October 23, 2007
Certificate of Medical Necessity for Ambulance Transfers
Data analysis by several agencies has found significant concerns regarding the proper use of Certificates of Medical Necessity (CMN)/Physician Certification Statement (PCS) to justify ambulance transport of Medicare beneficiaries. Of particular interest is the area of transport of ESRD patients.
As this area undergoes further review, both medical providers and the ambulance providers will be considered for audits/reviews. Physicians should be sure that the patient's medical record clearly supports the need for a CMN/PCS for ambulance transport to include the specific deficits that would require the ambulance transport. Physicians should routinely review the continuing need for a CMN/PCS as often the reason for the initial issuance resolves and a CMN/PCS is no longer valid. Be very careful in cases where a patient has no other obvious means of transport. In the absence of other reasons, lack of transportation is not a valid indication for a CMN/PCS for ambulance transfer. Medicare will not pay for transports that are not clearly medically necessary and reasonable and it is a violation to bill for such transports.
EMS providers should also be cognizant that the patient's condition has not changed such that a CMN/PCS is no longer valid. A patient who is able to walk from the porch to the ambulance is likely not eligible for ambulance transfer in routine non-emergent settings. Such cases should be brought to the attention of the provider signing the CMN/PCS. Abuse of a CMN/PCS should be reported to the Medicare Carrier or the Medicare Program Safeguard Contractor for further review. Failure to report suspected fraud and abuse in the Medicare Program is a violation.
