Understanding Medicare Part B and Ambulance Services

Ambulance Coverage

To be covered, ambulance services must be both reasonable, as well as medically necessary.

Medical necessity is established when the patient's condition is such that any other means of transportation is contraindicated. In other words, the patient could not be transported by any other means of transportation without endangering their health. If the patient could be transported by means other than an ambulance, e.g. wheelchair van, car, taxi, etc. without endangering the patient's health, then medical necessity does not exist. It does not make a difference whether or not the other means of transportation is actually available.

Medical necessity is determined based on the condition of the patient at the time of service. Medical necessity is presumed met if the patient:

was transported in an emergency situation, e.g.: as a result of an accident, injury, or acute illness, or
needed to be restrained, or
was unconscious or in shock, or
required oxygen or other emergency treatment on the way to his/her destination, or
had to remain immobile because of a fracture that had not been set or the possibility of a fracture, or
sustained an acute stroke or myocardial infarction, or
was experiencing severe hemorrhage, or
was bed confined before and after the ambulance trip, or
could be moved only by stretcher.

Emergency Definition

An emergency is defined as the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonable be expected to result in:

placing the patient's health in serious jeopardy;
serious impairment to bodily functions;
serious dysfunction of any bodily organ or part.

Conditions not meeting the above definition are considered non-emergencies.

Bed Confined Definition

A patient is considered to be bed confined only if they are:

unable to get up from bed without assistance, and
unable to ambulate, and
unable to sit in a chair or wheelchair.

Physician Certification

For scheduled non-emergency transportation of patients who have Medicare and are under the direct care of a physician, we must obtain a Physician Certification Statement signed by the attending physician before the transport, certifying that the ambulance was medically necessary. "Scheduled is defined as 24 hours or more prior to the transport."

A Physician Certification Statement is also required for unscheduled non-emergency transportation of patients who have Medicare, when the patient is under the direct care of a physician. In these situations, we have up to 48 hours after the time of the transport to obtain the Physician Certification Statement.

Once the Physician Certification Statement is obtained it is valid for 60 days for the same condition. If the patient is transported for a different condition during this 60 day period a new Physician Certification Statement must be obtained.

"Under the direct care of a physician" means the physician is responsible for supervising the medical care of the patient, including reviewing the program of care, ordering medications, monitoring changes in status and signing all orders. This is very helpful as it excludes most patients at home or in a facility other than an SNF or hospital and, therefore, the PCS will not be needed for them.

Non-Covered Services

Medicare will not pay for ambulance services when the patient is transported for one of the following reasons, even if medical necessity exists.

Boarding home to a patient's residence
Hospice to hospice (may be covered under specific circumstances)
Hospital to hospital (may be covered under specific circumstances)
Hospital to radiological clinic
Nursing home to a patient's residence
Nursing home to nursing home
Patient's residence/SNF to a physician's office
Trips from any origination to a funeral home
Trips out of locale to see a physician, or simply because of the patient's preference

Questions concerning Medicare coverage for ambulance services may be directed to Missouri Medicare Services at (314) 212-1800 or (800) 392-3070.