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Documentation Guide
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AMBULANCE DOCUMENTATION GUIDENCE INFORMATION
THE ARKANSAS MEDICARE PROVIDER’S REQUIREMENTS FOR PAYMENT FOR
GROUND AMBULANCE SERVICE:
“THE TRIP RECORD MUST INCLUDE”:
“A detailed description of the patient’s condition at the time of transport. Coverage will not be
allowed if the trip record contains an insufficient description of the patient’s condition at the
time of transfer for Medicare to reasonable determine that other means of transportation are
contraindicated. Coverage will not be allowed if the description of the patient’s condition is
limited to conclusory statements and/or opinions, such as the following:
 Patient is non-ambulatory.
 Patient moved by draw sheet.
 Patient could only be moved by stretcher.
 Patient is bed-confined.
 Patient is unable to sit, stand or walk.”
“The trip record must paint a picture of the patient’s condition and must be consistent with
documentation found in other supporting medical record documentation (including the
physician’s certification). The trip record must include the following:
 A concise explanation of symptoms reported by the patient and/or other observers and
details of the patient’s physical assessments that clearly demonstrate that the patient
requires ambulance transportation and cannot be safely transported by an alternate
mode.
 An objective 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.
 Description of the traumatic event when trauma is the basis for suspected injuries.
 A detailed description of existing safety issues.
 A detailed description of special precautions taken (if any) and explanation of the need
for such precautions.
 A description of specific monitoring and treatments required, ordered and
performed/administered. That a treatment (such as oxygen) and/or monitoring (such as
cardiac rhythm monitoring) were 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. For example, when oxygen is supplied as a basis for ambulance
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transportation, the patient’s pretreatment capillary blood oxygen saturation and clinical
respiratory description must be recorded. The two must be consistent with oxygen
need.”
“Statements such as the following, absent supporting information in relevant bullets above,
are insufficient to justify Medicare payment for ambulance services:
 Patient complained of shortness of breath.
 History of stroke.
 Past history of knee replacement.
 Hypertension.
 Chest pain.
 Generalized weakness.
 Is bed-confined.”
STUDENT AMBULANCE SERVICE DOCUMENTATION REFERENCE GUIDE:
REASONABLENESS:
Medicare requires that a transport be “reasonable”; as in there must be a valid reason for
transport, (such as a patient who requires care or services that are not available at home or at
the facility where the patient currently resides). For a transport to be “reasonable”, it must also
be more economical to transport the patient than to bring the service to the patient.
DESTINATION:
Medicare will only pay loaded mileage to transport a beneficiary to the closest appropriate
facility, (as in to a facility within the “locality”). Mileage should be documented with vehicle
odometer readings.
MEDICAL NECESSITY:
Medicare requires that the patient’s condition meet “medical necessity” requirements for
transport by ambulance. This means that transporting the patient by any other means is
contraindicated by the patient’s condition. (This means that the patient cannot safely be
transported by other means, such as car, taxi or wheelchair van). There must be accurate
documentation (patient care report, physician certification statement, dispatch records)
supporting the claim that CLEARLY AND ACCURATELY DEMONSTRATES MEDICAL NECCESSITY
FOR AN AMBULANCE AT THE TIME OF TRANSPORT.
 CERTAIN CONDITIONS FOR WHICH MEDICAL NECESSITY IS GENERALLY PRESUMED IF
PRESENT AND PROPERLY/ACCURATELY DOCUMENTED:
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Transported in an emergency situation, (accident, injury or acute illness).
Patient needed to be restrained to prevent injury to self or others.
Patient was unconscious or in shock.
Patient required oxygen or other emergency treatment during transport
Patient exhibits signs and symptoms of acute respiratory or cardiac distress,
(shortness of breath or chest pain).
Patient exhibits signs and symptoms that indicate the possibility of acute stroke.
Patient had to remain immobile because of a fracture or the possibility of a
fracture which has not been set or treated by a physician.
Patient was experiencing severe hemorrhage.
Patient could only be moved only by stretcher, (must describe why).
Patient was bed-confined before and after the ambulance trip, (“BED CONFINED”
means that the patient was unable to ambulate, AND unable to get out of bed
without assistance, AND unable to sit self supporting in a chair or wheelchair).
BENEFICIARY SIGNATURE REQUIREMENTS:
Medicare requires the signature of the beneficiary by obtained for all claims, emergency and
nonemergency.
 Exceptions:
o No signature is required if the beneficiary has died.
o If the beneficiary is otherwise physically or mentally incapable of signing the
claim, the claim may be signed on their behalf by one of the following:
 The beneficiary’s legal guardian.
 A relative or other person who receives governmental benefits on behalf
of the beneficiary.
 A relative or other person who arranges the beneficiary’s treatment or
handles other responsibility for the beneficiary’s affairs.
 A representative of an agency or institution (other than the ambulance
service) that furnished care, services or assistance to the beneficiary.
EMERGENCY TRANSPORT LEVELS – GROUND AMBULANCE:
Basic Life Support – Emergency Transport (BLS-E)
Advanced Life Support – Emergency Transport, Level – 1 (ALS1-E)
Advanced Life Support, Level – 2 (ALS2)
 EMERGENCY RESPONSE: Emergency codes under Medicare rules requires an
“emergency response”, which means: responding immediately at the BLS or ALS1 level
of service to a 911 call or the equivalent direct call to the ambulance service’s dispatcher
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and the dispatcher uses standard dispatch protocols to determine an emergency
situation. An immediate response is one in which the ambulance entity begins as quickly
as possible to take the steps necessary to respond to the call.
ALS – Level – 1 (ALS Assessments and ALS Interventions): ALS Level 1 Emergency code
requires an “emergency response”, or a patient situation which requires the upgrading
of the patients treatments from a BLS nonemergency encounter to an ALS treatment
intervention for life saving purposes.
o PLUS either/or a qualifying “ALS assessment” (an assessment performed by an
ALS crew as part of an emergency response that was necessary because the
patient’s reported condition at the time of dispatch was such that only an ALS
crew was qualified to perform the assessment) OR an ALS intervention (a
procedure that is, in accordance with State and local laws, required to be
furnished by only ALS personnel). Assessments/Interventions should be
documented on the PCR.
ALS – Level – 2: May be used for an emergency or non-emergency transport, provided
that one or more ALS – Level – 2 interventions were performed or attempted. These
include the following:
o Manual defibrillation/cardioversion
o Endotracheal intubation
o Central venous line
o Cardiac pacing
o Chest decompression
o Surgical airway
o Intraossesous line
o Three or more separate administrations of medications by iv push/bolus or
continuous infusion, (excluding crystalloid fluids).
NON-EMERGENCY TRANSPORT LEVELS – GROUND AMBULANCE:
Basic Life Support, Non-emergency Transport (BLS-NE)
Advanced Life Support, Non-Emergency Transport, Level – 1 (ALS1-NE)
Advanced Life Support, Level – 2 ((ALS2)
Specialty Care Transport
 Non-emergency transports under Medicare rules are any transports that do not involve
an “emergency response”.
o Medicare requires a Physician Certification Statement (PCS) for most nonemergency ambulance transports.
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o The only exception being a transport of a Medicare beneficiary who resides at home
or in a facility and is not under the direct care of a physician. (From home, doctors
office or SNF to the ED or a direct admit to the hospital the patient now coming
under direct care of a physician).
Basic Life Support, Non-Emergency Transport:
o Any patient transport where an “emergency response” is not involved and the
patient does not require and Advanced Life Support measures.
Advanced Life Support, Non-Emergency Transport, Level – 1:
o Any patient transport where an “emergency response” is not involved, PLUS:
o The patient requires an ALS assessment or continued reassessment, (document ALS
necessity completely on the PCS form). OR:
o The patient requires an ALS intervention, (a procedure that is, in accordance with
State and local laws, required to be furnished by ALS personnel only).
Advanced Life Support, Non-Emergency, Level – 2:
o See description in the emergency section.
Specialty Care Transports (SCT):
o Applies under Medicare rules only for interfacility transportation of a critically
injured or ill beneficiary at a level of service beyond the scope of the EMTParamedic.
o Specialty Care Transport is necessary when a beneficiary’s condition requires
ongoing care that must be furnished by one or more health professionals in an
appropriate specialty area, (nursing, emergency medicine, respiratory care,
cardiovascular care), or a paramedic with additional training (as determined by state
or local laws).
NORMALLY RECOGNIZED ALS EMERGENCY CONDITIONS – NON-TRAUMATIC:
 Severe Abdominal Pain – with other signs or symptoms (nausea, vomiting, fainting,
pulsating mass, distention).
 Abnormal Cardiac Rhythm/Cardiac Dysrhythmia – potentially life threatening
(bradycardia, v-tach, v-fib).
 Abnormal Skin Signs – (diaphoresis, cyanosis, delayed capillary refill, poor turgor,
mottled).
 Abnormal Vital Signs – with or without symptoms.
 Allergic Reaction – potentially life threatening (wheezing, difficulty swallowing, rapid
progression of symptoms).
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Blood Glucose – abnormal <80 or >250 with symptoms (altered mental status, vomiting,
signs of dehydration).
Respiratory Arrest – (apnea, hypoventilation requiring ventilator assistance and airway
management).
Difficulty Breathing
Cardiac Arrest – resuscitation in progress.
Chest Pain – non-traumatic – (substernal, epigastric, left sided chest pain, nausea,
vomiting, and palpitations).
Choking Episode – airway obstructed or partially obstructed.
Cold Exposure – potentially life or limb-threatening – (temp <95 degrees F, deep frost
bite and other emergency conditions).
Altered Level of Consciousness – non-traumatic – (acute condition with Glasgow Coma
Scale <15).
Convulsions/Seizures – seizing, immediate post seizure, postictal or at risk of seizure and
requires monitoring.
Non-traumatic Headache – with neurological distress conditions or sudden onset.
Cardiac Symptoms – other than chest pain (palpitations, skipped beats).
Cardiac Symptoms – other than chest pain – atypical pain or other symptoms.
Heat Exposure – potentially life threatening – (hot/dry skin, temp >105, neurologic
distress, heat stroke).
Hemorrhage – severe quantity and potentially life-threatening (uncontrolled or signs of
shock).
Haz-Mat Exposure – (toxic fume or liquid exposure via inhalation, absorption, oral,
radiation or smoke inhalation).
Medical Device Failure – life or limb threatening malfunction, failure or complication
(ventilator, pacemaker).
Neurologic Distress – (facial drooping loss of vision, aphasia, numbness, tingling, stupor,
delirium, paralysis).
Pain, Severe, Not otherwise specified – acute onset, unable to ambulate or sit due to
intensity of pain (7 out of 10).
Back Pain, Non-traumatic, Thoracic and/or Lumbar-Sacral – suspect cardiac or vascular
etiology.
Back Pain, Non-traumatic, Thoracic and/or Lumbar-Sacral – sudden onset new
neurologic symptoms.
Poisons Ingested, Injected, Inhaled, Absorbed – adverse drug reaction, poison exposure.
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Severe Alcohol Intoxication – airway may or may not be at risk, pharmacology/cardiac
intervention may be required.
Pregnancy Complication/Childbirth/Labor.
Psychiatric/Behavioral – abnormal mental status, drug withdrawal (disoriented, DT’s,
withdrawal symptoms).
Severe Dehydration – nausea and vomiting, diarrhea, severe and incapacitating resulting
in severe dehydration.
Unconscious, Fainting, Syncope, Near Syncope, Weakness or Dizziness.
NORMALLY RECOGNIZED ALS EMERGENCY CONDITIONS – TRAUMATIC:
 Major Trauma – with one of the following: GCS <14, systolic BP <90, RR <10 or >29,
penetration injuries to head, neck, torso; flail chest; combination of trauma and burns;
two (2) or more long bone fractures; or skull fracture.
 Other Trauma – need to monitor or maintain airway (decreased LOC, bleeding into
airway, head, face, neck trauma).
 Other Trauma – Major Bleeding – (uncontrolled or significant bleeding).
 Other Trauma – Amputation – arm or hand (partial or complete).
 Other Trauma – Amputation – leg or foot (partial or complete).
 Other Trauma – Closed – suspected internal, head, chest or abdominal injuries.
 Other Trauma – Open – suspected internal, head, chest or abdominal injuries (open
head injury, gunshot, stab, or penetration).
 Burns – Major – (partial thickness >10 % total body surface area; face, hands, feet,
genitalia, perineum, 3rd degree burns).
 Animal Bites, Stings, Envenomation – (significant face, neck, trunk and extremity
involvement; other emergency conditions).
 Lightning.
 Electrocution.
 Near Drowning.
 Sexual Assault – with major injuries.
NORMALLY RECOGNIZED ALS NON-EMERGENCY CONDITIONS:
 Cardiac/Hemodynamic Monitoring Required En Route – expectation monitoring is
needed before/after transport
 Advanced Airway Management – ventilator dependent, apnea monitor, possible
intubation needed, deep suction.
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Chemical Restraint – medication administered due to danger to physical safety or
patient or others.
NORMALLY RECOGNIZED BLS EMERGENCY CONDITIONS – NON-TRAUMATIC:
 Abdominal Pain – without other signs or symptoms.
 Allergic Reaction – Non-life-threatening – hives, itching, rash, slow onset, local swelling,
redness.
 Cold Exposure – with symptoms (shivering, superficial frost bite, and other emergency
conditions).
 Eye Symptoms, Non-traumatic – acute vision loss and/or severe pain.
 Heat exposure, Non-life-threatening – muscle cramps, profuse sweating, fatigue.
 Infectious Disease Requiring Isolation Procedures/Public Health Risk.
 Medical Device Failure – health maintenance device failures that cannot be resolved on
location (oxygen, ortho device).
 Alcohol Intoxication or Drug Overdose (Suspected) – unable to care for self, no airway
compromise.
 Post-operative Procedure Complications – non-life-threatening.
 Psychiatric/Behavioral – threat to self or others, acute episode or exacerbation or
paranoia, disruptive behavior.
 Sick Person – Fever – (with headache, stiff neck, suspected spinal meningitis).
NORMALLY RECOGNIZED BLS EMERGENCY CONDITIONS – TRAUMATIC:
 Other Trauma – suspected fracture, dislocation requiring splinting/immobilization (long
bones, joints, spinal).
 Other Trauma – penetrating extremity injuries (isolated with bleeding stopped and good
SMC’s).
 Other Trauma – Amputation – digits (fingers).
 Other Trauma – Amputation – digits (toes).
 Burns – minor
 Animal Bites/Sting/Envenomation – local pain and swelling or special handling
considerations.
 Eye Injuries – acute vision loss or blurring, severe pain or chemical exposure,
penetrating, lid lacerations.
 Sexual Assault – with minor or no injuries.
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NORMALLY RECOGNIZED BLS NON-EMERGENCY CONDITIONS:
 Suctioning Required En Route, Need for Oxygen Therapy or IV Fluid Management.
 Airway Control/Position Required En Route.
 Third Party Assistance Attendant Required to Apply, Administer or Regulate or Adjust
Oxygen En Route, (Does not apply to patient capable of self-administration of portable
or home oxygen).
 Patient Safety – Danger to self or others – in restraints.
 Patient Safety – Danger to self or others – monitoring (patient requires monitoring for
safety).
 Patient Safety – Danger to self or others – seclusion (flight risk) – attendant required so
patient does not exit ambulance.
 Patient Safety – Risk of falling off of wheelchair or stretcher while in motion, (patients
physical condition is such that patient risks injury during vehicle movement despite
restraints).
 Special Handling – Isolation required en route (communicable diseases, haz-mat
exposure).
 Special Handling Required to Monitor Orthopedic Device or Reduce pain En Route –
(halotraction, pins, and traction).
 Special Handling En Route – Positioning Requires Specialized Handling – (decubitus
ulcers, contractures).
TRANSPORTATION INDICATORS:
 Interfacility Transport – Certified interfacility transfer to a higher level of care.
 Interfacility Transport – Service not available at original facility.
 Medically Necessary Transport (but not to the nearest facility) – Facility is on divert
status; Service is not available at time of transport; [closest facility which will accept the
patient or their insurance provider].
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