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Responsibility of Providing a Properly Executed Physician Certification Statement/Certificate of Medically Necessity

Recent National Government Services educational efforts have highlighted an issue between facilities and the ambulance providers that serve them in regard to the PCS/CMN.

Although the responsibility of providing a properly executed PCS/CMN falls squarely on the ambulance provider, experience suggests that the source of this information is largely within the authority of the originating facility and its staff.

NGS reviewers repeatedly find it is difficult to identify the name of the certifying practitioner and their professional status due to illegibility and missing credential(s) within the PCS/CMN. While educational calls by our Medical Review and Provider Outreach staff are targeting the ambulance providers, a frequently repeated theme is that the provision of this information is “out of our hands.” It is imperative that the PCS/CMN includes a legible signature and professional credential(s) of the authorizing practitioner along with the date it was signed. If the signature is illegible, the practitioner’s typed or printed name should appear under the signature so that the identity of the author is absolutely clear. In nonemergent transport situations, transport by ambulance is appropriate if:

  1. the beneficiary is bed confined and it is documented that the beneficiary’s condition is such that other methods of transportation are contraindicated,
  2. his or her medical condition, regardless of bed confinement is such that transportation is medically required.
Certification is Required CertificationType Who May Sign the Certification Timeframe
Nonemergency, scheduled, repetitive ambulance services Attending Physician The physician’s order must be dated no earlier than 60 days before the date the service is furnished.

Other Information/Resources

Certification is Required Certification Type Who May Sign the Certification Timeframe
Nonemergency ambulance services that are either unscheduled or that are scheduled on a nonrepetitive basis. Resident of a facility under a physician’s care Physician (MD)
  • PA
  • NP
  • CNS
  • RN or discharge planner
The physician’s order must be obtained within 48 hours of the transport.

Other Information/Resources

If the ambulance provider or supplier is unable to obtain the required certification within 21 calendar days following the date of the service, the ambulance supplier must document its attempts to obtain the requested certification and may then submit the claim.

Acceptable documentation includes a signed returned receipt from the U.S. Postal Service or other similar service that evidences the ambulance supplier attempted to obtain the required signature from the beneficiary’s attending physician or other individual named above.

It is of value to review 42 CFR Section 410.40[d], CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 10 – Ambulance Services and CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 15 – Ambulance.

NGS Provider Outreach and Education makes a consistent effort to have routine meetings and calls with the ambulance associations in our jurisdictions. Their experience suggests that when facilities and the ambulance providers schedule routine meetings and calls, more correct claims processing occurs, and ultimately, a better and safer outcome for the patient is assured. Please work together as NGS proceeds with its targeted ambulance review.

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Responsibility of Providing a Properly Executed Physician Certification Statement/Certificate of Medically Necessity
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