Published Nov. 18 by HCFA

MD certification for unscheduled non-emergency transports

HCFA Memorandum

WASHINGTON, D.C. — 

With this memorandum the Health Care Financing Administration informs physicians of the Medicare requirement that ambulance transport suppliers obtain physician certification of medical necessity prior to or within 48 hours of unscheduled nonemergency ambulance transports.

On January 25, 1999 new regulatory requirements for Medicare Part B ambulance services were published in the Federal Register, and were effective February 24, 1999. These regulations revised the vehicle, staffing, level of service, and billing requirements for ambulance services. In addition, the regulations revised the medical necessity requirements to include a national definition of the term Abed-confined@ and established a new requirement that the beneficiary=s attending physician provide a written order certifying the medical necessity of nonemergency ambulance transports. This memorandum is to summarize the physician certification requirement, in the context of the new regulation, and informs physicians of their obligation to provide, where required, the requested certification statement.

Ambulance Medical Necessity Requirements

General Rule: Medicare covers ambulance services only if they are furnished to a beneficiary whose condition is such that other methods of transportation would be contraindicated. For nonemergency ambulance transportation, criteria for bed-confined states that the beneficiary is:

We have clarified that bed-confined is not meant to be the sole criterion to be used in determining medical necessity.

Requirements for Nonemergency Ambulance Transportation: Sections 42 CFR 410.40(d)(2), ASpecial Rule for Nonemergency, Scheduled Ambulance Services@ and 410.40 (d)(3), ASpecial Rule for Nonemergency, Unscheduled Ambulance Services@, specifies the circumstances under which the attending physician must provide a written order certifying the medical necessity of requested ambulance transports.

• 410.40(d)(2): Nonemergency, scheduled ambulance services are covered if, before furnishing the service to the beneficiary, the ambulance supplier obtains a written order from the beneficiary=s attending physician certifying that the medical necessity criteria (see General Rule) has been met. The written order must be dated no earlier that 60 days in advance of the transport for repetitive patients whose transportation is scheduled in advance;
• 410.40(d)(3): For residents in facilities where they are under the direct care of a physician, ambulance suppliers can obtain written orders from the attending physician, certifying that the medical necessity criteria have been met, Awithin 48-hours after the transport.@
• We have further clarified that the physician order may be signed by a physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS) (where all applicable State licensure or certification requirements are met).
• In addition, for unscheduled, nonemergency ambulance transports, a registered nurse (RN) who is employed by the attending physician or who is an employee of the hospital or facility where the patient is being treated may sign a physician certification statement on oral orders from the physician (or other qualified practitioner, i.e., PA, NP, CNS). The RN=s signature is acceptable in instances where nonemergency, unscheduled ambulance transportation is required and the attending physician is not physically present in the facility, but is in consultation with the RN, at the time the medically necessary transport is required. The physician must later countersign the written order. Before the billing for the service, the ambulance supplier is responsible for obtaining the signed written order with the appropriate signatures in as expeditious a manner as possible.
• A physician order is not required for emergency transports or for an unscheduled transport of a beneficiary, residing at home or in a facility, who is not under the direct care of a physician.

Physician Certification Statement Format: Because many ambulance suppliers had, prior to the implementation of this rule, their own certification forms, the Health Care Financing Administration did not impose a format requirement for the physician certification statement. Many Medicare carriers have established specific requirements for the content of the physician certification statements. Ambulance companies are working with their carriers to ensure that forms are capturing information that will assist the carriers in making appropriate medical necessity determinations. It is expected that ambulance suppliers will supply the approved forms to physicians for their use.

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