Dissecting the Certificate of Medical Necessity

By Chuck Humphrey, B.A., EMT-B, CAC, CADS*

Dissecting The Certificate Of Medical Necessity

The Non-Emergency Transport World

If you live in the non-emergency ambulance transport world, then the words “medical necessity form” or the letters “PCS” are most familiar to you. A certificate of medical necessity is required to bill a claim to Medicare for a non-emergency transport, but the entire concept is often so misunderstood we decided to write this blog as a guide to understanding the differences in the types of medical necessity forms required.

CMN

The industry has become accustomed to using the term PCS to refer to anything medical necessity. Last year, when the Centers for Medicare and Medicaid Services (CMS) created two distinct medical necessity categories, using PCS became inappropriate. So, we are suggesting you begin using the term certificate of medical necessity when referring to the two medical necessity documents as they relate to the permitted persons signing the documents- Physicians Certification Statement (PCS) and the Non-Physicians Certification Statement (N-PCS). These are the documents required by Medicare, some Medicaid programs, or are requested/ required by many commercial insurance payers to certify patient medical necessity for ambulance transport.

Remember…

Remember, as it pertains to Medicare, the Federal Government does not dictate what the medical necessity form must look like nor will you find a titled form template on any CMS website. Coverage of ambulance services and the rules surrounding the use of medical necessity statements are contained in the Federal Register (42 CFR § 410.40.) The language in the statute simply requires a “statement signed and dated…that certifies” that medical necessity of the patient is met.

The ambulance industry has developed a type of boilerplate form to make it easier for the healthcare professional signing to provide us with the information needed to support the billing of the claim for the transport provided. We have given our friends in the institutional world a nice generic checkbox and sign-here format.

PCS and N-PCS statements are a means for the proper person to sign a written statement attesting to the patient’s need to be transported from one location to another using an ambulance vehicle. In actuality, the person signing is so much more important than what he or she is signing. The document is all about the patient and whatever it looks like and whoever signs it does not guarantee payment for the ambulance trip plus it is useless as a stand-alone document when separated from associated patient care reports (PCRs).

It is NOT an ambulance prescription pad!

Any certificate of medical necessity must correlate with the corresponding PCR as the two documents are supportive of each other.

What’s the difference?

What’s the difference between a PCS and a N-PCS?

PCS

The Physicians Certification Statement can be used for all non-emergency transports routine, unscheduled and scheduled. A doctor executes a written statement as per the definition. It is physician-executed. The statement must be signed and dated by the patient’s attending physician certifying that the payer’s medical necessity provisions are met.

Whatever the end-product medical necessity statement looks like, it must be properly signed and include all of the information necessary to prove transportation by any other means other than an ambulance would not be an option for the patient without jeopardizing his/her health and well-being. Or, the statement certifies that the patient is bedbound as defined by the criteria established by the CMS.

A PCS is the only certification statement that can be used to verify medical necessity for Routine Scheduled Non-Emergency Ambulance Transports (RSNATs.) The PCS must be completed, signed, dated and executed prior to the first transport of the repetitive transport series (ie. 3 individual transports in a 10-day period or at least 1 transport each week for 3 consecutive weeks for the same reason.)

A N-PCS cannot be used to certify RSNATs.

N-PCS

The Non-Physicians Certification Statement is used for the non-repetitive scheduled or unscheduled transport scenario.

As with the PCS, it’s not about the form.

It is about who verified the medical necessity using a written document and certifies that transport by any other means other than an ambulance is contraindicated and the requirements pertaining to what person and their role can sign-off on this statement is relaxed.

For the N-PCS, the person signing the form must fit these criteria…

  • Have personal knowledge of the patient’s condition at the time the ambulance transport is ordered or when the service is provided.
  • Must be employed by the patient’s attending physician or by the hospital or facility where the patient is being or has been treated and from which the patient is being transported- the sending facility not the receiving facility.
  • The person signing and attesting to the medical necessity of the patient can be a…
    • Physician assistant (PA)
    • Nurse practitioner (NP)
    • Clinical nurse specialist (CNS)
    • Registered nurse (RN)
    • Licensed practical nurse (LPN)
    • Social worker (SW or LSW)
    • Case manager
    • Discharge Planner
    • Licensed Vocational Nurse (LVN- Texas only)

Let’s re-cap…

Certificates of medical necessity encompass two distinct categories, the PCS and the N-PCS. The Feds do not require a specific form or form format. Check state Medicaid and commercial payer requirements for those unique requirements which may differ from Federal mandates. Know the rules that drive what form is required but do remember that a certificate of medical necessity is absolutely required for all non-emergency transports billed to Medicare- scheduled or unscheduled, repetitive or non-repetitive.


*Chuck Humphrey is the Senior Director of Compliance and a Territory Sales Manager for Quick Med Claims. He is one of our industry experts with over 30 years of experience in the EMS industry.

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