Clear. Clinical. Documentation.
Bloggers note- we posted this blog almost a year ago to the day. It’s one of those topics that never gets old and the information remains as important as it was the first day we posted it. All of us must keep this important concept in mind when documenting our EMS transports. I hope you enjoy reading it again (or for some of you for the first time!)
CMS
Three words with impactful meaning anchor our discussion today. The Center for Medicare and Medicaid Services (CMS) sets the definition of medical necessity of an ambulance patient that all of us in the ambulance billing industry strictly adhere to.
The definition centers on the clinical requirement “where the use of other methods of transportation is contraindicated by the individual’s condition.” The direction we receive from “The Feds” includes the warning that EMS Patient Care Reports (PCRs) must include clear clinical documentation detailing the ambulance transport incident verifying that the patient truly met the clinical requirement.
Thus, once explained in the PCR, Medicare, Medicaid and most other insurance payers will reimburse the claim that your billing office submits for payment to cover the costs for you to provide an EMS service to your patient.
So let’s quickly breakdown our three key words.
Clear
The word clear is used as an adjective, adverb or verb. The overriding definition in the dictionary defines the word as denoting transparency or defining something as easy to perceive, understand or interpret leaving no doubt or ambiguity.
The medical necessity definition uses it as an adjective. So, clear clinical documentation calls for the documentation in your PCR to be easily interpretive to describe your patient’s medical necessity leaving no doubt or ambiguity that other methods of transportation were contraindicated (or not) for your patient given the condition they were in at the time of the transport.
It’s a very simple concept when you think about it and yet we, in EMS, struggle with it because many of us are just not good with words.
Remember your PCR does not have to be a best-selling novel, but the words in your PCR must be precise and clearly demonstrate why there was no other way to transport your patient without endangering or further exacerbating the patient’s medical condition.
If there were another way to transport the patient without further endangerment of your patient, then the decision can be made based on the clarity you’ve written into your PCR as to whether it is best to bill to the insurance payer or direct to the patient.
Clinical
Something is clinical when it coincides with and involves the actual observation and treatment of a patient. Of course we know that payment for ambulance is based on transportation but observation and treatment happens in the transporting ambulance, so the two go together.
This is where the focus of your documentation is placed.
When we are directed to support medical claim billing for ambulance transports by providing clear clinical documentation in the PCR, the clinical part calls for EMS providers to document that observation and treatment in such detail that it paints a picture in words regarding everything that happened on the scene, in the ambulance during transport and upon arrival at the facility leading to patient transfer.
Clinical is objective. Clinical involves numbers, readings and interpretations such as vitals with numeric values, readings from medical instruments in the ambulance with accompanied objective and scientific interpretations of the instruments’ values. The result is written statements about the patient’s medical condition such that the reader of your documentation clearly has a laser view into the patient’s condition in that moment of time.
It’s clear that the authors of the ambulance medical necessity definition were anticipating that every single ambulance transport that is billed for reimbursement will be supported by a PCR that is written in adequate detail to spell out the clinical relevance of the incident.
Documentation
And finally after two adjectives, we arrive at the noun to anchor the phrase.
Documentation is official information and/or evidence that comprises a record of an event or happening. We use documentation to classify (such as choosing a procedure code to denote the ambulance level of care- ie. Emergency vs. Non-Emergency, ALS vs. BLS, etc.)
We also use documentation to support the all-important ICD-10 diagnosis code that spells out the patient’s condition at the time of transport. Here text is primarily used to describe the patient’s condition and chisel in time the definitive historical clinical record of this one ambulance event.
Because the documentation is clear and clinical, the reader will be able to review the PCR and gain a full understanding of why this patient, in this moment of time used the ambulance for transport from one place to another in either an emergency or routine non-emergency event.
