In this post, we will define medical necessity and how the determination of medical necessity is driven by the crew documentation.

CMS (Centers for Medicare & Medicaid Services) defines medical necessity for ambulance transports as when the patient’s condition is such that the use of any other method of transportation is contraindicated. Simply put, the patient could not be transported by any other means without endangering their health or safety.

In order to determine if medical necessity is present for an ambulance transport, the patient’s entire medical condition at the time of transport needs to be evaluated.  To do this, we rely on the crew documentation.

The crew documentation needs to provide basic information regarding the patient’s condition at the time of transport. This would ideally include the following:

  • Chief Complaint – the patient’s stated complaint.
  • Primary Impression – the Medic’s impression of the patient’s medical condition based on the assessment of the patient at that time.
  • Physical Findings – associated with the “head to toe” assessment of the patient to identify any abnormalities or unusual physical findings.
  • Narrative – tells the story of what the Medic sees, hears, is told, performs, and how the patient responds to treatment.
  • Treatment and Response – information about vital signs, treatments provided, and the patient’s response to treatment.
  • Age – in conjunction with other conditions, may be a factor in determining if other forms of transportation are contraindicated.
  • Past Medical History – the medical history of the patient. This can be helpful when the history relates to the patient’s current need for ambulance transport.

This information will provide a clear view of the patient’s condition at the time of transport and assist with understanding whether or not the use of any other method of transportation is contraindicated.

If the crew documentation does not provide enough information to understand the patient’s condition at the time of transport, then medical necessity cannot be established. The inability to establish medical necessity may have the following impact:

  • Delays when billing the claim, if the crew needs to be contacted to obtain an addendum.
  • Delays in payment from the carrier.
  • Billing the carrier for denial if no addendum can be obtained.
  • Writing off the claim if the patient has Medicaid.

Determining medical necessity is asking if the patient could have been transported by any other means without endangering their health or safety. This question can only be answered by relying on the crew documentation.  If the crew documentation is missing or insufficient, it could have a severe impact on the revenue of the organization.

Missing or insufficient crew documentation can also have a significant impact on the patient. According to Credit Karma, in October 2020, 20 million Americans held $45 Billion of medical debt in collections, averaging $2,200 per person. If the documentation is not sufficient to meet medical necessity criteria, the patient is then responsible for the bill. If the patient is unable to pay for their medical care, the bill ends up in collections. Having a bill in collections has a significant impact on patients’ lives. Their credit has now been affected. Buying a new car, owning a home, obtaining a bank account, or leasing a better apartment are all affected by your credit score.  Through no fault of their own, the patients are receiving bills for ambulance transports that would have been covered by their insurance, if documented accurately.

If the crew submitted insufficient documentation, or documentation is missing, it could have a severe impact not just on an organization, but on the patient’s financial future.