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Physician Certification Statement – Ambulance PCS

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Medicare Ambulance Billing Rules – PCS

Medicare ambulance billing rules require providers to obtain a PCS (“Physician Certification Statement”) for most ‘non-emergency patient transports.  Providers are not required to use a specific version of the PCS form, but some rules must be followed.  This could be new information, so take your time.

 

Tips & Suggestions – Ambulance PCS Form

The first item we want to focus on is the title of your PCS form.  The federal regulations require a “Physician Certification Statement”, so be sure that is the title or name of your form.  Regardless of your form’s design, content, or intent, “Physician Certification Statement” is the title you need on your PCS form.  Other titles could cause your PCS form to be rejected by Medicare.  The federal regulations governing the Ambulance PCS form can be found at 42 CFR 410.40(d).

 

Specific information that must be on the Ambulance PCS form:

  • Patient name

  • Medicare / Insurance ID#

  • Date(s) of ambulance transport

  • Signature of an authorized clinician, printed name, and date of signature

  • Patient’s medical problem/condition necessitating transport by ambulance, including a specific explanation as to why other means of transportation would endanger the patient’s health

 

Non-emergency, Non-Repetitive Transports:

The PCS must be obtained before submitting a claim to Medicare but no more than 48 hours after the transport was provided. If the physician cannot or cannot sign the PCS, one of the following clinicians may obtain a signed certification statement.

  • Physician’s Assistant (PA)

  • Nurse Practitioner (NP)

  • Clinical Nurse Specialist (CNS)

  • Registered Nurse (RN)

  • Discharge Planner who has personal knowledge of the patient’s condition at the time the ambulance service is ordered or furnished

 

Non-emergency, Repetitive Patients – Ambulance PCS form:

An ambulance patient becomes “repetitive” after providing the third non-emergency ambulance transport in ten days or once per week for three weeks.  The definition of “repetitive” is based only on the quantity and frequency of transport.  These patients usually visit dialysis, wound care, or cancer treatment centers.

Once a patient becomes “repetitive”, the PCS rules change very importantly.  At that point, the PCS has to be in the ambulance provider’s hands before furnishing the transport.  Transports provided while no PCS is on file with the ambulance provider are not covered by Medicare.  Failure to have the PCS on hand prior to transport means that Medicare does not cover the transport.  Claims should not be submitted to Medicare for payment.  If you want to do additional research on this subject, coverage details are spelled out in federal regulation at 42 CFR 410.40(d)(2).

 

Some additional things you need to know:

  • Repetitive ambulance trips may be scheduled or unscheduled

  • Repetitive means…three or more transports during ten days or at least once per week for three weeks (Repetitive rules begin to apply after the third transport)

  • The term repetitive is based solely on the number of transports in the ten-day / three-week period (three transports in ten days or three weeks)

  • Dialysis, Radiation Therapy, & Wound Care are common examples of repetitive patient scenarios

  • A repetitive patient PCS can be used to support claims for up to 60 days beyond the date of signature

  • An Emergency Ambulance Response (BLS Emergency or ALS 1) does not require a PCS form to be signed

 

Ambulance PCS – Compliance Alert:

  • Transports of repetitive patients are not covered until the PCS is in the provider’s hands.  Services furnished before taking physician possession of the PCS are non-covered services.  Providers should advise the billing office of the date the PCS is obtained to prevent inappropriate billing.  Federal regulation & Medicare billing rules require providers to obtain the PCS before furnishing the transport when the patient becomes “repetitive”.  This happens after the third transport in ten days or the third week if transported once weekly.

  • Medicare reviews PCS forms during prior auth requests, prepayment medical reviews, and post-payment audits. Charts and their attachments are considered complete and accurate if they are advanced to the billing office. Our staff and the payers cannot presume missing medical information. Make sure you have a robust documentation quality improvement process. 

 

Billing Medicare Without the Required PCS:

A Physician Certification Statement (PCS) must be on file for all non-emergency transports before billing Medicare.  If the transport is not repetitive, the provider has 48 hours to obtain the PCS from the ordering physician.  If this is not possible, the provider can request a PCS by certified mail and return a signed receipt.  If no PCS has been returned for 21 days after the service date, and the provider has documentation of mailed requests, the provider can bill Medicare.  This exception does not apply to patients whose transports have qualified as a “repetitive” transport service.  Medicare only covers transport in those cases after the provider obtains the PCS.  When a PCS is delayed for a repetitive patient, Medicare does not cover the service.  Proof of mailing must be a certified receipt from the US Postal Service or similar service.  A PCS or proof of mailing do not alone prove that the transport was medically necessary.

 

Emergency Transports – PCS Forms:

Emergency ambulance responses that are provided in response to a 9-1-1 (or the equivalent) call, do not require a PCS form.

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If you have any questions, give us a call today at 678-696-1583

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