Checklist: Ambulance transports documentation
Concise medical record documentation is critical to providing patients with quality care as well as to receiving accurate and timely
reimbursement for furnished services.
This checklist was created as a tool to assist providers when responding to medical record documentation requests. It is the
responsibility of the provider of services to ensure the correct submission of documentation.
To ensure that medical record documentation is accurate, the following principles should be followed when submitting medical
documentation:
Please be sure documentation submitted is legible.
Please submit records for all dates of service on the claim.
Please ensure the medical records submitted provide proof the service(s) was ordered and rendered. Also, ensure the medical records
provide justification supporting medical necessity for the service by submission of the following documentation:
Trip/run sheet for the date of service and if available the dispatcher’s call with type of run requested
If required, a Certificate of Medical Necessity (CMN) or a Physician’s Certification Statement (PCS)
For hospital-to-hospital transports, the record should clearly indicate precise treatment and/or
procedure, date and legible identity of the observer, certification and rationale of necessity for non-
emergent transfers
For non-emergency transport, the record should clearly indicate the reason for the transport, what
medical monitoring was performed and why other means of transportation was contraindicated
Signatures/credentials of professionals providing services
Signature of beneficiary or representative
Any other records that may support medical necessity
Providers should refer to the Centers for Medicare & Medicaid Services (CMS) official Ambulance Services Center at
http://www.cms.gov/center/ambulance.asp
for additional information.
