CMNs and PPS Info

PPS Guidelines

  1. PPS Applies to skilled nursing facilities only.
  2. Applies to residents only during their 100 day "Part A" stay.
  3. Bill to SNF only if transport is part of patients normal care plan. (Rehab etc.)
  4. Sending SNF is Billed if Resident is transferred to another facility for upgrade in care.
  5. Wheelchair Services are still "Private Pay" and to be billed to patient.

Effective April 1, 2000 - Dialysis Transports excluded from PPS -As a part of the Consolidated Appropriations Act signed by President Clinton, Skilled Nursing Facilities (SNF) will no longer be required to cover the expenses of ambulance transports under the PPS for patients with End Stage Renal Disease (ESRD). Any patients transported on or after April 1, 2000, will fall under this new law.

Skilled Nursing Home Perspective Payment System

Skilled Nursing Homes with 100 day Part "A" Medicare Patients, are billed direct by the Ambulance Service for "Ambulance" transports that are part of the patients care Plan. This includes doctor office transports by ambulance.

Exceptions to this rule are

  1. Ambulance trips to the Skilled Nursing Facility for  admission or from the Skilled Nursing Facility after discharge.
  2. Ambulance trips to/from an outpatient  hospital, relating to the following services:
    • emergency services;
    • dialysis treatment;
    • cardiac catheterization;
    • computerized axial tomography (CT) scan;
    • magnetic resonance imaging (MRI);
    • ambulatory surgery involving the use of an operating room;
    • radiation therapy; - angiographies codes; and
    • codes for lymphatic and venous procedures.

The facility is billed direct for Ambulance Service for Non-Emergencies Only. Any "Emergency Requests"  going to an emergency room for treatment of life threatening illness or injury, or illness or injury that may cause severe pain or threat to the patients overall health.

Wheel Chair Transport Services are still billed direct to the patient and are not part of the PPS system.

Wheelchair Service is not part of Medicare  PPS in any way. Medicare will never pay for  Wheelchair Service under any circumstance.  Medicaid will pay if patient is unable ambulate  and is wheelchair bound all the time.  You will experience few ambulance trips that  will fall under PPS guidelines. Once patient is  off part "A" 100 days, the facility will no longer  be billed direct. The Ambulance Service can  then bill the Medicare carrier direct for  all Ambulance trips.

CMN Download (pdf)

Below are two "Certificate of Medical Necessity" forms, one for Wheelchair and the other for Ambulance. Click on the button to download the needed form, fill it out and return.

Certificates of Medical Necessity (CMN's)

The signature on the CMN can be from the attending physician or other trained health person but only if they are allowed to sign for the physician and their title is listed, e.g. John Doe, M.D. by Jane Smith, P.A.

No CMN is needed for transports that appear at the time of the response, in good faith, to be emergencies (e.g. 911, acute medical conditions etc.), even if they are subsequently downgraded to non-emergency.

Medically necessary non-emergencies transports must be "bed confined" or in need of special equipment, procedures, oxygen, or medical monitoring during transport to be covered by Medicare/Medicaid.

Types of Service

Emergency Care and Transport
CMN Reguired: No
TIMEFRAME: Not required

A call is considered "scheduled" if the "call for service"is made at least 24 hours before the transport.

Unscheduled, Non-Emergency
CMN Required: Yes
Within 60 days prior to the transport.

  1. SNF/Hospital patient under direct care of doctor.
    CMN Required: Yes
    TIMEFRAME: Prior to or Up to 48 hours after completion of transport.
  2. Resident of ECF under direct care of doctor.
    CMN Required: Yes
    TIMEFRAME: Prior to or Up to 48 hours after completion of transport.
  3. Resident of ECF not under direct care of doctor.
    CMN Required: No
    TIMEFRAME: Not Required.

If the CMN is not attained within these timeframes, then the bill becomes the responsibility of the patient thus it is imparitive that they are attained promptly at time of transport or before.

* A transport is considered scheduled if the call was received 24 hours or more prior to the transport.
** It is expected that the CMN will continue to be valid  for the periods indicated if there is no change in the condition of the patient.