Between the Lines
Never a Time
We’re going to begin this post with a blunt statement.
There is never a time when your ambulance billing office can read between the lines!
We talk A LOT about the documentation of ambulance transports in this space. Today we’re going to get about as fundament as we can get.
“What do you mean?”
“What do you mean, read between the lines?”
We mean be specific and put it on the paper using sufficient detail. Be precise, descriptive, quantitative, qualitative and leave nothing off the page.If the specific words to describe your incident aren’t on the page, we can’t create them nor can we assume. It’s gotta be there in black and white!
Frustration!
If you want to give the members of your billing office heartburn, turn in a PCR that lacks sufficient detail to allow them to submit a claim.
Folks, we billing people are religious (or at least we should be) about turning your PCR into cash! Period! It’s our purpose as part of the overall machine.
But, what frustrates us the most is when we read over a PCR and can begin to put together a picture in our minds of the patient and his/her medical condition but yet must stop our part of the process because there is just not sufficient documentation in the PCR for us to comfortably submit a claim.
Help Us!
So now that you know that we’re all “trip sheet Nazi’s” (Your term- we think of ourselves as Compliance Champions. But, what’s in a name?) do you really want to poke our collective “bear-iness”? We think not.
Then HELP US!
Here’s how you can do just that.
Quantify
Whenever possible apply numbers in your PCR.
The numbers that comprise a well-written PCR include 1-10 scale pain ratings, pulse oximeter readings, blood pressure readings and vital sign assessments, dextrose readings, measurements, heart rates- those kinds of concrete findings.
If the patient has pain, ask the patient to apply a number to it. If the patient has a laceration, estimate the size of the laceration. If the patient has hemorrhaged, provide us with your estimate of the amount of blood that’s been lost.
Time is another factor when discussing numbers. Be sure to note if the patient, family or even other healthcare provides provide you with information about the duration of the illness or injury. When was the point of onset? How long did the symptoms last? Is the illness or injury current or in the past?
You can even include timelines in your PCR to draw comparisons and paint a picture in words about the scenario you are documenting.
Qualify
In a word, describe.
Hopefully, this will also include first-hand accounts of what the patient is verbalizing to you.
We hate to focus so much on pain, but it lends us some good examples. So, when documenting any type of pain ask the patient to describe the quality of pain and document that description. Your documentation should include words such as dull, aching, stabbing or sharp, for example.
It’s okay, too, to use quotation marks to document the patient’s very own words when you can. For example, document remarks made by the patient such as…
The patient stated, “the room is spinning,” when describing dizziness, for example.
Be Specific
Your billing office cannot assume anything. We can’t assume that you provided a treatment if the treatment is not documented.
If you palpated the area, document that you palpated the area. If you assessed lung sounds, specifically state that you assessed lung sounds using a stethoscope and what areas you used to listen and following document your findings.
Tell us how that illness or injury presented upon your assessment. So the way to do that is to start at the beginning and paint the picture of the scenario from start to finish.
- When was the onset?
- What prompted the patient or other person to activate the EMS system for your patient?
- Describe your initial assessment upon accessing the patient initially.
- Describe your treatments, IN DETAIL.
- Describe the patient’s condition during transport. Has the patient’s condition changed? Is the patient’s condition better, worse, the same?
- Describe the patient’s condition upon arrival at the facility. Again, answer the questions that compare the patient’s condition to your initial assessment until now (comparison statements are really helpful to the billing office for a number of reasons.
It’s up to you…
Now it’s up to you to help your billing office. Don’t get upset with them when we question you.
Look in the mirror and ask yourself, “Did I really do everything I can to provide the billing office with the most detailed description of this incident possible?”
Whether or not you’ll admit it, you’ll know the answer. If you’re not confident, take another look. You probably missed something.
We hope you follow our suggestions. It’s harder than ever to convince payers they should reimburse us for what we’ve done. Don’t tie your billing office’s hands and never ask them to read between the lines!
