Setting the “Stage”
Landing the Series
Today we’re landing the “Documentation Review as a Habit” series. Our seventh and final installment of this series focuses on documenting the “stage” of the patient’s illness or injury in the Patient Care Report (PCR) and the importance of doing so.
For Emergencies and Beyond
When documenting the 9-1-1 scenario you are focusing on the initial treatment. All illnesses and injuries are episodic in nature. The 9-1-1 emergency is an initial episode of the illness or injury in most cases.
The reason the patient activated the 9-1-1 system is because they are suffering an immediate event which is the initial phase of the current event. As the first responder/provider, it is now up to you to document this event in the Patient Care Report describing the event in sufficient detail using clear clinical documentation to explain that this was a sudden onset, acute, potentially life-saving initial episode.
Not So Much
Of course we all know that sometimes the 9-1-1 emergency turns out to be not so much an emergency.
Here’s where your writing skills will be challenged as you seek to explain using truthful statements that the patient activated the 9-1-1 system and yet may not have required the type of response initially believed to be of an immediate nature. There are times where this becomes very tricky. However we urge you to be truthful and detailed in your explanation of the scenario when documenting, so your EMS billing office can make a definitive decision regarding how to bill the incident and to what source to bill- patient or insurance.
Non-Emergency, Routine Transports
Documenting non-emergency, routine transports- scheduled or unscheduled, presents some unique challenges to all of us as we are preparing the PCR.
Here it’s vitally important for you to effectively record the stage of the event when painting a picture in words about the incident.
Consider that you may be recording the transport of your patient for ongoing treatment. This can be follow-up, maintenance-related needs that the patient has following surgery or for continuing treatment for a chronic condition. Of course, it is probably important to contrast the ongoing needs of the patient by looping back to the initial cause of the illness or injury. Effectively contrasting and comparing different stages of the patient’s overall health picture is an effective way to call attention to the detail of the illness and injury, how it affects the patient and ultimately creates medical necessity where there is no doubt for your billing office or for the eventual insurance payer that your patient could not have been transported by any other means- thus justifying payment for the resulting claim.
Beyond subsequent, ongoing treatment sometimes comes complications. The sequence of events that may follow an illness or injury, especially in chronic conditions, must be spelled out.
Debilitating lasting effects and complications such as infections, deficits, paralysis, neurological and progressively worsening terminal conditions must be explained from onset to current condition. Here another form of staging such as beginning and end stage explanations or numeric medical grading of conditions play a big role in creating an indisputable case for the need for ambulance transportation.
Explain in great detail all complications that have arisen in a patient’s condition and note any exacerbations that have worsened the patient’s condition such that transportation by any other means is contraindicated for the patient you are transporting (of course if that is truly the case.)
Bed Bound
It’s pertinent to loop into yet another reminder about the bed bound criteria issued by the Centers for Medicare and Medicaid Services (CMS). Be certain that you know the criteria and cite references to the criteria when documenting bed bound or bed confined status.
To meet the definition of a bed bound patient, the patient must meet all three criteria points. The patient must be…
- Unable to get out of bed without assistance
- Unable to sit in a chair
- Unable to ambulate
Your documentation in the PCR must be specific as to what illness or injury is causing your patient to be bed bound.
The Final Product
Once the PCR is written and submitted to your EMS billing office, the staff there will read over your words and determine the ICD-10 diagnosis codes that best describes the scenario. Your description of the stage the patient’s illness or injury is in be it initial, ongoing or with complication will translate into specific diagnosis codes applied to best represent the patient’s condition the best. ICD-10 allows for the most combinations and without your precise description the EMS billing office will be unable to choose the most appropriate code.
