Physician certification statements (PCS) are required for patients who are under the direct care of a physician and are required for:
Scheduled non-emergency ambulance transports
Unscheduled non-emergency ambulance transports
Ambulance suppliers must obtain certification from the patient’s attending physician verifying the medical necessity of ambulance transportation in certain circumstances. The physician certification must be accurate and timely as it enables billing Medicare to receive payment for ambulance services.
The attending physician is responsible for supervising the medical care of the patient by:
Reviewing the patient’s program of care
Monitoring changes in the patient’s medical status
Signing and dating all orders
Note: The signed PCS does not, by itself, demonstrate that the transport was medically necessary and does not absolve the ambulance provider from meeting all other coverage and documentation criteria.
PCS requirements for non-emergency scheduled repetitive ambulance transportation include the following:
The PCS for repetitive transports must be signed and dated by the attending physician before furnishing the services to the patient.
The PCS must be dated no earlier than 60 days in advance of the transport for those patients who require repetitive ambulance services and whose transportation is scheduled in advance.
The PCS may include the expected length of time ambulance transport would be required but may not exceed 60 days.
Definition of Repetitive Ambulance Service:
A repetitive ambulance service is defined as medically necessary ambulance transportation that is furnished three or more times during a 10-day period; or at least once per week for at least three weeks.
Repetitive ambulance services are often needed by beneficiaries receiving dialysis or cancer treatment.
PCS requirements for non-emergency unscheduled or scheduled on a non-repetitive basis ambulance transportation include the following:
The PCS must be obtained from the attending physician within 48 hours after transport.
If the ambulance provider is unable to obtain the PCS from the attending physician within 48 hours of transport, the provider may submit a claim if a certification has been obtained from one of the following who is knowledgeable about the patient’s condition and who is employed by either the attending physician or the facility to which the patient is admitted:
Clinical Nurse Specialist
If unable to obtain the written order within the 48-hour limit, the supplier may submit the claim after 21 days if there is documentation of attempts to obtain the order and certification. When the PCS cannot be obtained in accordance with 42 CFR 410.40 the ambulance supplier may send a letter via U.S. Postal Service certified mail using the return receipt and/or proof of mailing or other similar service demonstrating delivery of the letter as evidence of the attempt to obtain the PCS.
CMS does not require a particular form or format for the certification and it can be simply a written statement that supports the need for ambulance services.
Novitas recommends that the form:
Contain a section that allows the physician to provide a narrative description of the patient’s physical condition at the time of the transport.
Be a patient-specific form that is signed and dated by authorized personnel.
Contain pertinent medical information in the narrative portion that will assist Medicare in making medical necessity determinations.
Confirm or support the medical information submitted on the trip sheet and the diagnosis information submitted on the claim form.
Note: A PCS is not required for emergency transports or for non-scheduled, non-emergency transports of patients residing at home or in facilities where they are not under the direct care of a physician.
The PCS must:
Be signed and dated by the patient’s attending physician:
The signature of the medical professional completing the PCS must be legible/ readable (or accompanied by a typed or printed name name) and include credentials
The prefix “Dr.” is a title and not a credential
Stamped signatures or file signatures are not acceptable
Local Coverage Determination, L35162 Ambulance Services (Ground Ambulance)