Medical Necessity

The Medicare Benefit Policy Manual Chapter 10 – states “…… The ambulance service must meet all program coverage criteria in order for payment to be made.” So what entails “program coverage criteria”? First of all there must be a transport, it must be a covered service, and it must be a covered destination. There are two other elements that are required, REASONABLENESS for the ambulance service AND MEDICAL NECESSITY. It appears that a lot of EMS personnel get these two elements confused. REASONABLENSS IS, 10.2.2 “…..the LEVEL of medically necessary services actually furnished. That is payment is based on the level of service furnished”…. So the level of service needs to be “REASONABLE”. Now, that “reasonable” service must also be medically necessary”. So what is Medical Necessity? 10.2.1 “Medical Necessity is established when the patient’s condition is such that use of any other method of transportation is contraindicated. In any case in which some means of transportation other than an ambulance could be used without endangering the individual’s health, whether or not such other transportation is actually available, no payment may be made for the ambulance services.” So, let’s take a more in depth look at these two factors of the ambulance transport. A patient is being transported for Dialysis – we know that the level of service for most dialysis patients are going to be a BLS transport – therefore, does DIALYSIS meet the Reasonableness or the Necessity for the Service? About 99% of ambulance crew will answer this, Dialysis meets Medical Necessity. However, the actual answer is dialysis meets the reasonableness for the BLS transport. Medical Necessity needs to be documented in regards to the patient’s condition at the time of transport that requires an ambulance. Therefore, if after assessment, the crew determines the patient is not alert and oriented to person, time, place, etc., then the confusion level of the patient would meet the medical necessity. There has been a lot of issues with crews documenting the medical necessity of the ambulance transport as dialysis. The ambulance service then fails to provide medical necessity and could be required to pay Medicare back any payment made on the transport. Make sure you are providing the correct level of service (reasonableness) and the condition of the patient that requires an ambulance to transport them (medical necessity) in the narrative of every transport to ensure payment on transports that meet all other program criteria will not be required to be refunded if ever audited.


-Phil Horn