What do I need to do?
The Big Question
As we talk with people in the industry, administrators and street providers alike, we field this question the most.
“What do I need to write/not write in my Patient Care Report?”
The companion discussion always centers on…
“Can you provide me a “list” of things we should be documenting in our PCR’s?”
Or, then there’s the question posed from the opposite angle.
“Can you share things that we should never document in our PCR?
No…
Pretty much the answer to the questions is “NO”, but with explanation.
Your billing office cannot tell you what you need to write or not write in your PCR. We cannot provide you with a “list” of things you should be documenting and we cannot share with you things that you should never document in your PCR.
Why?
Well, because only you are on the scene of your EMS incident so only you can share what really happened in this incident.
That we can do…
Your billing office can offer suggestions, hypothetical situations and guide you by providing a basic framework for what good PCR documentation looks like. That we can do.
For example, we all know that we must document how we were dispatched and who dispatched us to our incident. This is a no-brainer.
Of course you should be documenting the condition of your patient, treatments you provided to your patient, times, mileage readings. All that we can coach you on. We can’t write it for you, but we can tell you how and where this information should be. All you have to do is plug in the details.
But, your billing office CANNOT dictate what you write.
For example, no billing office should ever dictate something like…
“Never document that your patient walked to the stretcher.”
That’s an absolute blaring, red-flag, lights and sirens sign to RUN from that billing office!
Unless it’s truthful, your PCR should never reflect any information that is “fed” to you to document. So the bottom line is, we- as the billing office, just cannot tell you what to write.
The “Lists”
Let’s get this straight. There is no magic “do” or “don’t” list.
The billing office can’t provide you with the magic “list” of “Here’s what we want to see in the PCR.” The billing office can’t provide you with the magic “list” of “Here’s what we don’t want to see in the PCR.”
You are the provider. Only you and your partner are on the scene. Only you and your partner are adequately qualified to relate the events of your EMS incident.
Now, your billing office can share guidance provided by Medicare, Medicaid and other insurance payers about what those payers reasonably expect to see in your documentation. But that’s global guidance on how to properly prepare a PCR, based on the information given as guidelines.
You, the author of the PCR, must then apply that guidance and prepare your PCR to reflect your EMS incident accurately and truthfully, while incorporating all the elements that are required by your local EMS system, including the requirements as put in place by the State agency that governs your EMS system.
Leave opinions at the door
You are never writing a PCR in order to make an incident billable.
You are preparing a PCR that accurately reflects the condition of the patient and the treatments you provided. This means that if the patient called 9-1-1 and they are not truly medically necessary to justify payment, then your PCR must accurately reflect your assessment and findings from that assessment.
As the primary care provider and the author of the supporting documentation for this incident, you are providing sufficient detail and clear clinical documentation to paint a picture in words about your scenario. If it happens that your picture in words does not justify billing this incident to insurance for payment, then so be it.
It’s our job at the billing office to sort that out.
Leave opinions at the door of your station. Be factual, concise, truthful and detailed.
We’ll take it from there!
