Billing Compliance Issues for Ambulance Services-Medical Necessity

This is the first article in a series of articles that will detail common medical billing compliance issues for ambulance services. Ambulance billing hosts a number of unique compliance challenges. In recent years, ambulance services have been under increasing scrutiny from both state and federal regulatory agencies, and as such, there has been a significant increase in government audits and enforcement activities.

Medical necessity for ambulance services may be one of the biggest compliance issues. Not only is the definition for medical necessity vague and ill defined, often times it's subjective.

Federal law defines medical necessity for ambulance service as when other means of transportation are contraindicated by the patient’s condition. While CMS regulations and manuals provide some additional clarification, the medical necessity standards for ambulance transport are centered on whether the patient could safely be transported by other means.

To put it another way, if the patient could have been safely transported by car, taxi, wheelchair van, or other means, without endangering the patients health: medical necessity is not met, and reimbursement may not be made. It is important to note that it is irrelevant if those other means of transportation are actually available. It is only the patients condition at the time of transport that matters.

Ambulance billers shouldn't assume that medical necessity is met. Thorough, accurate and complete documentation on a patient care report (PCR) should be present for each claim submitted. Some examples of patient conditions where medical necessity may be met when accurately documented include: unconscious or shock, restraints were needed for the safety of the patient or others, acute cardiac or respiratory distress, signs of acute stroke, severe hemorrhage.

Our next article in the series dealing with billing compliance issues for ambulance services will be on patient signature requirements.