-confined before and after the ambulance trip. The term 'bed confined' is not synonymous with 'bed rest' or 'non-ambulatory'. Bed-confinement, by itself, is neither sufficient nor is it necessary to determine the coverage for Medicare ambulance benefits. It is simply one element of the beneficiary's condition that may be taken into account in the intermediary's/carrier's determination of whether means of transport other than an ambulance were contraindicated. A beneficiary is bed-confined if he/she is:
    • Unable to get up from bed without assistance
    • Unable to ambulate
    • Unable to sit in a chair or wheelchair
  • Could be moved only by stretcher
  • Needed to be restrained to prevent injury to the beneficiary or others
  • Had to remain immobile because of a fracture that had not been set or the possibility of a fracture
  • Needed advanced airway management (e.g., ventilator dependent, apnea monitor, possible intubation needed, deep suctioning)
  • Required non-self-administered IV meds en route
  • Required chemical restraint
  • Required suctioning en route per transfer instructions
  • Required airway control/positioning en route per transfer instructions
  • Required third party assistance/attendant to apply, administer or regulate oxygen en route. Does not apply to patient capable of self-administration of portable or home 02. Patient must require oxygen therapy and be so frail as to require assistance.
  • Has a condition such that patient risks injury during vehicle movement despite restraints
  • Has morbid obesity which requires additional personnel or equipment to handle
  • Has a communicable disease or hazardous material exposure and must be isolated from the public or whose medical condition must be protected from public exposure
  • Has an orthopedic device that requires special handling en route (e.g., backboard, halo traction, use of pins and traction)
  • Has severe pain aggravated by transfers or moving vehicle such that trained expertise of EMT is required. Pain is present, but is not sole reason for transport.
  • Required positioning special handling to avoid further injury (e.g., less than grade 2 decubiti on buttocks). Does not apply to transfer of greater than 1 hour.
  • Required positioning special handling that is inappropriate in a wheelchair or standard car seat due to contractures or recent extremity fracture (e.g. post-op hip surgery)

Reference:  

Contact Palmetto GBA JJ Part B Medicare

Provider Contact Center: 877-567-7271

Email JJ Part B

Contact a specific JJ Part B department



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