DOs and DON’Ts of Documentation

DOs and DON’Ts of Documentation

  • DON’T copy information.

Write each transport as if this is the first time you have seen or treated this patient. Do not copy information, especially your narrative, from a previous report. Each patient care report must be a stand-alone report.

  • DON’T use vague terms

Patient is experiencing “pain” or has “weakness”. These are insufficient terms and should be avoided. Your impression should be detailed, walking through signs and symptoms shown before and during the transport. If the patient or family states the patient is weak, do an assessment and document what limitations are associated with the weakness. Can they not hold their head up? Unable to hold their arms out? Will the patient fall out of chair if left in sitting position without restraints?

  • DON’T use P.U.T.S. in place of the patient’s signature.

CMS has indicated there should be very few occurrences in which a patient is unable to sign the patient care report such as cardiac arrest, patient having a stroke or a dementia. If there is a true medical reason the patient is unable to sign the patient care report, you must document all the medical reasons for this. CMS has also provided instructions in the Ambulance Billing Manual for those few cases the patient is unable to sign such as having an authorized family member sign for the patient.

  • DO support medical necessity

By definition, medical necessity proves why transportation by any other means is contraindicated for the patient. In order for insurance to pay, medical necessity must be proven within the documentation and should include the primary impression, chief complaint, and all corresponding treatment to the patient. Note that the Centers for Medicare and Medicaid Services (CMS) has stated that the diagnosis of a disease or illness may not be enough without corroborating evidence/statements to support medical necessity for ambulance transport.

  • DO be specific

Include in your patient care report a detailed assessment on every transport as well as the findings of your assessment. Include Glascow coma scale, skin conditions, mental status, pain level, ect. Be very specific in documenting all the signs and symptoms of the patient’s chief complaint.

  • DO be truthful

Make sure your documentation is truthful. It is not in your best interest to develop a list of terms or symptoms to use to get the transport paid. Your patient care report is a medical legal document. Using false statements in your report to support medical necessity can result in a prosecution in the court of law.

  • DO document treatment results.

Remember to note all treatments in your narrative. Explain the situation, symptoms, actions taken, and the effects of treatment. If a medication is administered to the patient, include in your report whether there was a positive, negative, or no reaction.

 

3 Definitions of Medical Necessity as Defined by Payers

A response from the following article

http://www.ems1.com/paramedic-chief/articles/2154154-Getting-paid-for-ambulance-transport-requires-good-EMS-documentation/

Ambulance reimbursement is unique in that insurance payout is not guaranteed based on providing service. Medical necessity must be proven through documentation in order for reimbursement. This can be both confusing and frustrating to EMS staff, because generally speaking, “medical necessity” is subjective.

There are typically three payer categories separated by their definition of “medical necessity”.

 

  1. COMMERCIAL

For these providers, a transport is deemed payable if a “prudent layperson might anticipate serious impairment to his or her health in an emergency situation.” In other words, would an average person consider the situation a medical emergency? Would the condition seem to warrant calling an ambulance rather than seeking alternative help?

 

  1. MEDICARE

Medicare is a federal government insurance provider that states they cover only ambulance transports in which no lesser alternative method of transportation could be used. This rather strict definition of medical necessity is reason for a majority of Medicare audits.

 

  1. MEDICAID

Medical necessity for government insurance provider, Medicaid, is defined at the state level. These requirements are more specific than Medicare’s federal definition and require quality documentation of conditions, interventions and procedures at the site.

 

In conclusion, payer requirements vary based on the insurance agency and their particular definition of medical necessity. It benefits all involved to understand various insurance payer standards. A good rule of thumb to receive full reimbursement is to make sure you provide a detailed report that describes your patient assessment, medical interventions and reason for transport. Play it safe. If it is not known to where you will submit the report, edge on the side of caution, abiding by the most stringent requirements. Be detailed on the reason ambulance transport was required and remember, good documentation is good patient care.

 

Grant Helferich is employed as the EMS Advisor/Client Trainer with Omni EMS Billing in Wichita, Kansas. He is a former member of the KEMSA Board and has also served as the treasurer and president of the KEMSA Administrator’s Society. He was certified as an EMT, EMT-I, M.I.C.T. , and T.O. II. Grant has worked EMS for over 35 years in roles such as an EMT, EMT-I, M.I.C.T., Field Supervisor, Flight Paramedic, Cardiovascular Specialist, Assistant Director, and Director of EMS.

Documenting Medical Necessity 101

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Current EMS news is littered with stories of fraud and abuse cases involving ambulance companies and insurance carriers. Some ambulance companies have actually been guilty of shady business practices and others may have been guilty by ignorance of the law. Either way, verifying medical necessity plays a large role in these negative allegations. The Centers for Medicare and Medicaid Services (CMS) has indicated that $350 million a year is paid to ambulance companies due to fraud or abuse.

Medicare and Medicaid payers will only reimburse for the ambulance transport if the services is “Medically Necessary.” In which it would have been unsafe or would have caused harm to the patient if they would have been transported by any other means of transportation. So, if the patient is able to ambulate, sit up in bed or sit in a wheelchair these types of patients are normally found to be not “Medically Necessary.”

Ambulance companies must not develop key terms for their providers to use such as “bed-ridden” or “stretcher-bound” to attempt to justify medical necessity. The patient assessment must be detailed and completely describe the patient’s medical condition to meet the requirements of “Medical Necessity” at the time of transport. Include the medical care that was required at the time of transport to make to assure the patient arrived at the receiving facility safely.

Other vague terms that should be avoided in the patient care report include, “Weakness”, “ESRD”, “Dialysis Transport”, “Unknown” and even “other”. The documentation of the detailed assessment within the patient care report should describe the body systems affected by the weakness and its limitations. The detailed assessment of the patient should describe what is occurring at the time of transport and why the patient needs the ambulance to transport them to the dialysis center for their treatment.

Unfortunately, some ambulance companies have had their employees remove any terms that might indicate the patient could have been transported by another means of transportation. Each patient care report must be factual and specific in regards to the patient’s condition at the time of transport.

Here are 10 recommendations to avoid investigations, audits, and denied claims:

  1. EMS company owners and management must educate themselves on the rules and regulations of submitting ambulance transport claims to insurance companies.
  2. Each EMS company must have a policy in regards to the completion of the patient care report.
  3. Each EMS company must have a quality assurance/quality review program to review patient care reports to assure each patient care report is detailed and complete.
  4. All documentation within the patient care report must be truthful.
  5. Patient care report documentation must be factual and accurate.
  6. The documentation must be detailed and support the “Medical Necessity” of the ambulance transport.
  7. Each patient care report must stand alone. Do not copy a previous transport report.
  8. Each EMS company must develop a policy for their staff on how to handle those patient transports that may not be “Medically Necessary”.
  9. Do not have a list of key terms to be inserted in all patient care reports to meet the medical necessary requirements.
  10. Make sure you receive a complete, detailed Physician Certification Statement (PCS) for all scheduled non-emergency transports. Each PCS must be signed, dated and indicate the medical reason for the ambulance transport.

 

Grant Helferich

Grant Helferich is employed as the EMS Advisor/Client Trainer with Omni EMS Billing in Wichita, Kansas. He is a former member of the KEMSA Board and has also served as the treasurer and president of the KEMSA Administrator’s Society. He was certified as an EMT, EMT-I, M.I.C.T. , and T.O. II. Grant has worked in EMS for over 35 years in roles such as an EMT, EMT-I, M.I.C.T., Field Supervisor, Flight Paramedic, Cardiovascular Specialist, Assistant Director, and Director of EMS