Ambulance Decision Tree
This set of questions will assist with review of Basic Life Support Documentation requirements:
1. Is this a patient that is being transported to or from a hospital, dialysis center, rehab center,or residence?
1a. Is this patient transported to a physician's office or diagnostic center?
Yes No
2. Is there a Beneficiary or representative signature accepting assignment and submitting claim to Medicare?
Yes No
3. Medical Necessity: Does the patient’s condition show an injury or illness that prevents transportation by other means?
Yes No
4. Is there a signature, with credentials, of the crew member responsible for the care of the beneficiary?
Yes No
5. Is there any additional documentation incorporated into the certifying physician’s certification statement (PCS)? Please note any incorporation of documentation must be corroborated by the submitted clinical/medical documentation
Yes No
6. Does the documentation support the mileage billed?
Yes No
This set of questions will assist with review of Transportation requirements:
7. Select Type of Transport (Emergent examples: potential injury, broken bone, neurological; Non-Emergent examples:…)
Emergent Non-Emergent
Medicare considers an emergency to be any situation when health is in serious danger and the beneficiary cannot be transported safely by other means. If the trip is scheduled when health is not in immediate danger, it is not considered an emergency.
8. Does the physician/facility documentation indicate one of the following? (Please note clinical/medical documentation must support any of the described scenarios)
- Patient need to be restrained to protect self or others from injury
- A need for oxygen or other emergency treatment during transport to nearby facility (monitoring based on oxygen required; oxygen that needs to be titrated based on patient O2 sats or condition.)
- Patient unconscious, in shock, confused, combative or with mental diagnosis that needs to be supervised
- Patient exhibit signs and symptoms of acute respiratory distress or cardiac distress such as shortness of breath or chest pain
- Patient exhibit signs and symptoms that indicate the possibility of acute stroke
- Patient needed to remain immobile due to injury or condition
- Patient experiencing severe hemorrhage
- Transport due to bedbound status / unable to sit up in wheelchair for length of trip
Yes No
9: Does the physician/facility documentation indicate one of the following?
- Transport due to bedbound status / unable to sit up in wheelchair for length of trip
- Patient need to be restrained to protect self or others from injury
- Patient unconscious, confused, combative or with mental diagnosis that needs to be supervised
- A need for oxygen or other emergency treatment during transport to nearby facility (oxygen that needs to be titrated based on patient O2 sats or condition)
Yes No
10: Was the transport Repetitive or Non Repetitive?
Repetitive Non-Repititive
11: Does the physician/facility documentation support all of the following:
- Is the transport for dialysis or scheduled repetitive procedure?
- Is the PCS signed by the primary MD or Nephrologist?
- Has PCS been signed and dated no earlier than 60 days before transport?
- Does PCS documentation correlate with documentation in transport note? Please note any incorporation of documentation must be corroborated by the submitted clinical/medical documentation
Yes No
For additional resources, see Part B Medical Review.
11: Does the physician/facility documentation support all of the following:
- Is the transport for non-scheduled or scheduled non-repetitive?
- Is PCS signed by NP, MD, Discharge Planner or RN before furnishing the service?
- Has the PCS/Order been signed within 48 hours after transport?
- Does PCS documentation correlate with documentation in transport note? Please note any incorporation of documentation must be corroborated by the submitted clinical/medical documentation
Yes No
For additional resources, see Part B Medical Review.
8: Does the physician/facility documentation indicate one of the following?
- Transport due to bedbound status / unable to sit up in wheelchair for length of trip
- Patient need to be restrained to protect self or others from injury
- Patient unconscious, confused, combative or with mental diagnosis that needs to be supervised
- A need for oxygen or other emergency treatment during transport to nearby facility (oxygen that needs to be titrated based on patient O2 sats or condition)
Yes No
9: Was the transport Repetitive or Non Repetitive?
Repetitive Non-Repititive
10: Does the physician/facility documentation support all of the following:
- Is the transport for dialysis or scheduled repetitive procedure?
- Is the PCS signed by the primary MD or Nephrologist?
- Has PCS been signed and dated no earlier than 60 days before transport?
- Does PCS documentation correlate with documentation in transport note? Please note any incorporation of documentation must be corroborated by the submitted clinical/medical documentation
Yes No
For additional resources, see Part B Medical Review.
10: Does the physician/facility documentation support all of the following:
- Is the transport for non-scheduled or scheduled non-repetitive?
- Is PCS signed by NP, MD, Discharge Planner or RN before furnishing the service?
- Has the PCS/Order been signed within 48 hours after transport?
- Does PCS documentation correlate with documentation in transport note? Please note any incorporation of documentation must be corroborated by the submitted clinical/medical documentation
Yes No
For additional resources, see Part B Medical Review.
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