Before ordering a Medicare patient to be transported by ambulance, ask yourself these questions:
Is this transportation for an emergency situation?
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Medicare defines an EMERGENCY as: Services provided in the hospital emergency room after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in:
- Placing the patient's health in serious jeopardy or
- Serious impairment to bodily function or
- Serious dysfunction of any bodily organ or part.
- Does the patient need to be restrained?
- Is the patient unconscious or in shock?
- Does the patient require oxygen or other emergency treatment on the way to his or her destination?
- Does the patient have to remain immobile (stretcher bound) because of a fracture that has not been set or is there a possibility of a fracture?
- Has the patient sustained an acute stroke or myocardial infarction?
- Is the patient experiencing severe hemmorhage?
- Is the patient bed confined before and after the ambulance trip?
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Medicare currently defines "bed confined" as
- The patient is unable to get up from a bed without assistance and
- The patient is unable to ambulate and
- The patient is unable to sit in a chair or wheelchair.
- This is the current definition of "bed confined". The Final Rule does not include patients that need transport to other medical facilities with continuous high-flow oxygen, IV in place and/or cardiac monitoring. These patients may not be "bed confined" but still need non-emergency ambulance transportation.
- Can the patient be moved ONLY by stretcher?
If you are about to order ambulance transportation for any of the reasons listed below Medicare WILL NOT pay and the patient will be responsible for charges resulting from these types of of ambulance transports:
- Transportation to the doctor's office
- Transportation to be closer to home or family
- Transportation to a hospital out-patient facility for non-emergency care
- Transportation to a hospital to receive VA benefits
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Please keep in mind that while Medicare may pay for ambulance transportation to the hospital emergency room, the transport back to the nursing facility, personal care home or residence, it WILL NOT be covered unless the patient meets one of the conditions above. If a patient meets one of the conditions above and is returning to a nursing facility (i.e. nursing home) the patient's physician will also have to complete a Physician Certification Statement form prior to transport. We can supply you with a copy of the PCS, along with a brief explanation as to why this form it must be completed in order to meet Medicare requirements.
Dialysis Patients:
Medicare coverage is now extended to ESRD patients residing at home, or a non-skilled facility, to and from free-standing dialysis facilities. The patient must meet the criteria above and must have a current PCS on file, dated no more than 60 days prior to transport.
When ordering ambulance transportation, please provide the ambulance service with detailed information regarding the reason for each ambulance trip.
If you're not sure, please ask. The ultimate responsibility for payment lies with the patient if Medicare does not cover the transportation.
Non-Covered Services
The following are some commonly billed non-covered services:
- Transport to a physician's office
- Transport to be treated by a preferred physician
- Transport to be closer to home or family
- Transport to a hospital's out-patient facilities for non-emergency care (certain specialized services may be allowed if PCS is sent
- Transport to a hospital in order to receive VA benefits