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CERTIFICATION OF MEDICAL NECESSITY FOR AMBULANCE
NON-EMERGENCY TRANSPORTS
Notes concerning NON-EMERGENCY transports:
>A physician letter must be on file with the ambulance company for certain patients, but not all, as defined by HCFA—those needing a letter are PATIENTS UNDER THE DIRECT CARE OF A PHYSICIAN. This is vague, but usually excludes transports to/from residences.
>Under no circumstance does Medicare pay for transports Residence to Physician offices / clinics, including emergency, except when this is an intermediate stop to hospital
>Medicare will only pay for patients who cannot sit erect, and substantiating documentation must be submitted with specific reason(s)
>Medicare does not pay when patient could travel by other means (wheelchair van, auto etc.)—regardless of availability of other means
>Medicare does not pay for facility to facility transports when care could have been provided at the first facility
| NON-EMERGENCY Transports for Patients Under
The Direct Care of a Physician o Yes o No Patient is in an SNF Bed o Yes o NO Patient in SNF Part A Stay Service Required o Tube Insertion/Reinsertion Type Tube__________________________________________________ o Yes o No Could tube have been inserted/reinserted at the patients bedside o X-Ray Body Area/reason_________________________________________________________________ o Diagnostic Test-What Type______________________________________________________________ o Dialysis o Radiation Therapy o Hyperbaric Oxygen Therapy o Other-Specify__________________________________________________________________________ Comments_________________________________________________________________________________ |
FACILITY TO FACILITY TRANSPORT (Hospital to Hospital, for example) o Emergency (immediate transport reqd) o Non-emergency (delay not detrimental to patient) Service Required Enroute and/or potentially needed due to patient condition Oxygen o Used o Potential Method_______________________________________ LPM______________ EKG Monitoring o Used o Potential -–List Readings_________________________________________ o Fluids -–Type___________________________Rate______ (Added Medication)__________________ o Other Meds required enroute____________________________________________________________ o Stabilization devices required enroute_________________________________________________ o Other-Specify__________________________________________________________________________ Comments_________________________________________________________________________________ |