Summary of Proposed PCS Rule Changes

The Centers for Medicare and Medicaid Services (CMS) just released a Proposed Rule  that could spell significant changes for the rules regarding Physician Certification Statements (PCSs).  Right now these changes are proposed.  But, if the changes are adopted, they would drastically impact PCS requirements and compel ambulance services to update their existing PCS forms.  Comments on the Proposed Rule are due on September 27, 2019. 

Here is a summary of the proposed changes:

Distinction Between Types of Certification Statements

CMS is proposing to distinguish between a Physician Certification Statement and a Non-Physician Certification Statement by defining those terms independently in the regulations. Under the Proposed Rule:

  • A Physician Certification Statement is defined as a statement signed by the beneficiary’s attending physician
  • A Non-Physician Certification Statement is defined as a statement signed by an individual other than the beneficiary’s attending physician who has personal knowledge of the beneficiary's condition at the time the ambulance transport is ordered or the service is furnished and is 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. 

This distinction will likely cause the industry to change the name of their current PCS form(s).

Additional Non-Physician PCS Signers

CMS is also proposing to add to the list of non-physician PCS signers.  Currently, for nonemergency transports that are either unscheduled or scheduled on a nonrepetitive basis, the following individuals can sign a PCS:

  • Physician assistant (PA)
  • Nurse practitioner (NP)
  • Clinical nurse specialist (CNS)
  • Registered nurse (RN)
  • Discharge Planner

Under the Proposed Rule, the following individuals would also be able to sign for non-repetitive and unscheduled transports:

  • Licensed practical nurse (LPN)
  • Social worker
  • Case manager

CMS says that they now believe that LPNs, social workers, and case managers who have personal knowledge of a beneficiary’s condition at the time ambulance transport is ordered and the service is furnished have a skill set similar to the other authorized signers. Thus, they are proposing, as part of the new proposed definition of non-physician certification statement, to add them to the list of staff who may sign a certification statement when the ambulance provider or supplier is unable to obtain a signed PCS from the attending physician. CMS is also requesting comments on whether other staff should be included in this regulation.

Clarification About Format of PCSs

CMS emphasizes in the Proposed Rule that the regulations have never prescribed the precise form or format of the PCS and CMS says they want to ensure that ambulance providers and suppliers understand that they have flexibility in the PCS form that they use.  But, the form must, at a minimum, establish that other means of transportation are contraindicated and that ambulance transport is medically necessary.  The bottom line is there is still no CMS-prescribed form for physician certification statements as long as the form states that the patient’s condition meets Medicare’s medically necessity rules.

Removing Reference to “Physician’s Order”

The current language in 42 CFR §410.40 (d)(2)(i), which says:

“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.”

Is being replaced with:

“obtains a physician certification statement dated no earlier than 60 days before the date the service is furnished.”

In other words, they are no longer referring to a PCS as a “Physician’s Order” in that regulation.   

CMS states that these rule changes and clarifications to the PCS requirements could result in fewer claims being denied.

Learn more at the upcoming PWW Media Webinar:

CMS Proposes Rule Changes - What it Means for the Industry and What You Can Do Today

September 12, 2019 2:00 - 3:30 pm Eastern

Register Now!