Documentation Tips for Medicare Part B Providers

Last week, Wisconsin Physician Services (WPS) hosted the Medicare Part B provider meeting. Some of the information provided at the meeting serves to benefit all EMS providers–topics including dispatch information and protocols, provider impressions and Physician Certification Statement (PCS) legibility. 

Dispatch Information

Dispatch information in patient care reports (PCRs) serves to give reviewers enough information to determine the level of response required and coordinate reimbursements. Recently, it seems Medicare reviewers are not getting a clear picture of why EMS is being called to the scene, and this lack of information results in the Centers for Medicare & Medicaid Services (CMS) requesting a refund. Emergency dispatchers should be using established dispatch protocols to assist in determining emergent or non-emergent response; they need to be able to gather enough information to determine if advanced life support (ALS) or basic life support (BLS) is needed. This is key in getting fast, accurate payment and avoiding audits.

The WPS reviewers indicated that some of the drop-down options used for “dispatch reason” did not provide enough information to justify care level. One example provided was the use of the selection “sick person” for “dispatch reason for transport.” There could be many different situations for a sick person in which some would require an emergency response and others would not.

Provider Impression(s)

Insufficient provider impressions continually are an issue with WPS’ post-payment audits. Many times, the information provided within the PCR does not accurately describe the patient’s medical condition at transport. The use of vague terms such as “weakness” or “fall” is not considered an adequate impression for reimbursement.

The impression indicated on a PCR should be obtained after a complete patient assessment is performed. Using your medical expertise, provide a sound medical impression of the patient’s condition using descriptive words. Instead of “patient has fallen” an accurate impression might read, “patient complains of pain to the right hip and discomfort upon movement and palpation.”

Be aware that the options listed for provider impression may not dictate enough information to prove medical necessity. If providers are using provided options in their PCRs, follow up with more detailed information describing the patient’s assessment in the narrative.


The issue of legibility centers on manual PCRs and the completion of the physician certification statement (PCS) form. The handwriting on some of these forms is difficult to read, and knowing who signed the form can prove to be impossible. WPS’ recommendation is to either clearly print or type the name and credentials of the person who signs the PCS form below their signature.

In addition, EMS providers should review the PCS form before transport to assure the appropriate signatures are legible. As a side note, some EMS agencies have found it beneficial to have the requesting facility fax the PCS form to them prior to transport. This allows them to review the form to assure medical necessity requirements are met and legibility is not an issue.

If you have any questions about your agency’s PCRs or documentation, contact us today to learn more about our helpful webinars and billing service.

To read more about this issue, download WPS’ “Rolling with Medicare Ambulance Requirements.”

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