PCS – Not a Prescription!

“Never mimic the PCS . . .”

If you’ve ever attended an Enhanced documentation class, you’ll probably remember hearing the caution “Never mimic the PCS in your narrative.” We’ve taught this for years. Now CMS is backing that statement up with their new final rule amending the regulations for schedule, repetitive ambulance transports.

The bottom line . . . the PCS does not ultimately establish a patient’s medical necessity for ambulance transport.

Read on.

Let’s Back up a Minute

The PCS, Physician’s Certification Statement, is required to be obtained from a physician (ie. the physician must sign the document) for all scheduled, repetitive transports before billing those claims to Medicare. A patient is a scheduled, repetitive patient when he/she is transported at least 3 times in a 10-day period or once per week for 3 consecutive weeks.

The PCS is a document prepared by the patient’s physician to document the patient’s medical necessity status and must be obtained and held on file to support the claim documentation.

Remember, we’re talking about repetitive transports here, which is why I mention physician signatures. We won’t get into non-repetitives in this discussion nor will we muddy the waters by discussing who can sign and when. We’ll tackle that one in another blog sometime soon.

Just One Piece of the Puzzle

The common misconception is the PCS is like a prescription. EMS providers have treated this document like it is the final word and once the doc says the patient must go by ambulance then that’s it- end of story.

Well, that’s not it.

In fact, the street provider’s independent documentation of the patient’s medical necessity status actually trumps the PCS. Look at this scenario as puzzle pieces. In order to see the eventual picture, each piece of the puzzle must fit together in harmony to present the final product.

So the Call Intake, the PCS, the documentation contained in the Patient Care Report and any other medical necessity supporting written record combine as underlying proof of the patient’s need for ambulance transport.

The PCS is a piece of the medical necessity puzzle, but not the most important piece. Now, CMS is making that official.

Final Rule Statement

Effective January 1, 2013, the regulation pertaining to scheduled, repetitive transports regarding the inclusion of the PCS will state the following:

“The presence of the signed physician certification statement does not alone demonstrate that the ambulance transport was medically necessary.”

This rule removes any ambulance company’s argument claiming that a properly signed PCS for scheduled, repetitive transports can alone establish medical necessity.

Document, Document, Document!

By extension, this rule effectively makes clear that the PCS does not establish medical necessity for any non-emergency transport- repetitive or not.

This means that your ambulance staff members must document the patient’s condition and “Paint a Picture” in words to fully and adequately describe in the Patient Care Report the patient’s need for an ambulance and thus their need to pay for that transport. Or put another way, the documenter must present a written explanation to answer the classic question, “Why was transportation by any other means contraindicated for this patient transport?”

Medicare can only be billed for payment when all of the requirements have been met, including the presence of the PCS, but most importantly the independent documentation as prepared in the Patient Care Report by the EMS provider on the call.

Need Direction?

If you’re a client you probably get tired of hearing us preach this sermon over and over. But it’s an important one!

If you’re not a client, then it’s possible you may need direction on how to proceed given the new final rule. Education is a big part of the services offered here. Contact us today if your billing solution isn’t guiding you how to meet this and other important directives as provided by CMS and other regulating agencies.

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