Minimizing EMS and Ambulance Audit Risk

Posted by: Edelberg & Associates

Ambulance and EMS billing require the same level of compliance and accurate code submission as hospitals and medical practices. As Medicare expands its audits of ambulance billing, risk controls are critical. However, due to the differences between physician/hospital coding rules and those established for ambulance/EMS, many ambulance companies increase their audit risk with every transport.

Medicare strongly encourages providers to establish a detailed documentation policy for ambulance compliance programs. A compliance program serves a dual role to (1)establish policies and procedures for documentation, coding and billing and (2) functions as an educational tool for staff. The complexities of ambulance billing are complex. In addition to basic coding guidelines, the ambulance must meet Medicare rules for the vehicle, crew, and supplies. Medicare covers only transport to a hospital or a skilled nursing facility with few exceptions.

Documentation and coding must support medical necessity for the ambulance trip through documentation that the transport is the only way to safely move a patient. Correct use of the codes and modifiers to identify these medically necessary services is key to assuring accurate billing and compliance. As payers have highly individualized medical necessity requirements, there is no clear universal medical necessity standard. Medicare Manual 100-02 Chapter 10 Section 10.2.1 clarifies for Medicare patients that Medical necessity is established when the patient’s condition is such that use of any other method of transportation is contraindicated.

Poor documentation quality is frequently the limiting factor for billing ambulance/EMS services. Or, when poor documentation us used to bill for ambulance and EMS services, payer audits often catch discrepancies and omissions that result in refunds and penalties for improper billing.

For starters, documentation must be complete and legible. There are two elements of documentation that must be addressed: patient demographics and clinical justification for the service. In order to assure accurate payment for services, documentation must include accurate patient demographic information; insurance information; prior authorization if required by payer, (not applicable for Medicare), Physician Certification Statement; patient signatures; designation of the responsible party; service levels; and documentation of medical necessity relevant to ambulance or EMS services.

In order to minimize the work necessary to manage requests from payers for documentation to validate site of service, medical necessity of the service provided, documentation must establish the proof that services have been accurately reported. This can be achieved with a detailed documentation policy that is supported with checks and balances to assure that documentation is complete and is properly used to support accurate coding and billing. Personnel should be notified on a routine basis if documentation is not adequate to support the services that are performed. All providers should be encouraged to maintain documentation competency through ongoing monitoring of improvement. It takes organization and resources to maintain a system of checks and balances but the rewards are well worth the effort.

Clinical documentation includes: the patient presentation; patient chief complaint; the history of the patient’s present illness; past medical, family and relevant social history; documentation of current medications and status of allergies; physical assessment; clinical impression; treatments provided; method of transfer; changes in patient status; and transfer of care. The level of certification of the technician (EMT, Paramedic, BLS, ACLS) must also be documented.

Documentation for demographics and billing require recording the address where patient was found including city, county, state; the correct name of person who initiated call and the source of the call; the type of location where the incident occurred (home, nursing home, hospital, etc.); the accurate date of incident; the patient’s chief complaint; nature of call with related response; time of the event; response mode; service type (ambulance v. EMS); incident number; response number; patient record number; agency and unit number; vehicle type; crew members and level of certification; transport mode; destination type; mileage; and patient disposition. Each individual encounter should be documented as a stand-alone service as information may change from encounter to encounter.

For additional information on this or any other ambulance coding and billing compliance topic contact Caral Edelberg at

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