Closest Appropriate? Explaining Destinations in the PCR

Closest Appropriate Facility
In the ambulance billing world, this 3-word phrase is discussed more than you’d realize- Closest Appropriate Facility.
There are rules that differ in many cases between insurance payers, most notably between Medicare and Medicaid and even some commercial insurance payers regarding payment for transport miles to the ambulance provider. It’s even possible that payment for the entire transport could be based on the destination facility.

Typically we key on the Medicare rules, as they apply to many cases by extension. Medicare agrees to pay for loaded miles (the miles driven by the ambulance when the patient is loaded in the ambulance enroute to a facility) when the transport is completed to the closest appropriate facility that can provide the patient with the best and most fitting care.

However, it’s important to also know that each insurance payer may have differing rules from the Medicare rules and the documentation provided in the Patient Care Report (PCR) defines how those payment rules are applied based on the scenario and the needs of the patient.

It’s the defining of what facility is the closest appropriate one that produces the challenge in the billing office.

Sound complicated?
Does this sound like it’s a bit complicated? Well, quite frankly; it is.

While Medicare keys on the closest appropriate facility, the rules also allow for some latitude applying in many cases what is called the “locality rule.” Explained simply, the locality rule allows when patients normally seek medical attention at a few regional hospitals on a regular basis. So, even though Hospital A may be a bit more distant than Hospital B, Medicare will allow payment for the additional miles to Hospital A because patients regularly seek medical attention at both facilities.

However, that’s Medicare. Be sure that your billing office researches and has a clear understanding of the facilities. Also, be sure that your billing office knows how the other insurance payers apply their payment rules. Some States limit payment for Medicaid claims to the strict “Closest Appropriate Facility” interpretation and refuse to pay additional mileage, regardless of circumstances. 
Be Specific
It is extremely important that EMS providers be specific about the reasons we transport particular patients to a facility.

It appears many times like it’s lost on us providers that explaining the choice of destination facility is even a factor and quite frankly it may just be that we don’t even realize that there is an importance of explaining the reason why we transported to Hospital A versus Hospital B.

Say it!
Of course, there are the “no-brainers.” Trauma patients must be transported, in most scenarios, to a trauma center. Dialysis patients are best served when they are transported to a facility that can provide inpatient dialysis. Psychiatric patients need to be transported to a hospital with psychiatric services.

But even when it appears to be obvious the reason why a patient is transported to a particular facility, be sure to say it!

When documenting your incident, make specific reference to not only the facility you are transporting to, but why that facility was the most appropriate.

“Patient transported to ABC Hospital Level I trauma center for care of traumatic injuries.”

“Transport of this ESRD patient to XYZ Hospital is due to inpatient dialysis capabilities.”

“Due to patient exhibiting signs and symptoms of an acute psychiatric episode, the most appropriate facility was ABC Hospital which has an inpatient psychiatric unit complete with psychiatric staff available to care for the patient’s needs.”

Of course there are also scenarios where a hospital is diverting, so explain it. There are also times when the patient chooses a certain facility over another. The patient’s request must be documented as the billing office may need to decide if the patient may be liable to pay for transport to the more-distant facility, either all or some of those miles, out-of-pocket.

Don’t assume…
Remember if the reasons for transport to a specific facility are not expressly documented in the PCR then it’s as good as not explained. Don’t assume that the reason will be implied. Say it!

The Ambulance Billing Services blog is brought to you as an educational tool by Enhanced Management Services, Inc. Enhanced Management Services, Inc. is an all-EMS, third-party billing contractor serving Fire/EMS clients across the United States. To contact us, visit our website at and click on the “Get Started” button located on any landing page.

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