Saturday, January 28, 2012

What are the documents required when you submit the claims to Medicare

Documentation Requirements for Ambulance Billing
The trip record documentation of each patient encounter should include the following:
 Complete and legible information.
 Reason for the transport.
 A concise explanation of symptoms reported by the patient and/or other observers and details of the patient’s physical assessments that explain why the patient requires ambulance transportation and cannot be safely transported by an alternate mode.
 Relevant history (when available).
  Observations and findings (patient’s condition at the time of transfer).
  A description of the patient’s physical condition in sufficient detail to demonstrate that the patient’s condition or functional status at the time of transport meets Medicare limitation of coverage for ambulance services.
 A detailed description of existing safety issues.
  A detailed description of special precautions taken (if any) and explanation of the need for such precautions.
 Assessment and clinical evaluations that should include:
oVital signs.
o Neurological assessment.
o Cardiac information.
                 Documentation of procedures and supplies provided such as:
O IV therapy.
o Respiratory therapy.
o Intubation.
o Cardiopulmonary Resuscitation (CPR).
o Oxygen administered.
o Drug therapy.
o Restraints. 
 A description of specific monitoring and treatments ordered and performed/ administered; that a treatment (such as oxygen) and/or monitoring (such as cardiac rhythm monitoring) was performed absent sufficient description of the patient’s condition (to demonstrate that the treatment and/or monitoring was medically necessary) is inadequate on its own merit to justify payment for the ambulance service. 
 The patient’s progress, responses to treatment and changes as treatment is given (e.g., monitoring of vital signs after medication has been given).

· Point of pickup (identify place and complete address). 
 Number of loaded miles/cost per mile/mileage charge. For services rendered with dates of service on or after January 1, 2011, miles must be reported as fractional units. For instructions on fractional units refer to “Mileage” under the “Services and Procedure Codes” section in this manual. 
 Minimal or base charge and charge for special items or services with an explanation/itemization of the special items or services. 
 For hospital-to-hospital transports, the trip record must clearly indicate the precise treatment or procedure (or medical specialist) that is available only at the receiving hospital. Non-specific or vague statements such as “needs cardiac care” or “needs higher level of care” are insufficient. 
 Any additional available documentation that supports medical necessity of ambulance transport (e.g., emergency room report, Skilled Nursing Facility (SNF) record, End-Stage Renal Disease (ESRD) facility record, hospital record). 
 A separate run sheet for each transport (e.g., two run sheets for round trips).
 Date and legible identity of the observer. Note: Refer to Signature Guidelines for Medical Review Purposes in this section.

Note: The HCPCS codes and ICD-9-CM codes reported on the health insurance claim must be supported by the documentation on the run sheet

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