It’s Football Season- Documentation Hints for Sports Injuries

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It’s Football Season-Documentation Hints For Sports Injuries

Our billing office headquarters is in Pennsylvania. High school football is king in The Commonwealth so many of our clients treat and transport football-induced injuries.

Right now, young people everywhere are heading back to school and they are participating in sporting events.

With that in mind, this week’s blog space focuses on documenting sports injuries with an eye toward billing for the treatment and transport of these young athletes.

4 Key Areas of Focus

As you’re treating and transporting patients who have suffered sports injuries, we offer four key areas that your billing office wishes you would place your focus when documenting. These four areas are…

  • Patient Identification
  • Injury location
  • Injury severity
  • Mechanism/Causation

Patient Identification

Many of these sports injuries will involve your interaction with students who are not yet adults. To help the billing office, it is extremely important to collect information relevant to the parent or guardian.

When identifying parental or guardian information, please be sure to obtain the name and contact information for the adult in the student’s life, especially the adult whose insurance plan will ultimately be the primary reimbursement source for the ambulance claim.

Gathering the responsible party’s signature is also a key element that will greatly help your ambulance billing office following your incident sports-related incident.

Injury Location

The ten gallon term here is laterality. Thanks to the billing office’s need to choose and apply the closest appropriate ICD-10 diagnosis code set, comes the need for specific location and nature of the injury.

Of course, sports injuries often involve breaks, sprains and strains involving the musculoskeletal system. With these types of injuries, we naturally invoke relational words which are so helpful if the providers include them when documenting in the patient care report (PCR).

Is the injury medial, lateral, distal, proximal in relation to the body part(s) affected? Obvious explanations are important such as recording right or left extremities. Documenting torso injuries and recording quadrants in terms of upper right, lower right, upper left, lower left when documenting the assessment and treatment of chest and or abdominal injuries.

ICD-10 coding requires that your billing office chooses the most appropriate code, so specifics matter.

Consider the stark difference between documenting… “Treated and transported a 16 y/o male patient who suffered a broken leg at local high school football game” versus “Treated and transported a 16 y/o male patient who suffered a closed mid-shaft left tibia/fibula fracture. The second example with no more than just a few extra words provides the kind of detail that is key to properly choosing the correct ICD-10 code when preparing the claim for billing after the call is complete.

Injury Severity

Documenting the severity of the injury typically involves explaining the extent, and most often including the level of pain.

You’re going to know, in most cases, when your student is severely injured because it’s going to hurt and hurt big time. With pain, we are capturing and documenting a numeric rating from the patient on a 10-point scale as expressed to you by your patient.

Severity will also include key elements of a fracture such as compound versus simple fractures, displacement and recording your assessment of present/absent pulses and/or discoloration in the affected areas.

We can think of many scenarios including documenting such potentially present realities such as swelling, bruising, discoloration and even relevant skin temperature.  Of course, your hands-on assessment of the area peripheral to the injury will be assessed and documented such as if you find skin that is cool to touch indicating potential circulation compromise. All of this is extremely important information to include in your PCR.

Plus, with severity comes explanation of assessment for potential closed head injuries, soft tissue involvement and includes your recording of the head to toe assessment while noting findings of fluid drainage or bleeding. Certainly you’ll be looking for, treating and documenting level of consciousness compromise and drill down to adversely affected motor skills, if they exist.


Finally, we call your attention to your level of documentation detail when explaining the mechanism or cause of the injury. The fact that we now use ICD-10 diagnosis coding, allows for an actual 6th and 7th digit (ICD-9 maximum was 5 digits) specifically to include an expanded detail for etiology and with the 7th digit place reserved for added code extensions that include injuries and the external causes of injuries.

Please remember to always explain the events leading directly to the injury. Your documentation must answer what activity the patient doing at the time of the injury to explain the mechanism thus explaining the reason you treated and packaged for transport.

And finally, always document how you were alerted to the injury and the amount of time that passed from onset to your involvement in the scenario.

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