I Can’t Breathe!

Why this subject?

We’ve heard it dispatched a whole bunch of ways… shortness of breath, respiratory distress, dyspnea. If you’ve been in the ambulance business long enough these calls are second nature and they occur a lot.

So, why tackle this subject in an ambulance billing blog?

Simple answer… just because we do it a lot doesn’t necessarily mean we document our run effectively.

“Objective Evidence”

The key to whether or not payers will compensate your department for completing these runs is always the documentation of the run. For this discussion it is important that there is objective evidence of abnormal respiratory function.

A lot of people…

A lot of people have breathing issues and many of them function daily without using an ambulance.

For our purpose here today, the bottom line is whether or not the patient is suffering from a respiratory condition right now, right here such that the person’s life is in jeopardy and transportation and treatment from any other source other than trained ambulance personnel has the potential to be life threatening endangering the overall safety of the patient.

Sudden Onset or Ongoing Condition

Once you’ve determined the patient’s chief complaint (for example… “I can’t breathe”) then it’s time to assess and treat the patient. Of course, following all of this will eventually be the documentation of the incident either handwritten or via computer ePCR generation.

What you find and record in the Patient Care Report (PCR) is crucial to the billing part of the loop.

One big element is whether or not the scenario is a sudden, uncontrollable onset of symptoms. Be sure to mention this fact in the PCR you write following the run, especially when documenting 9-1-1 trips.

Ambulance 10 crew arrived on scene to find a 59 year old female patient complaining of severe shortness of breath. Patient was unable to speak more than a word or two at a time and her family stated that the respiratory distress began about 20 minutes ago following a walk around the block.

Or it may be a severe ongoing scenario for a routine trip that is documented.

This crew arrived to find a 79 year old male patient who is intubated and a respirator is in place (duration 2 days). Transport is being completed to a higher level of care due to increasing loss of adequate respiratory function without any improvement overall. Patient was not conscious at the time of the transport.

Be Descriptive

Always be sure to describe your patient and how he/she appears to you upon assessment. This can be an effective technique for helping to prove the medical necessity of the ambulance trip overall.

For example, “Found patient sitting on the edge of his bed in a tri-pod-like, seated position with excessive accessory muscle use. Patient noted to have audible wheezes from across the room and appeared to be somewhat cyanotic with noted diaphoresis”.

Record Values and Condition Changes

Be sure to record all the values complete with patient condition statuses.

For example, it’s advisable to document a recorded pulse-oximeter oxygen saturation reading upon arrival (most likely on room air) and then further record the oxygen saturation reading following whatever treatment you have provided.

Upon arrival we noted the patient’s oxygen saturation to be 90%. Following the administration of oxygen at 4lpm via nasal cannula, the patient’s saturation improved to 95% and the patient’s breath-per-minute improved from a rate of 28 bpm to 20 bpm.

Make note of the overall condition of the patient before and after EMS treatment and transport. Especially be sure to document if that condition improves which further helps to provide documentation to satisfy the medical necessity requirements for this scenario.

It’s the numbers that count here. Make sure you have a value for each and every measurement recorded on the report.

What “they’re” looking for…

The payer billing guides we review here in the ambulance billing office tell us what payer sources are looking for when they review claims for respiratory difficulties of any type. Symptoms and findings are expected to be documented that includes some mention or combination of documentation that includes tachypnea, labored respirations, hypoxemia requiring oxygen administration or might include documentation of the patient’s requiring advanced airway management of some sort including the need for deep airway suctioning due to a build-up of secretions obstructing the patient’s airway.

We also see guidance where medical necessity can be established when it is noted the patient requires positioning in the ambulance that would not be possible in another vehicle (always remember to explain why you believe the patient would be potentially harmed or a condition worsened by not being transported by ambulance.)

Oxygen alone doesn’t cut it

We know that many providers simply believe that administering oxygen nails the medical necessity for the payment of the transport. That’s not the case.

Most payer sources, especially Medicare and Medicaid, warn us that the patient must require oxygen therapy and be so frail at the time of the transport that only trained medical personnel can assist the person in sustaining their basic life function.


The burden of the EMS provider is to prove that the patient’s condition worsened to the point or is exacerbated to the point that there is no way they can self-regulate their oxygen saturation levels without a potential detriment to the patient’s overall condition.

Especially make notation when you have to change an oxygen delivery device, such as when you have to remove a nasal cannula and apply to non-rebreather mask. Or, in the ALS world documentation of application of a nebulizer treatment would be crucial, as obviously the patient would not be able to receive that treatment in a taxi cab.

One more example…

This blog is one more example of how we provids helpful tips to assist your organization in receiving accurate and compliant payment following the ambulance run.

Contact us today if you need this kind of continual education for your organization. It’s as easy as picking up the phone or shooting an e-mail out to us.

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