Please see the attached questions and answers (Q & A) that have been posed as a result of the Federal Register publication of the Coverage of Ambulance Services and Vehicle and Staffing Requirements: Final Rule on January 25, 1999. As additional questions for clarification are received, the Q & A list will be updated.

1Q: Section 410.40(d)(1) lists the criteria needed for nonemergencies. Is it correct that these criteria apply to the patient's condition at the time of service?

A: Yes, the criteria outlined in section 410.40(d)(1) are applicable to the condition of the patient at the time ambulance services are provided.

2Q: Is it correct that nonemergencies not meeting the criteria in 410.40(d)(1) may still be covered as long as the medical condition of the patient contraindicates transportation by other means and other requirements (i.e., vehicle, crew, origin/destination, physician order if needed, etc.) are met?

A: The intent of section 410.40(d)(1) was not to exclude conditions other than bed confined. The fact that the definition has been adopted was not intended to suggest that bed confinement is the sole determinant of medical necessity. It is the responsibility of ambulance suppliers to furnish complete and accurate documentation to demonstrate that the ambulance services being furnished meet the medical necessity criteria.

3Q: Since we are tied to the nursing homes via PPS why are there two different definitions of bed confined?

A: We recognize that it is a standard practice of both hospitals and nursing homes to take steps to ensure that patients are up and out of bed as often as their condition permits. Our purpose was to develop an ambulance specific definition that would identify, as eligible for covered services, only those individuals who are not able to be up and out of bed under any condition and therefore unable to tolerate being transported by other methods of transportation.

Physician Certification:

4Q: What is HCFA's definition of "under direct care of a physician"?

A: HCFA's applicable definition of "under the direct care of a physician" can be found in 42 CFR section 483.40, Physician Services. Specifically, the physician is responsible for supervising the medical care of the patient including reviewing the patient's program of care, ordering medications and monitoring changes in the patient's medical status, and signing and dating all orders.

5Q: Presumably, a patient in a SNF would be deemed to be "under the direct care of a physician." Is that correct?

A: Yes, that is correct.

6Q: Does HCFA have expectations in the event that a physician's certification is inconsistent with the condition of the patient when the crew arrives for transport, (e.g., condition worsens), will the documentation of the trip sheet be acceptable?

A: It is the responsibility of ambulance suppliers to furnish complete and accurate documentation of the patient's condition, the complaints as observed and the demonstrated symptoms, at the time of the transport, to demonstrate that the ambulance service being furnished meets the medical necessity criteria.

7Q: Is a fax copy of the physician certification statement acceptable in lieu of an original?

A: Yes. Whenever possible, however, effort should be made to obtain the original certification statement/form.

8Q: How much will the physician certification statement count for carriers?

A: The physician certification will be considered, along with other supporting documentation, by carriers in the processing of claims.

9Q: Will the carrier be instructed to pay all claims submitted if we have a physician certification statement?

A: No. Carriers are responsible for considering all submitted documentation when processing claims.

10Q: Will a 60-day physician certification be all-inclusive during that period or will a separate one be needed for each service that is provided?

A: No, the 60-day physician certification is not all inclusive. At the time that the certification is ordered, it is ordered on the basis that a specific condition exists that warrants the need for ambulance transportation service. Other conditions may occur that also warrant the need for nonemergency scheduled or unscheduled ambulance transportation, if the other condition falls within the guidelines set forth in sections 410.40(d)(2) and (d)(3) the supplier is responsible for obtaining the necessary documentation. Any and all documentation submitted should reflect the patient's condition at the time the ambulance service is furnished thereby supporting the need for the ambulance service.

11Q: Will the physician certification be required with each claim submission or will HCFA add a modifier that would indicate that the physician certification is on file?

A: The ambulance supplier is required to obtain (410.40(d)(2) and 410.40(d)(3)) and retain (410.41(c)(1)) physician certifications on file and to make the certifications available upon request by HCFA or the Medicare carrier or intermediary. It is important to note that at this time, HCFA has not made the necessary modifications to the claims forms that will allow ambulance suppliers to indicate that the physician certifications are on file. Absent the ability to provide such notification, ambulance suppliers are still required to obtain the certification, retain the certification on file and, upon request from the carrier, present the requested certification documentation. When the modifications are made to the claims forms, a Program Memorandum will be released advising how ambulance suppliers are to notify the Medicare carrier or intermediary that the required documentation is on file.

12Q: Since there is no standard format for the physician certification statement, are we to accept forms with a typed statement of, "By my signature, I certify that nonemergency ambulance transportation was medically necessary and that other means of transportation were contraindicated"? These are signed by the physician. Can a RN sign? They are currently filling out and signing some of these since physicians refuse to.

A: The purpose of the certification is to obtain specific information about the patient's condition is at the time that ambulance services are ordered that substantiates the need for ambulance transportation services. Sections 410.40(d)(2) and (d)(3) require the attending physician to certify that the patient's condition meets the medical necessity requirements of 410.40(d)(1). In addition, it is also acceptable to obtain signed certification statements when professional services are furnished by physician assistants (PA), nurse practitioners (NP), or clinical nurse specialists (CNSs) (all applicable State licensure or certification requirements must be met).

13Q: We assume that HCFA or the carriers will advise the physicians that they must complete the certifications. Is that correct?

A: To facilitate awareness of the Medicare rules as they relate to the ambulance service benefit, ambulance suppliers may need to educate the physician (or the physician's staff members) when making arrangements for the ambulance transportation of a beneficiary. Ambulance suppliers may wish to furnish an explanation of applicable medical necessity requirements as well as the requirements for the physician certification and to explain that the certification statement should indicate that the ambulance services being requested by the attending physician, PA, NP, or CNS are medically necessary. HCFA will also be advising the Medicare carriers to educate physicians regarding the medical necessity requirements governing the Medicare Ambulance Service benefit.

14Q: Assuming the ambulance responds in good faith, thinking that the condition is an emergency (e.g., 911 call) and the carriers subsequently downgrades the call from an emergency to a nonemergency, would you agree that a physician certification is not required?

A: In the situation described, we agree that a physician certification would not be required

Scheduled/Unscheduled Nonemergency Ambulance Transportation:

15Q: There is no definition of "scheduled" in terms of a time frame. While there is no industry standard we believe that a 24 hour rule would be appropriate due to the physician certification requirement. Therefore, we believe "scheduled" should refer to calls made 24 or more hours prior to the ambulance transport. Is that acceptable?

A: We agree that "scheduled" may refer to calls made 24 or more hours in advance of the transport.

16Q: Are scheduled transports from home considered only repetitive?

A: No.

17Q: Is the reference to the 48 hour time frame to obtain the physician certification a rule or a guide for unscheduled transports? Will it matter that the service is not billed until the certification is received?

A: The "with in 48 hours" time frame specified in section 410.40(d)(3)(i) is the rule. Ambulance suppliers are required to obtain and retain the certifications on file and to make the certifications available upon request by the Medicare carrier or intermediary.

18Q: We understand 410.40(d)(2) refers to repetitive patients such as dialysis and radiation therapy patients. The confusion is over scheduled and unscheduled nonemergencies. Would it be correct to advise our members that the requirement for the physician certification does not apply to patients residing in their homes or in an extended care or other facility not under the direct care of a physician, except for repetitive patients?

A: Section 410.40(d)(2) provides that the physician certification will be required for patients for scheduled, repetitive transports and scheduled, nonrepetitive transports. In addition, for patients who reside in a facility and are under a physician's care, the physician certification is required for unscheduled ambulance transports. For nonemergency, unscheduled, ambulance transports section 410.40(d)(3)(ii) states, "For a beneficiary residing at home or in a facility who is not under the direct care of a physician, a physician certification is not required."

Miscellaneous:

19Q: The National Medical Transportation Association (NMTA) provides nonemergency door through door transportations for the wheelchair and stretcher bound. These transportation services are medically necessary, but do not require medical treatment or services en route nor do these services require medical treatment. Nonemergency door through door transportation services are often used to transport dialysis patients in a cost effective manner under Medicaid. Please explain, how, under this Final Rule, nonemergency medical transportation providers will be able to begin providing the nonemergency services described under Medicare.

A: The Medicare law, unlike Medicaid, contains no provision for "transportation" but rather provides for ambulance services. Under Medicare law, the only transportation service that can be paid for as a supplementary medical benefit (Part B) of the Medicare program are ambulance services. The Social Security Act authorizes payment for ambulance services only if the "patient's condition is such that other methods of transportation is contraindicated." Medicare law requires that ambulance services be furnished in a vehicle equipped and staffed to respond to a medical emergency or an acute care situation (Medicare regulations do not limit ambulance services to emergencies). Transportation by ambulance is covered under the Medicare program only if "(a) normal transportation would endanger the health of the patient..." If a patient can use normal transportation without endangering his or her health, there would be no justification for ambulance services and therefore no Medicare coverage for such services. In short, the provisions contained in the Ambulance Final Rule are not applicable to the type of nonemergency medical transportation services you describe.

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Last Updated March 17, 1999