Part 3 (of 5): Justifying Medical Interventions
Last month, we shared the second part of a 5-part series on writing good patient care reports (PCRs) that focused on avoiding vague terminology (See Full Article: How to Write Good Patient Care Reports (PCRs) Part 2 of 5: Avoiding Vague Terminology in Patient Care Reports).
This month we will be focusing on justifying medical interventions documented in your PCRs.
Encourage your staff or colleagues to use these criteria as guidelines to writing complete and accurate PCRs that reduce the chance of insurance denials.
Diagnosis codes or signs and symptoms? A valuable debate has been going on in the EMS industry on the right way to code claims. Omni EMS Billing recently did a nationwide survey and found the following results:
So should you use a diagnosis code or signs & symptoms when coding claims?
Standards for coding claims can vary widely across state and county lines. However, the most acceptable method of coding claims is justifying your impression, regardless of whether a diagnosis code is present, by using descriptive signs and symptoms in the assessment section of the patient care report narrative.
For example, if your impression says “chest pain cardiac, muscular, or trauma related”, you must detail the signs and symptoms in your assessment that led you to determine this impression: “Patient indicates pain on palpation during examination of sternal and right midcavicular chest areas. Patient states chest pain radiates to lower right arm upon movement and palpation. Patient’s skin is cool, pale, and moist to touch. Pulse rate is 85, and irregular.”