Another important aspect of good documentation as a whole is medical necessity.  Medical necessity plays a huge role in the reimbursement your department or agency will receive from Medicare and Medicaid as well as a large role in how your department preforms in an audit. For ambulance transports, Medicare defines medical necessity as “the use of other methods of transportation is contraindicated by the individual’s condition.” Your documentation needs to display why the patient’s transport was medically necessary or Medicare will not be reimbursing your department for the trip. It’s crucial to explain that there was no other option and the patient could have been harmed by being moved in any other way.

The existence of medical necessity impacts essentially everything dealing with the documentation process. It should really serve as the backbone of your report if you’re transporting someone. Why was this trip needed? Your whole report should reinforce why what happened needed to happen. Keep this in mind and you’ll help your department stay in the best standing possible with CMS and other regulatory entities.

As EMS providers, we have a responsibility to provide accurate, complete and honest documentation to Medicare. Again, it’s important to provide narrative examples for when your reports inevitably are under review. Make the report as detail laden and complete as possible. Elaborating on the medical necessity of the run helps keep your department in overall compliance with CMS.

Always remember, your report becomes part of the patient’s medical history. So, use as much detail as possible as this could have an effect on future care and diagnosis. Try to avoid using generic phrases like “bed-ridden” and really explain the situation. Why could they not get out of bed? Unfortunately, just because someone calls 911 does not automatically make the trip medically necessary. These are the types of details that Medicare really wants to see.

For EMS providers, your first priority is always your patient. While proper documentation may seem to be a less pressing part of your patient care responsibilities, it serves as an extremely important record for that patient as well as the overall wellbeing of your department or agency. So, keep giving your patients the best care possible, and remember that documenting medical necessity is part of that overall care process!

If you’re interested in a little more detail on this subject, ask your biller, or check out the Medical Ambulance Transports guide from CMS.

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