Physician Certification Statement (Pcs) Form - Interfacility Ambulance Transportation

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Physician Certification Statement (PCS)

Date of Service ____________

Interfacility Ambulance Transportation

Transporting Agency

# _____________________

- ____________________________________

Report

First Name __________________________________

Last Name_______________________________________

Date of Birth __________________________

Age _________

Pt weight ___________________

Patient transported from ___________________________________________________________________________

Patient transported to _____________________________________________________________________________

Medicare guidelines state, ambulance transportation would be covered when the patient’s condition is such that use of any other method of transportation is

contraindicated. If other modes of transportation could have been used without dangering the patient’s health, then benefits cannot be paid for ambulance services.

This form in itself does not establish medical necessity or guarantee payment for Medicare coverage of ambulance transportation. In such event, your facility may be

held responsible for payment of the services rendered.

Medical Necessity Qualifying Documentation

Qualifying documentation supporting reasons that transport by any other means than ambulance is contraindicated. Supporting documentation

for any boxes checked must be maintained in the patient’s medical records.

Check ALL that apply:

___ Bed confined ( All three must be met to qualify for bed

___ Contractures

confinement)

___ Non-Healed fractures

___ Moderate to severe pain on movement

(1) Unable to ambulate

___ DVT requires elevation of lower extremity

(2) Unable to get out of bed without assistance

___ Morbid obesity requires additional personnel/equipment to

(3) Unable to safely sit up in a wheelchair

handle

___ Orthopedic device (backboard, halo, use of pins in traction, etc.)

___ Unable to maintain erect sitting position in a chair for time

requiring special handling in transport

needed to transport, due to moderate muscular weakness and de-

___ Severe muscular weakness and de-conditioned state precludes

conditioning

physical activity

___ Unable to sit in chair or wheelchair due to Grade II or greater

___ Restraints (physical or chemical) anticipated or used during

decubitus on Buttocks, Sacral, Back or Hip

transport

___ Third party assistance /attendant required to apply, administer,

___ Danger to self or others

or regulate or adjust oxygen en route

___ Risk of falling out of wheelchair or stretcher while in motion (not

___ IV medications/fluids required during transport

related to obesity)

___ Cardiac/hemodynamic monitoring required during transport

___ Confused, combative, lethargic, comatose

___ Special handling en route – isolation

___ Requires airway monitoring and suction during transport

SIGNATURE OF HEALTHCARE PROFESSIONAL

I certify that the above information is true and correct based on my evaluation of this patient, and represent that the patient requires transport by ambulance due to

the reasons documented on this form. I understand that this information will be used by the Centers for Medicare and Medicaid Services (CMS) to support the

determination of medical necessity for ambulance services, and have personal knowledge of the patient’s condition at the time of transport.

________________________________________________

_________________________________________________

____________________________

Signature of healthcare professional

Printed name

Date signed

__Physician Assistant

__ Clinical Nurse Specialist

__ Registered Nurse

__ Nurse Practitioner

__ Discharge Planner __ MD/DO