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Ambulance Services: Incomplete Documentation

June 3, 2014
FROM:     CGS Administrators, LLC (CGS)
RE:          Ambulance Services: Incomplete Documentation

This article highlights current Comprehensive Error Rate Testing (CERT) denials for Ambulance Services. In all of these instances, the reason for denial was incomplete documentation, even after multiple attempts were made to obtain more information. Although your organization may not have had claims denied for this reason, CGS strongly encourages all ambulance providers to review these examples and be aware of common documentation errors.

  1. Missing Physician Certification Statement (PCS) for non-emergent BLS transport, or documentation of attempts to obtain certification for submitted date of service 09/21/2012. Received the transport record only. The CERT contractor requested additional documents; however, no further documentation was received.
  2. Submitted BLS ambulance service with HCPCS modifier EJ modifier- residence/ domiciliary to non hospital based dialysis) and 3 units for mileage. Missing the ambulance record that contains the pickup address and the destination address and the total loaded miles for the transport to the Dialysis Center. Submitted documentation consists of ambulance transport record, unsigned Patient Evaluation Form for 01/08/2013 (after date of service), billing form, beneficiary signed consent, Physicians Certification Statement for ambulance transport for dialysis which is signed 09/15/12 (for 90 days). CGS called the provider in order to obtain documentation to support the pickup point with full address and the delivery address as well as the mileage billed. No documentation to support addresses for pickup and destination was submitted.
  3. This claim was submitted for Ambulance Service, Basic Life Support with HCPCS modifier RH for date of service 09/29/2012. Missing documentation to support why patient was transported by ambulance for a non-emergent problem and why other means of transportation was not used. Documentation received initially includes hospital face sheet and EMS Report for 09/29/2012 which documents chief complaint: constipated, paid. Findings: "32 y/o male patient met us at the door to his apartment. Patient stated he had not had a bowel movement for at least a day and that he had lower right quadrant abdominal pain… felt he was constipated after having difficulty producing stool." The CERT contractor requested additional documentation and received a duplicate EMS report and ED note stating: "32 y/o male presents with constipation. He is seen here frequently for constipation and urinary retention. He has no abdominal pain at this time. There is no nausea, vomiting, diarrhea or GI bleed." There was inadequate documentation to support medical necessity of the billed service.
  4. Submitted basic life support emergency ambulance transport service with HCPCS modifier RH for date of service 11/10/2012. Missing copy of the beneficiary's signature to authorize accepting of assignment and claim submission for this date of service, or that of his or her representative if the beneficiary was unable to sign the claim form; and authenticated ambulance transport record for submitted date of service supporting BLS emergency ambulance transport. Submitted records include unsigned transport data flow sheets dated 11/09/2012 and 11/10/2012, beneficiary's name not listed. The CERT contractor requested additional documentation; none was submitted. Documentation is insufficient to support this claim per Medicare guidelines.

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