Tip of the month: Documentation with Appeal Request 
 
When you need to submit medical record documentation with your appeal, include all pertinent documentation including the medical record detailing the service and the medical necessity of the service in question. In addition, providers should supply a separate statement indicating the specific information to evaluate in the medical record that supports the rationale for the appeal.
  -Medicare 
by Grant Helferich 
  • DON'T   copy information.
Write each transport as if this is the first time you have seen or treated this patient. Do not copy information, especially your narrative, from a previous report. Each patient care report must be a stand-alone report.
  • DON'T  use P.U.T.S. in place of the patient's signature.
CMS has indicated there should be very few occurrences in which a patient is unable to sign the patient care report such as cardiac arrest, patient having a stroke or a dementia. If there is a true medical reason the patient is unable to sign the patient care report, you must document all the medical reasons for this. CMS has also provided instructions in the Ambulance Billing Manual for those few cases the patient is unable to sign such as having an authorized family member sign for the patient.
  • DO support medical necessity
By definition, medical necessity proves why transportation by any other means is contraindicated for the patient. In order for insurance to pay, medical necessity must be proven within the documentation and should include the primary impression, chief complaint, and all corresponding treatment to the patient.Note that the Centers for Medicare and Medicaid Services (CMS) has stated that the diagnosis of a disease or illness may not be enough without corroborating evidence/statements to support medical necessity for ambulance transport.
  • DO be truthful

Make sure your documentation is truthful. It is not in your best interest to develop a list of terms or symptoms to use to get the transport paid. Your patient care report is a medical legal document. Using false statements in your report to support medical necessity can result in a prosecution in the court of law.
Grant Helferich
Grant is employed as EMS Advisor/Business Development Manager with Omni EMS Billing in Wichita, Kansas. He is a former member of the KEMSA Board and has also served as the treasurer and president of the KEMSA Administrator's Society. He was certi­ed as an EMT, EMT-I, M.I.C.T. , and T.O. II. Grant has worked as an EMT, EMT-I, M.I.C.T., Field Supervisor, Flight Paramedic, Cardiovascular Specialist, Assistant Director, and Director of EMS.
 

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