Start your PCR narrative with a description of the condition of the patient as called in to dispatch.
From a billing perspective, the most severe condition encountered may be the one described by the caller to the 911 dispatcher. The regulations allow for billing using the most severe condition, even if that is not what is found on scene. The rational is, billing for the level of skill required and used to assess the patient condition (confirm or rule out..) that was called in to the 911 dispatcher. In general, the need for an ALS Assessment is determined at the time of dispatch based on the condition of the patient as reported to dispatch by the 911 caller. Therefore, it is very important that the condition of the patient, as called in to dispatch be both recorded in the dispatch log and used in the PCR narrative by the responding crew.
The following are two items that I like to remind all clients about periodically. They are very important compliance items for your ambulance service:
RULE: BENEFICIARY SIGNATURE REQUIREMENT
On November 1, 2007, CMS posted the Final Rule for physicians and other suppliers. Under this rule is the Beneficiary Signature Requirement for ambulance transports. Medicare regulations, specifically 42 C.F.R. §424.36, require a patient’s signature on a claim, unless the patient has died or the ambulance provider/supplier can qualify for one of a number of listed exceptions. As a Medicare participating provider, the ambulance service is obligated to understand and comply with this requirement for all patient care reports used for billing Medicare.
AMBULANCE PROVIDER LICENSURE AND CREW MEMBER CERTIFICATION
In order for your service to qualify for reimbursement by Medicare and other payers, your service must be licensed and all crew members must certified by your state. As a Medicare participating provider, the ambulance service is obligated to understand and comply with this requirement.