Documenting Causation for Illnesses


Our “Documentation as a Habit” series moves on to Part V this week. In it, we’ll discuss causation or the synonym we use a lot in healthcare terminology, etiology.

Documenting Causation for Illnesses

Last week we talked about mechanism of injury which is basically the trauma part of any causation discussion. This week, we tackle the illness side. We’ll focus on the importance of documenting the causes of the illness suffered by the patients you are transporting.

Just Good Questioning

We find when educating EMS providers we sometimes get a little bit of push back on this issue.

“I simply pick-up the patient and transport them using what I learn from the patient during the transport. How can I know what caused the problem?”

The above can be a typical retort when we, as the billing office, press for more information. Of course, the provider part of our brain tends to agree and certainly we sympathize with the challenges of collecting information not only about the present illness, but also past medical history from many patients.

It’s not always easy and, frankly, for some of our patients they just don’t know or remember and many don’t see the need to share with the ambulance crew either.

It all boils down to developing some good questioning techniques.

When it’s obvious what the illness is, it’s a slam dunk. Treat, collect info, document in the Patient Care Report and move on.

But what about when it’s not so obvious? That’s when you have to ask questions, probe using thorough hands-on assessments and find out the story behind the story.

Emergency versus Non-Emergency

The Patient Care Reports that seem to trip up your billing office most often are the non-emergency or routine transport runs.

Emergencies always seem a bit easier to document because the immediate present history of the patient is, for the most part, right there in front of your face. It’s likely you have been called soon after onset of the illness complete with acute or potentially life-threatening symptoms. The patient vividly remembers these, and can explain in fairly sufficient detail what went on leading up to the patient’s activation of the EMS system.

But for the routines, whether scheduled or non-scheduled, medical necessity and the causation factors may be very vague and not so clear. Here’s where a few things come together to help you paint the picture…

  • Call Intake- before the provider comes in contact with the patient, the call intake persons can obtain background and underlying causation.
  • Facility staff and records- we find that most facility staff will “give report” in sufficient detail prior to a non-9-1-1 transport, plus hand off key information for you to review even while completing the transport.
  • Assessments- whether your trip is a 9-1-1 emergency or a routine transport across town, providers must assess their patients which includes asking those important questions (assuming your patient is mentally and physically capable of answering them).

Coding Selection Application

As we’ve consistently done in this series, we close out this discussion with a coding example.

I pulled down the coding book and took a look at all the “pain” ICD-10 diagnosis codes. Abdominal pain is a good example. As I list some of the potential choices, it’s easy to see why our billing office Certified Ambulance Coders cringe when they receive a PCR with very little detail.

The abdominal pain choices can be pain from colic (R10.83), neoplasm related (G89.3), postprocedural (G89.18), cancer associated (acute or chronic- G89.3) to name just a very few.

Simply document that your patient had “chest pain” and you’ll drive your billing office crazy because that chest pain can be due to ischemia (120.9), musculoskeletal or non-cardiac (R07.89) or cardiac in nature such as heart wall pain/precordial (R07.2) or any one of many other root causes.

It’s a more difficult job than many EMS street providers realize. But, those same EMS street providers hold the keys to the ultimate coding formula.

Once again…it’s all in the details provided to nail the causation and the ultimate correct illness diagnosis code.

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