Comprehensive Error Rate Testing
Common CERT Errors - Ambulance
In upcoming Communiqué articles, we will be focusing on CERT errors received by specific provider specialties. This will allow us to identify documentation needs and inadequacies and the impact that these specialties have on our CERT error rate. Our focus this month is on ambulance service suppliers.
Analysis of our current CERT error findings show that the most common errors assessed for this specialty involve services determined to be medically unnecessary and insufficient documentation. Below is a sample of the services involved, and the corresponding CERT reviewer's comments.
Medically Unnecessary Service or Treatment
A0428 - Ambulance service, basic life support, non-emergency transport (BLS)
CERT Comments:
- Per NCP #AMB-001 and SSA 1833(e). Missing ambulance transportation mileage documentation and physician certification statement to support services billed.
- Per NCP AMB-001, Required PCS not submitted for scheduled non-emergency dialysis trip.
A0427 - Ambulance service, advanced life support, emergency transport, level 1 (ALS1-emergency)
CERT Comments:
- Claim is for advance life support emergency transport. Submitted documentation consists of copy of "EMS Medical Report". Vital signs were taken in addition to patient history. In the narrative report it states, "Pt recent sprained ankle. Patient was prescribed Vicodin/Ativan and is out of both. Unable to refill until next week's check. Pt seeking pain relief . . . Pt in good spirits." Per CERT reviewer and CERT Medical Director, ALS ambulance transfer is not reasonable or necessary.
Insufficient Documentation
A0425 - Ground mileage, per statue mile
CERT Comments:
- Per NCP #AMB-001 and SSA 1833(e), missing ambulance transportation mileage documentation.
Insufficient documentation of services and medical necessity issues based on documentation submitted, continue to be areas of concern due to their impact on our CERT error rate. As a result of our follow-up calls to obtain outstanding CERT documentation from providers, we have often found that the patient's file is missing the documentation to support all services billed.
Please be aware that services billed to Medicare Part B must be documented as billed in the medical records. Without adequate documentation, the services will be considered non-rendered, or not provided at the level at which they were billed.
If your facility receives a CERT request for medical records, please review the services billed in order to ensure that documentation for all services is present, prior to forwarding to the CERT contractor. This includes a physician certification statement (or documentation of your attempts to obtain one) for non-emergency trips and documentation of mileage billed. It is also important to verify that the records are legible and that they clearly identify the patient.
If you have questions regarding what documentation is needed to fully comply with the CERT record request, you may contact the CERT Contractor at the number indicated on the request letter.
(Dated 11/10/05)
