Documentation Review as a Habit

Put it on the calendar!

Because more than ever before, detailed clear clinical documentation in the Patient Care Report (PCR) is critical to the mission, it’s time for every EMS agency to pick a date and time to regularly meet and discuss run sheet documentation.

Documentation Review as a HabitOf course, this blog space is all about EMS billing and we’ll focus on that point today. But, beyond the important billing issues it is critical that your EMS agency also look continually for how your crew members are following protocols and meeting the demands of the Scope of Practice that your organization have set-up.

Reviews can include a myriad of issues including the impact of documentation on cash flow, potential compliance risks (especially with Medicare and Medicaid programs), potential negative and positive effects for State licensing, liabilities and most importantly to potentially improve on patient care and impose positive patient outcomes.

If you don’t intentionally schedule meetings that focus solely on documentation and charting issues, you and I both know that it will never happen. Set a plan today to make this happen.

Medical Necessity Nailed

Again, focusing on the billing side of the EMS equation, the intent of any and all documentation peer reviews should be to improve and make suggestions among your staff members to find a way to nail the medical necessity question for each and every patient you transport where you also wish to be paid for said transport.

We must leave no doubt that the patient medically required an ambulance for transport such that transportation by any other means would endanger the patient’s health and well-being. The only document that is going to definitively represent the condition of the patient is the PCR. It is the overriding document in determining if your billing office can bill to an insurance payer within the payment guidelines or not.


Coding Considerations

Thanks to our new ICD-10 world, documentation reviews should focus more than even on specific details. The level of specificity in the PCR’s documentation (primarily the written narrative portion) must be complete.

Now that your billing office potentially has 68,000 coding choices; no stone can be left unturned in the documentation loop.

PCR documentation must be precise regarding several issues…

  • Location
  • Severity
  • Mechanism (if an injury)
    Causation (illness or injury)
  • Relationship (Time/Date/Onset)
  • Stages (Initial/Ongoing/Complications or Exacerbation)

Gone are the days of “Ill person transported without incident” (yeah, believe it or not we’ve read some of these charts… hard to believe, huh?)

If your billing office is going to choose the correct and most appropriate diagnosis code, you must provide details that include a clear and precise clinical representation of your ambulance incident and that includes whether or not the incident was an emergency or a non-emergent or routine transport.

Peripheral Considerations

In your documentation review sessions, be sure to also focus on some of the peripheral issues surrounding run documentation.

Be sure to continually review the surrounding things like patient signatures and how to properly procure the all-important signature.

Review Physician Certification Statement requirements so your crews know how to quickly look over a PCS that they receive prior to a transport and know they have a valid PCS, in hand.

Make sure you go over how to properly document things like defining a transport to the closest appropriate facility and what to do if it turns out the facility is not the closest appropriate. Make sure you field a discussion about how to properly document dispatches to fulfill billing requirements for payment at various levels of service.

If your EMS agency requires your crews to obtain Advance Beneficiary Notices and or Waivers of Liability be sure to constantly re-hash the proper presentation and execution of such forms so to not cause a problem down the road when billing the EMS incident.

Future Focus

Over the next few weeks, we’ll break down and focus on some of the parts of the equation we mentioned above. We hope you’ll join us each week as we unpack this discussion further.

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