“Ambulance Service: Incomplete Documentation”- The CERT Perspective

It Doesn’t Happen Often…

Not often do we ever get a chance to gain a first-hand look into how decisions are made by Medicare compliance auditors.

This week we had the chance to do so.


Our e-mail inbox chimed a few days ago, pretty much like any other day. Another Medicare listserv e-mail


But, on Wednesday it “dinged” with an e-mail from CGS Administrators, LLC, the Jurisdiction 15 Medicare Administrative Contractor covering the Part B payment responsibilities for the States of Ohio and Kentucky.

“Ambulance Service: Incomplete Documentation”- The CERT PerspectiveThis particular e-mail blast piqued our interest.

The subject line read Ambulance Service: Incomplete Documentation.

The article gave insight into the continuing high rate of error determined by the Comprehensive Error Rate Testing (CERT) program. It’s this program that the MAC’s use to show CMS how they are performing as a contractor (or not performing, as the case may be.)

“I’m not in Ohio or Kentucky. So what?”

So, what does this communication mean if you’re not operating and ambulance service in Ohio or Kentucky?

Good question.

While this particular communication came from that one MAC, remember; the CERT program is a nationwide program and follows similar guidelines that cross State lines. It’s reasonable to conclude that if we learn how one CERT contractor reviews claims we pretty much gain a window into how, pretty much, other CERT contractors review claims.

Example- BLS Transport

The article highlights CERT denials for ambulance service and makes a special point to note that the denial issued was because of incomplete documentation (their emphasis not ours)

So to illustrate their point, CGS provided this example of a reviewed claim that the CERT auditors declined.

“This claim was submitted for Ambulance Service, Basic Life Support with HCPCS modifier RH for date of service 09/29/2012. Missing documentation to support why patient was transported by ambulance for a non-emergent problem and why other means of transportation was not used. Documentation received initially includes hospital face sheet and EMS Report for 09/29/2012 which documents chief complaint: constipated, paid. Findings: “32 y/o male patient met us at the door to his apartment. Patient stated he had not had a bowel movement for at least a day and that he had lower right quadrant abdominal pain… felt he was constipated after having difficulty producing stool.” The CERT contractor requested additional documentation and received a duplicate EMS report and ED note stating: “32 y/o male presents with constipation. He is seen here frequently for constipation and urinary retention. He has no abdominal pain at this time. There is no nausea, vomiting, diarrhea or GI bleed.” There was inadequate documentation to support medical necessity of the billed service.”

Take note…

Take note of a few things…

  • EMS handles a lot of abdominal pain runs. The provider side of us knows how serious these kinds of calls can turn out to be and most of the time we probably are required to transport by protocol. Bowel obstructions can be serious there may be potential for bleeding and many other complications too.
    • But…while we may be required to transport on the operations side it doesn’t necessarily mean that Medicare is required to pay on the billing side.
    • Or…Medicare may pay and then later ask for their money back, regardless of whether we “must” transport or not.
  • The CERT auditor was fair and requested additional documentation when upon first pass the initial documentation didn’t pass muster. The ambulance supplier did not provide any additional documentation other than to pass on emergency department notes (which, in our opinion, made things worse.)

Take Away Conclusions…

  • We can believe patient scenarios are “operations” serious all we want, but if we do not do a good job documenting the medical necessity of these scenarios in our PCR’s, we can expect the claims will be denied…over and over and over.
  • We continually hear from clients how they just don’t understand why hospital documentation (even Physician Certification Statements) shouldn’t “fix” inadequate field documentation.
    • It’s important to keep in mind that the Medicare auditor has been trained to look at each transport based on the condition of the patient at the time of the transport. If we (the ambulance industry) don’t do a good job making our case, in-writing, on the Patient Care Report, then we can expect the auditors, CERT and otherwise, to be cranking out trip denials like they were going out of style!
  • It’s important to take notice of the very last line of the CGS communication about this example scenario. It reads…
    • “There was inadequate documentation to support medical necessity of the billed service.”

What will your billing office do?

So the million dollar question is; will your billing company bill a claim to Medicare without adequate PCR documentation?

This billing office, Enhanced Management Services, will not!

Had the billing office in the above scenario taken a good look at the documentation for this run, the CERT contractor would have had nothing to review.

Enhanced clients can rest assured we review each claims very carefully.

But if you’re not a client and if you’re billing office isn’t requiring detailed documentation, then you need Enhanced.


Leave a Reply

Your email address will not be published. Required fields are marked *

Name *