As with most aspects of the EMS industry, Medicare sets the standards for what constitutes medical necessity for ambulance transport. According to the Centers for Medicare & Medicaid Services (CMS), medical necessity occurs when a patient has a medical condition for which other means of transportation are contraindicated.
For ground ambulance services, Medicare assesses the medical necessity of emergency and non-emergency transportation before issuing reimbursement. Emergency transports must provide the patient with Basic Life Support (BLS) or Advanced Life Support (ALS), meet the destination limits of the closest appropriate facilities, and be an ambulance service licensed by the state. Non-emergency transport guidelines are met when certified as medically necessary by a physician directly responsible for the beneficiary’s care.
Medical reasonableness for ambulance transport signifies a condition that requires medical attention and can’t be adequately addressed through other transportation. Aspects considered “medical attention” are medical monitoring, medical procedures en route, potential deterioration, and contagious diseases requiring isolation.
In an emergency scenario, the beneficiary cannot go to the hospital by other means, and the absence of immediate medical attention could place the patient’s health in serious jeopardy, cause impairment to bodily functions, or dysfunction of any bodily organ or part. Some examples of medical necessity for emergency ambulance transport are:
- Injury resulting from an accident or illness with acute symptoms like hemorrhage, shock, chest pain, respiratory distress, etc.
- Oxygen administration due to hypoxemia, syncope, airway obstruction, or chest pain.
- Immobilization because of a suspected fracture, a compound fracture, severe pain, or suspicion of neurological injury.
- The need for restraints as a means of preventing injury either to the patient or to another person.
- A transfer between facilities for necessary services not available at the transferring institution (patient must meet the criteria above).
In non-emergency situations, ambulance transport must meet medical necessity guidelines. A common reason is bed confinement caused by immobility creating non-ambulatory status, severe generalized weakness, severe vertigo, or immobility of lower extremities.
All ambulance transports must provide complete and accurate documentation indicating they meet the medical necessity criteria for reimbursement. CMS requires the documentation to display:
- Detailed statement of the condition necessitating the ambulance service.
- Point of pick-up (identify place and complete address).
- Destination (identify place and complete address).
- Number of loaded miles (the miles traveled when the beneficiary was in the ambulance).
- Cost per mile and mileage charge.
- Minimal or base charge.
- Charge for special items or services, with an explanation.
- Rationale for the condition (bed-confined, if applicable) and any further documentation that supports the medical necessity of ambulance transport.
- For interfacility transfers: Name and address of the certifying physician and physician ordering the service, if other than the certifying physician.
EMERGICON’s teams are experts in processing ambulance claims efficiently and compliantly. If you have questions about the medical necessity for ambulance transport, contact our EMS & Client Hotline: 866-839-3671 | email@example.com.