As a member of the Medicare Provider Outreach and Education Advisory Group and having visited ambulance services, hospitals, and nursing facilities all across the state of Kentucky, there is one thing I have learned. There is a lot of confusion around the Physician’s Certification Statement (PCS). This confusion is shared among the Ambulance Services, Hospitals, Nursing Homes, Doctor offices, and pretty much everyone. It appears no one escapes the confusion surrounding the PCS.
So, let’s start at the beginning and look at what the PCS is. Information regarding the PCS can be found in the Code of Federal Regulations, Title 42 subsection 410.40(d). This regulation in both (2) and (3) refers to the ambulance service needing to “….obtains a written order from the beneficiary’s attending physician certifying that the medical necessity requirements of paragraph (d)(1) of this section are met…”. Therefore, the PCS is the Physician’s Order certifying that the Medical Necessity of the ambulance transport is met. It is important to note that the PCS is only required for non-emergent transports. A PCS is NOT required for emergency transports. It appears that some facilities provide the PCS’s for emergency and non-emergency transports. Another extremely important fact causing the confusion over the PCS is that since it is the “Physician’s Order” for the ambulance service, the PCS belongs to the facility ordering the transport and NOT to the ambulance service. Therefore, it is the facility’s responsibility to provide a copy of the form to the ambulance crew, and the original goes into the Patient’s file. Whatever is on the PCS needs to match that patient’s medical record at the ordering facility. For example, if the medical necessity indicated on the PCS is bed confinement it would be imperative that the patient’s history match that the patient was unable to walk, unable to get out of bed without assistance, and unable to safely sit in a wheelchair before and after the ambulance transport.
An article by Derek Gilliam on Saturday, May 2, 2015 demonstrates the significant pitfalls with the PCS’s and states the following:
“A federal prosecutor in Jacksonville has developed a legal strategy that could have hospitals across the country on the hook for billions of dollars in unnecessary ambulance services. U.S. Attorney A. Lee Bentley II said a group of Jacksonville hospitals has agreed to reimburse the federal government for ambulance companies’ inappropriate billing despite the hospitals not receiving direct financial gain. The legal strategy allows the government to sue because the hospitals were the cause of the fraudulent billing by calling the ambulance services to take patients from the hospital to their residence and provided the necessary forms to bill federal health care programs, according to the U.S. Attorney’s Office. The hospitals agreed to reimburse the government 6.25 million for non-emergency ambulance rides.”
“The government’s position essentially forces hospitals to become knowledgeable about complicated federal regulations applicable to ambulance companies,…”
Although the article was about hospitals and non-emergency transports to residence, we can reasonably assume that any facility ordering a non-emergency ambulance service going anywhere is subject to this same scrutiny.
Now let’s talk about who can sign a PCS. For non-repetitive non-emergent transports, a MD/DO, RN, PA, CNS, NP, and a discharge planner (who has knowledge of the patient) are considered authorized signers of the PCS. Note that a LPN CANNOT sign this form. I see LPN’s signatures and credentials on this form all the time and unfortunately, it makes this an invalid form. It should be noted however, for repetitive (3 times in a 10 day period or once a week for 3 weeks or more for the same reason) non-emergent transports, only the attending physician that is ordering the ambulance can sign the PCS and this PCS is good for 60 days.
The ambulance service needs to make sure it is documenting medical necessity in its patient care report and not only relying on the PCS. In a perfect world the PCS and the documentation of the ambulance service would closely match and provide the necessity of the transport by ambulance. But we know we do not live in a perfect world. If auditors were to come into an ambulance service and audit its documentation for medical necessity, they would not go to the PCS, but would go to the patient care report. If the facts indicate, then it is appropriate for the patient care report to contradict the PCS. So, if the PCS states that the patient is bed-confined and you find the patient sitting in a wheel chair, or ambulatory to stretcher, that’s what you document. Although it is the crew’s responsibility to assess the patient according to published guidelines and document in an objective, accurate manor, the crews should NEVER be told to add or remove information in order for the transport to be billed.
Philip Y. Horn
Medical Compliance Services, Inc.
Cell: 859-492-9377 email@example.com