PCS Form Requirements for EMS Transport

Federal regulation 42 CFR 410.40 (COVERAGE OF AMBULANCE SERVICES) specifies how ambulance services are billed to Medicare/Medicaid, including the requirements for a "Physician Certification Statement" -- better known as a PCS document.

These regulations are expressed in AngelTrack's ePCS form and in the Prior Authorization Queue's report of missing PCS forms.

PCS Form Basics

The "Physician Certification Statement" form is used to prove medical necessity for stretcher transport.

PCS forms are required for non-emergent stretcher transports that will be covered by Medicare or by other federally-funded problems... including Medicare HMOs administered by commercial carriers.

PCS forms are not required by commercial insurance carriers (other than Medicare HMO plans). That said, a PCS form would be an effective counterargument if a commercial carrier were to deny an insurance claim based on medical necessity.

And just to repeat: they are never required for emergent transport.

AngelTrack will automatically prompt your crews to collect a PCS signature while on-scene, whenever the patient's insurance is unknown or is known to be Medicare.

There are many rules concerning who can sign the PCS form, and how long the form remains valid. Keep reading.

Doctor signature

Federal Regulations

First, the official regulations. CFR section 410.40 lays out the cases where PCS documents are required (as of 2014 publication):

  1. Medical necessity requirements

    1. [...]
    2. Special rule for nonemergency, scheduled, repetitive ambulance services.

      1. Medicare covers medically necessary nonemergency, scheduled, repetitive ambulance services if the ambulance provider or supplier, before furnishing the service to the beneficiary, 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. The physician’s order must be dated no earlier than 60 days before the date the service is furnished.
      2. In all cases, the provider or supplier must keep appropriate documentation on file and, upon request, present it to the contractor. The presence of the signed physician certification statement does not alone demonstrate that the ambulance transport was medically necessary. All other program criteria must be met in order for payment to be made.
    3. Special rule for nonemergency ambulance services that are either unscheduled or that are scheduled on a nonrepetitive basis.

      Medicare covers medically necessary nonemergency ambulance services that are either unscheduled or that are scheduled on a nonrepetitive basis under one of the following circumstances:

      1. For a resident of a facility who is under the care of a physician if the ambulance provider or supplier obtains a written order from the beneficiary's attending physician, within 48 hours after the transport, certifying that the medical necessity requirements of paragraph (d)(1) of this section are met.
      2. For a beneficiary residing at home or in a facility who is not under the direct care of a physician. A physician certification is not required.
      3. If the ambulance provider or supplier is unable to obtain a signed physician certification statement from the beneficiary's attending physician, a signed certification statement must be obtained from either the physician assistant (PA), nurse practitioner (NP), clinical nurse specialist (CNS), registered nurse (RN), or discharge planner, who has personal knowledge of the beneficiary's condition at the time the ambulance transport is ordered or the service is furnished. This individual must be employed by the beneficiary's attending physician or by the hospital or facility where the beneficiary is being treated and from which the beneficiary is transported. Medicare regulations for PAs, NPs, and CNSs apply and all applicable State licensure laws apply; or,
      4. 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 return receipt from the U.S. Postal Service or other similar service that evidences that the ambulance supplier attempted to obtain the required signature from the beneficiary's attending physician or other individual named in paragraph (d)(3)(iii) of this section.
      5. In all cases, the provider or supplier must keep appropriate documentation on file and, upon request, present it to the contractor. The presence of the signed certification statement or signed return receipt does not alone demonstrate that the ambulance transport was medically necessary. All other program criteria must be met in order for payment to be made.

Definition of "repetitive"

You may have noticed the critical term "repetitive" in the regulations. So what exactly is a repetitive transport under the law?

CMS Program Memorandum AB-03-106 defines "repetitive":

A repetitive ambulance service is defined as medically necessary ambulance transportation that is furnished three or more times during a 10-day period or at least once per week for at least three weeks. Dialysis and respiratory therapy are types of treatments for which repetitive ambulance services are often necessary. However, the requirement for submitting the PCS form for repetitive, scheduled, non-emergency ambulance services is based on the quantitative standard (three or more times during a ten-day period or at least once per week for at least three weeks). Similarly, regularly scheduled ambulance services for follow-up visits, whether routine or unexpected, are not "repetitive" for purposes of this requirement unless one of the quantitative standards is met. PCS requirements for other types of ambulance transports are specified in PM AB-03-007.

Definition of "emergency"

Because emergency transports do not require PCS forms, it is important to know exactly what qualifies as emergent transport.

The Medicare Ambulance Transports Guidebook… from the CMS Medicare Learning Network… states:

An emergency response is one that, at the time you are called, you respond immediately. A BLS emergency is an immediate emergency response in which you begin as quickly as possible to take the steps necessary to respond to the call.

So you see, the term "emergency" refers only to the fact that EMS begins to respond immediately. It does not require lights, sirens, speeding, or blasting through busy intersections. It does not even require that an ambulance rolls immediately, if all units are busy. "Emergent" requires only that EMS agrees and intends to respond as soon as they possibly can.

Although the definition of "emergency" does not specify criteria for the patient's condition, or for the type of destination, such criteria are implied by the fact that the patient needs an immediate EMS response. Therefore, if the patient is not in condition yellow or red, or if the destination is not a hospital ER, then be very cautious about dispatching or billing the trip as emergent.

In AngelTrack, the dispatcher indicates the emergence of the response via the priority control:

Dispatch priority control

The control is designed to correspond to the CMS meaning of "emergent". Thus, the "Lower acuity" priority level means EMS is not responding as soon as possible; instead, the patient can wait until all emergent patients have been serviced first.

Executive summary of the regulations

The regulations as written allow for the following types of PCS in the four circumstances of EMS stretcher transport:

Trip type Physician signature Proof of attempt to contact physician PA, NP, CNS, RN, or discharge planner
Non-emergency transport Unscheduled
Scheduled, non-repetitive
Scheduled, repetitive
Emergency transport [No PCS is required]

AngelTrack's built-in ePCS form knows these regulations and will exactly apply them when operating in ☑ Strict mode. We will learn more about AngelTrack's PCS modes further below.

"Painting a Picture"

The problem with the regulations as written is the difficulty of getting in touch with the physicians, and persuading him or her to fill out and sign the necessary forms.

Medicare acknowledged this difficulty and published §410.40(d)(3)(iv) to permit EMS companies to document their attempt to get a PCS signed. The documented attempt is equivalent to a signed PCS form. Unfortunately, this helpful provision does not apply to scheduled repetitive transports, including dialysis and wound care.

So what's an honest EMS company to do?

One approach is called "painting a picture", which means gathering supporting documentation from whichever qualified individuals are available in lieu of the physician. This includes collecting a PCS from a PA, NP, CNS, RN, or discharge planner... even though the regulation does not specifically recognize those signatures on a PCS for a repetitive transport. The goal is to paint the best possible picture of medical justification given the resources available, even though the physician refuses to do their part.

This approach was popularized by the 2012 court case of First Call Ambulance Services, Inc., which provoked Medicare into adding new regulation §410.40(d)(2)(ii), shown above. The new regulation declares that a PCS signed by the patient's physician was not enough to prove medical justification:

"The presence of the signed physician certification statement does not alone demonstrate that the ambulance transport was medically necessary."

With that change, it is more important than ever to collect a variety of documentation -- whether or not the physician does their part. That can include a PCS signature from the PA, NP, CNS, RN, or discharge planner every time the patient travels.

Clear it with your legal team first

Before adopting this approach into your EMS operation, you should consult your legal team and develop your policy for PCS and supporting documentation requirements. Be sure to consult with someone who has experience surviving a Medicare audit and who has been through Prepayment Reviews, who therefore understands the difference between what the CFR says versus what the auditors are actually looking for. For example, even though the CFR says that a PCS signed by an LVN is not sufficient for a repetitive transport, it may nevertheless have value in "painting a picture" of compliance for the auditor.

If your legal counsel gives their blessing to this approach, AngelTrack will help you implement it. Visit the Preferences item under the Settings page and review the options for PCS completion mode, explained just below.

Dealing With Doctors Who Refuse to Sign PCS Forms

A patient's physician is obliged to judge whether the patient requires stretcher transport. This obligation arises naturally and obviously from the physician's duty of care: the patient is counting on the doctor to tell him or her whether stretcher transport is required to protect their health and wellbeing.

If the answer is yes, then the physician is obliged to sign a PCS document saying so. This obligation arises from the following facts:

Doctors are eternally overloaded, and so they sometimes forget about the connection between PCS forms and the patient's welfare. When gently reminded of this connection -- of the two facts above -- a responsible doctor will see that PCS forms are part of the standard of care.

When persuasion fails, there is always certified mail

You may never get the chance to speak with the doctor, to demonstrate that PCS forms are part of the standard of care. When you give up trying to reach the doctor, Medicare has arranged for a fallback plan.

Per §410.40(d)(3)(iv), if you mail a PCS form to a doctor and he or she fails to complete it and return it, your proof of mailing will serve as an alternate PCS form. That means you should send the letter by certified mail, and scan or photograph the envelope before mailing.

Remember, EMS is forbidden from filling out any part of the PCS form; that must be done by the doctor's office. So you must mail them a blank form. Attach a post-it note to the form, giving the patient's name and SSN or DOB.

Keep painting the picture

As noted above, the regulations do not specifically recognize a proof of attempt as a valid PCS when the transports are scheduled and repetitive... such as dialysis treatments. Unfortunately, an uncooperative physician leaves the patient and EMS with no other choice.

In that situation, you will not be able to satisfy the regulations as written. Nevertheless you may be able to satisfy the auditors, by doing all of the following:

  1. Document your attempt to get the PCS signed by the physician.
  2. Before each round trip, have the crew collect a one-shot PCS from an on-scene nurse who has responsibility for the patient.
  3. Have the crew ask the patient (or the patient's family) to ask the physician to sign the form, during his or her next visit. You can even leave a blank paper PCS form with the patient for that purpose. Patients and families will be willing to help when informed that a signed PCS will protect them from receiving a stretcher bill.
  4. Continue attempting to contact the physician, filing away a new proof of attempt every 60 days.

These steps "paint a picture" of an EMS company that seeks compliance every way it can with whatever it's been given.

Using AngelTrack to Document an Attempt

In AngelTrack it is easy to document an unsuccessful attempt to collect a signed PCS form. You will need a scan or photograph of the envelope showing its Certified Mail coupon, plus a scan or photograph of the blank PCS form that was mailed. Attach those two scans to a new electronic document in AngelTrack, using the Patient Document Upload facility under Billing Home.

When creating the document, take care to specify the exact destination approved by the physician (e.g. the exact dialysis facility). For the start date, specify the date you mailed the form to the doctor. For the end date, specify exactly 60 days into the future from the start date.

Once that's done, then your two scans (the envelope and the form) will automatically appear inside the run report for each trip the patient makes to or from the selected destination, within the date range you specified.

Choosing a PCS Completion Mode in AngelTrack

The Preferences page under Settings offers three PCS Completion modes to match your company policy:

Do not change your PCS completion mode without first consulting your legal team and/or someone with experience in demonstrating compliance to a Medicare auditor.

AngelTrack's PCR will guide the crews

Your PCS completion mode setting will be put into practice by AngelTrack's PCR, which uses dark yellow and bright yellow indicators to show the attending that a PCS is requested or demanded, respectively.

To learn more about how the PCR uses color to guide the attending through report completion, read the Report Writing guide.

PCS Coverage Reports

AngelTrack's reports show what fraction of your transports have the necessary PCS, and which do not.

Under Billing Home there are two reports: the general PCS Coverage which shows across-the-board percentages, and the PCS Coverage By Facility which breaks out the percentages by origin facility.

Both reports break out the numbers like this:

Global PCS coverage

"Obtained prior" means the PCS form -- be it electronic, or be it a scanned paper form -- was recorded in AngelTrack prior to the date/time of service. A high number of "obtained prior" PCS forms indicates that your billing office is busy and prudent.

"Obtained after" means the PCS form was recorded in AngelTrack on the day of service or at some point afterward.

The PCS Coverage By Facility report shows you which facilities have the most PCS coverage gaps, so that you can arrange a visit to get caught up:

PCS coverage by facility

The row labelled "[Locations Not Defined as Facilities]" refers to origin addresses that were not stored as facility records in AngelTrack. You can still attach PCS documents to these dispatches, but they cannot be covered by multi-day PCS documents because multi-day PCS documents are indexed by destination facility.

Retroactive PCS Signatures

Federal regulations do not give any guidance for PCS signatures collected after the date of service. Therefore it is up to your region's MAC to publish guidelines about who can sign a retroactive PCS, and how far back in time the form can go.

If in doubt, consult your legal team. If you do not have a legal team, or if your legal team is not experienced in matters of Medicare compliance, then consult Page, Wolfberg, and Wirth EMS Law Firm. AngelTrack LLC has no financial interest in that firm but does rely upon them for legal advice; you should too.

Also keep in mind: just because your MAC does not specifically recognize a retroactive PCS signature, doesn't mean the signature has no value. It can still be part of "painting the picture" of medical necessity, and it can still help signal your organization's positive attitude towards compliance.

Visiting a Facility to Collect Many PCS Signatures At Once

The aforementioned reports will show you which facilities are missing the PCS paperwork for upcoming transports, as well as for recently completed transports.

You can visit the facility and take a tablet computer with you, to knock out many PCS forms in one sitting. To learn how, read the Bulk PCS Form Collection Guide.

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