Medical Necessity is a Necessity

By Definition

Effectively documenting the Medical Necessity of an ambulance transport to support billing has always been a central component of complying with all of the many rules and regulations, as spearheaded by the Center for Medicare and Medicaid Services (CMS, a.k.a “The Feds”). Enhanced Management Services has been a strong advocate of all things compliance and making iron-clad sure that medical necessity is expressly documented in words for each and every ambulance run our clients take, when intending to bill to any insurance source.

CMS provides a definition for Medical Necessity:

“Ambulance transportation is covered when the patient’s condition requires the vehicle itself and/or the specialized services of the trained ambulance personnel. A requirement of coverage is that the needed services of the ambulance personnel were provided and clear clinical documentation (emphasis added) in the patient’s medical record validates their medical need and their provision.  The patient’s condition, as well as changes in that condition and the treatment provided, must be in the record of the ambulance service (usually on the run sheet).”


When you think about it, what is the purpose of an ambulance?

In my mind an ambulance is for the transportation of an ill or injured person that cannot be transported safely by any other means. The use of an emergency vehicle, in theory, should be limited to the transportation and treatment of those persons who cannot be safely transported by any other vehicle given their medical condition without a threat to their life or at least their immediate well-being. However, we all know that isn’t always the case.

So Why Should I Pay?

This is the million dollar question that the insurance companies ask. And they are asking this question with increasing frequency. Oh, and they are posing that question by using our least-favorite means— that little thing called the audit.

Really, when it comes down to it can you blame them? Do you spend dollars on things that you don’t step back periodically and ask, why am I paying this? Or, can I continue to do life by paying a little less for this? It’s a sound business question in a challenging economic climate. We cannot expect Medicare, Medicaid and commercial insurance payers not to periodically review the legitimacy of paying large numbers of ambulance-related claims.

Not Just Medicare

So this all boils down to our ongoing mantra… DOCUMENT, DOCUMENT, DOCUMENT!

Your patient care providers must develop the mindset that every single ambulance transport they are part of and subsequently prepare documentation for must be explicit regarding the medical necessity that’s required the ambulance be used to move the patient. This is why the definition above stresses the words clear clinical documentation. Put another way, another buzz line easy for providers to understand is encouraging them to “paint a picture” in words concerning the ambulance transport.

On that note, allow me to issue one big warning.

Documenting medical necessity doesn’t only pertain to Medicare. It never did. But, I think that our industry has been so keyed up and worried about Medicare that we fail to realize that other payers, especially Medicaid, commercial payers like Medicare Advantage Plans, Medicaid HMO’s/PPO’s and insurance plans with whom your service has a participating provider relationship all retain the right to conduct both post- and pre-pay audits. And they are conducting those audits with increased frequency.

Education is Key

To insure that your service hits the bullseye on meeting compliance and medical necessity guidelines, commit to developing a continual culture of education. This means that you must constantly educate and re-educate your staff regarding both positive and negative trends in their documentation.

Conduct regular in-house audits via your QA/QI process. Maintain continual education between you and your billing office- be it in-house or outsourced regarding what they are seeing overall in your documentation that may cause issues down the road. That ongoing dialogue will go a long way toward galvanizing you against a compliance problem with your trip documentation that may never be found by any other means.

Education also means you may want to provide education to your patient population. Disseminating communication either by presentations, meetings, website, mail pieces, facility interaction or whatever means in order to educate the residents of the response area you serve about when or when not to call an ambulance can go a long way toward controlling their expectations for you to provide services when those services may not be totally needed. The public only understands that ambulances are those vehicles with red lights that transport patients on stretchers. Most people don’t understand that there may be other options such as a wheelchair van program or local taxi service who provide discount ride programs to the doctor’s office for appointments, instead of calling for an ambulance.  Now may be the time to help them understand and control your risk of taking requests for questionably medically necessary transports.

Use us as a Resource

How can we help? We stand ready to assist you with the deciphering of your medical necessity and compliance needs. Current clients can reach out to contact our knowledgeable and Certified Ambulance Coder trained Client Services representatives.

Not a client? Well then feel free to contact us for more information on how you can become one of our valued clients.

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