Medicare Contractor Reviews

  Medicare Contractor Reviews

Centers for Medicare and Medicaid Services (CMS) recently initiated a CERT (Comprehensive Error Rate Testing) Review for ambulance claims.  Many of the contractors will be participating in this CERT review by requesting documentation for randomly selected claims.  The documentation will be reviewed to determine if the transport meets medical necessity, if the destination represents a covered service, if the level of care provided is fully documented and if the appropriate signatures are in place.

When a claim is randomly selected for prepayment review, the proper documentation must be submitted to the Contractor for review.  Rather than the typical 14 payment floor, these claims will require additional review and may take as long as 30-60 days in order for payment to be issued.  If the claim is denied by the Contractor, the claim must be appealed that will further delay the payment cycle.

Contractor Notifications

The attached links are articles from some of the Medicare Contractors notifying Ambulance Providers of their intent to extensively review ambulance claims.

Cahaba Government Services

CIGNA Government Services

Keep in mind that these contractors must review these claims according to Federal Guidelines issued by CMS.  There are some references in these articles that are not in compliance with Federal Regulations.  For example, one article states that Lights and Sirens are an indication of whether an ambulance transport can be billed as an emergency transport.  This is contradictory to the Federal Guidelines issued by CMS.  It is important that any denials are reviewed and appealed to the highest level applicable when they are denied incorrectly.

Below is a recent newsletter published by EMS|MC to share with your staff as it relates to Patient Care Report Documentation and Medical Necessity.

Medical Condition Codes

Centers for Medicare and Medicaid Services (CMS) introduced Medical Condition Codes in 2007 as a primarily educational guideline. The Condition Codes were implemented to assist ambulance agencies to communicate the patient’s condition to Medicare contractors. While the use of the condition code was said to be voluntary and does not guarantee payment of the ambulance service; they will provide a standard benchmark in which we can identify the CMS “intent” for medical necessity. A list of commonly used Medical Condition Codes can be found on page 3 of this article. The complete list can be found at: Medicare Condition Codes page 51

Establishing Medical Necessity

In many cases, the ambulance transport may be medically necessary; however, the Patient Care Report (PCR) may not be sufficiently documented to the patient’s specific condition in order to determine whether it warranted medical necessity. Based on the patient’s chief complaint, the PCR should provide a detailed assessment of the organ system or area in which the complaint exists. For example, a chief complaint of abdominal pain should include a detailed assessment of the abdomen region and any associated signs and symptoms. If the chief complaint is related to pain, the documentation should reflect the location, severity, duration, onset, and aggravating and/or alleviating factors of the pain.  In addition to the chief complaint, the PCR should provide any associated signs and symptoms and past medical history as applicable.

Narrative Fields

With the evolution of Electronic Patient Care Report (ePCR) documentation systems, the standard in ePCR technology allows for mandatory specific data fields that allow the paramedic to document the patient’s medical condition, assessment, and treatment provided, thus requiring less of a free form narrative field.  However, many of the contractors are denying these claims as the ePCR failed to paint a detailed picture of the medical necessity of the ambulance service.   Crews should be required to write a free form narrative to provide specific documentation of the patient’s medical condition in greater detail than what can be captured in the pull down menus and specific treatment fields.


Chief Complaint: Abdominal Pain

Secondary Compliant: Nausea and Vomiting

Abdomen Exam: Soft, Tenderness, Guarding upon Exam

Narrative Field

Upon arrival, witnessed patient lying on bed complaining of abdominal pain. The patient describes the pain as a severe, jabbing pain, and rates it as a 7/10 on pain scale. The patient began experiencing abdominal pain approx. 12 hours ago along with nausea and vomiting. The pain has worsening of symptoms over the past 2 hours. Upon examination, the abdomen was found to be tender upon palpation and witnessed the patient guarding upon exam.

Do I Really Need to Document That?

Keep in mind that your audience may include health insurance claims processers, CMS policy staff, OIG auditors and others that do not have EMS experience. These auditors are trained to review the patient care report and determine whether medical necessity exists based solely on the documentation contained in the report. Typical treatment provided within your EMS protocols may seem to be redundant or self explanatory; however, the insurance companies will not assume that an assessment or treatment was provided unless it was actually documented.

Imagine reading the Patient Care Report (PCR) several years from now. Based on the documentation alone, would you be able to give an account of the patient’s medical condition, the assessment and treatment interventions provided and determine the medical necessity of the transport. Upon a government audit, the documentation may be reviewed several years after the service took place. Only the information that is clearly documented will be used to prove the service warranted payment.

 Commonly Used Medical Condition Codes

Condition(General) Comments and Examples(not all inclusive)
Severe Abdominal Pain nausea, vomiting, fainting,   pulsatile mass, distention, rigidity, tenderness upon exam, guarding
Abnormal Cardiac Rhythm Bradycardia, junctional and   ventricular blocks, non-sinus tachycardia’s, PVC’s >6, bi- and trigeminy,   ventricular tachycardia, ventricular fibrillation, atrial flutter, PEA,   asystole, AICD/AED fired
Altered level of consciousness   (nontraumatic) Acute condition with Glascow Coma   Scale < 15.
Chest Pain Dull, severe, crushing,   substernal, epigastric, left sided chest pain associated with pain of the   jaw, left arm, neck, back and nausea, vomiting, palpitations, pallor,   diaphoresis, decreased LOC
Cardiac symptoms other than chest   pain Persistent nausea and vomiting,   weakness, hiccups, pleuritic pain, feeling of impending doom, and other   emergency conditions
Convulsions, seizures Seizing, immediate post-seizure,   postictal, or at risk of seizure and requires medical monitoring/observation.
Difficulty Breathing/Respiratory   Arrest Apnea, hypoventilation requiring   ventilatory assistance and airway management.
Neurologic Distress Facial drooping, loss of vision,   aphasias, difficulty swallowing, numbness, tingling extremity, stupor,   delirium, confusion, hallucinations, paralysis, paresis, abnormal movements,   vertigo, unsteady gait/balance, slurred speech, unable to speak
Pain, Severe not otherwise   specified Acute onset, unable to ambulate or   sit due to intensity of pain. If Pain is the reason for transport, use   severity scale (7-10 for severe pain) or patient receiving pharmological   intervention.
Alcohol Intoxication Unable to care for self and unable   to ambulate.
Severe Alcohol Intoxication Airway may or may not be at risk.   Pharmalogical intervention or cardiac monitoring may be needed. Decreased   level of consciousness potentially resulting in airway compromise.
Psychiatric/Behavioral Abnormal mental status, drug   withdrawal, disoriented, DTs, withdrawal symptoms, suicidal, homicidal, or   violent, threat to self or others, acute episode or exacerbation of paranoia,   or disruptive behavior
Unconscious, fainting, syncope,   near syncope, weakness, or dizziness Transient unconscious episode or   found unconscious. Acute episode or exacerbation.
  • Trauma to head, face, or neck
  • Major bleeding, uncontrolled        or significant blood loss
  • Suspected        Fracture/dislocation requiring splinting/immobilization
  • Suspected internal, head,        chest or abdominal injuries


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