Friday Night Lights, EMS and ICD-10
BLOGGER’S COMMENT – Every year, this week in time, we take a minute to review specific documentation tips when treating sports injuries. Let’s hope we never have to use these skills. Have a safe and enjoyable Friday Night Lights!
It all Begins Tonight!
Our billing office is located in Pennsylvania and across our great Commonwealth it’s one of the biggest nights of the year. High school football is king in Pennsylvania and tonight is opening night for the 2017 season.
It reminds us that young people everywhere, probably even in your back yard—whether you’re in Pennsylvania or not, are heading back to school and participating in sporting events. This week’s blog focus centers on tips to properly document sports injuries in the EMS Patient Care Report (PCR).
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
Because many of these sports injuries will involve your interaction with students who are not yet adults, 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 the incident.
Injury Location
The ten gallon term here is laterality. With the ICD-10 diagnosis code set comes the need for specific location and nature of the injury.
Of course, sports injuries often involve breaks, sprains, strains focusing on the musculoskeletal system. With these types of injuries we naturally invoke relational words which are so helpful as part of the PCR.
Is the injury medial, lateral, distal, proximal in relation to the body part(s) affected? Obvious explanations are important such as right or left extremities. Documenting torso injuries and recording quadrants in terms of upper right, lower right, upper left, lower left such as when assessing 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 the necessary key to properly applying an ICD-10 code to the claim prepared by your billing office.
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. Here we once again talk about musculoskeletal injuries and with pain, other than the obvious, always be sure to capture a numeric rating from the patient on a 1-10 scale (1 less pain, 10 maximum pain).
Severity will also include key elements of a fracture such as compound versus simple fractures, displacement and even recording your assessment of present/absent pulses and/or discoloration in the affected areas.
We can think of many scenarios including recording of swelling, bruising, discoloration even relevant skin temperature such as if the skin turns cool to touch indicating circulation compromise. All of this is extremely important to explain.
Also with severity comes explanation of assessment for potential closed head injuries, soft tissue involvement and includes your recording your head to toe assessments with findings of fluid drainage or bleeding. This further morphs into assessing and documenting level of consciousness compromise and drill down to affected motor skills, as well.
Mechanism/Causation
Finally, we call your attention to your level of documentation detail when explaining the mechanism or cause of the injury. In fact, the move to ICD-10 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.
Always explain the events leading directly to the injury. What was the patient doing at the time of the injury? Was the injury witnessed? Does the student remember the injury? Specifically how did the injury happen?
Of course, explain how you were alerted to the injury and the amount of time that passed from onset to your involvement in the scenario.
