Supporting Upgrades in Care Using Detailed Documentation

Dispatched to…Arrived to Find

You’re riding an ALS rig today, the BLS crew is tied up and you and your partner are dispatched by default for a call that has been determined via EMD to be a BLS Emergency for a patient with back pain. You respond accordingly and arrive on the scene and access the patient’s residence to find the patient leaning over her kitchen counter moaning in pain.

Supporting Upgrades In Care Using Detailed Documentation 05 03 2019

The patient tells you that she has been experiencing severe back pain that she rates as a 10 out of 10 on the severity scale and denies falling or any type of traumatic injury. She points to the location of her pain as being in the lower back in the area of her kidneys

You begin by assessing her vital signs and find her to be hypertensive which the patient states is unusual. Given her elevated BP, you apply the cardiac monitor and do a 12-lead EKG and initiate ALS protocol, then prepare the patient for transport to the local emergency department.

How to bill?

Once your billing office receives the patient care report you have completed, now comes the decision at what level this trip is to be billed. Every good biller will take time to carefully read the documentation provided by the crew on the call to be certain that there will be no issues moving forward should Medicare, Medicaid or even a commercial insurance payer decide to add this trip to an audit sampling somewhere down the line.

You’ll recall that the EMD on this trip indicated that only a BLS level response was necessary. However, your assessment of the patient’s vitals and overall complaints caused you to take a step into an ALS assessment and treatment which was completed by the ALS provider for this crew.

Given this upgrade in care this trip would seem to fit the criteria for an ALS Emergency procedure code to be used when creating the claim for billing and the upgrade will need to be supported in the documentation provided that ALS care was appropriately initiated.


But this important billing decision hinges, as all EMS billing decisions do, heavily on the documentation used to support the claim.

In these upgrade scenarios, it is extremely important for the crew members on the call, most notably the primary caregiver who ultimately winds-up to be the author of the PCR, provide more than just summary detail about the circumstances that lead the crew to consider ALS level assessment, following established protocol for the geographical area the ambulance operates within.

We know by having conversations with our colleagues in the industry who audit trips that these are the kind of trips that raise the red flag. Of course, we know that there have been unscrupulous EMS providers (we’re certain our readers are not those people) who are looking to create a higher level of billing by adding perceived unnecessary upgraded treatment to the scenario in order to collect more money at the end of the day.

It may not be enough…

So, we don’t believe it to be adequate to assume that a payer’s reviewer will fully understand your intent to add a higher level of assessment and treatment without expressly documenting your decision to upgrade in detail in the PCR.

In our example, if you were the author for this PCR and you barely stated a summary set of details (how dispatched, demographics, summary details of how you found the patient) and then added vitals- even listing the elevated BP reading, there may still be questions in the mind of an auditor regarding whether or not raising the level of care and billing for ALS versus BLS is appropriate. This is especially true given that you naturally recorded that you were dispatched BLS which means a third-party public service access point (PSAP) provided you the trip at an initial lower acuity level.

What is most appropriate and lands this scenario into the realm of “no doubt” would be for the author of the PCR to definitely state his/her reasons for upgrading care. It really doesn’t take too many extra words to do so.

For example, adding a phrase like this to your PCR can erase ambiguity and resulting doubt; “Upon finding this patient to be hypertensive, coupled with the severity and location of the patient’s pain without relief during our contact with this patient, this crew felt it was necessary to initiate ALS protocols to treat the possibility of a potentially more serious condition not initially described upon activation of the EMS system.”

Always remember…it’s easier to explain the reasons for providing care up-front in your initial PCR, than it is to try to justify by explaining after the fact, especially when under the scrutiny of an audit.

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