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.”
Part 1 (of 5): Collecting Patient Information
An often underrepresented issue that EMS staff need to work on is writing detailed patient care reports (PCRs) that provide a clear clinical picture of the patient’s needs. While providing the best care for the patient is important, it’s vital that this care be accurately reported.
Why should this be your concern? For many EMS services, the bulk of revenue comes from insurance reimbursements. An incomplete or inaccurate PCR may result in a denial of reimbursement for services from the insurance company or even a demand for a refund after payment has already been made. Continued patient care can also depend on well written PCRs, as receiving facilities may use these as a guide to what treatment patients have already received and for future treatment plans.
This series focuses on 5 criteria EMS staff need to review while writing PCRs. Each month we will focus on one new criterion.
Encourage your staff or colleagues to use these criteria as guidelines to writing complete and accurate PCRs that reduce the chance of insurance denials.
Criterion 1: Are you collecting all necessary patient information for your PCRs?
While completing each PCR, report all the following information:
☑ Detailed dispatch information
This information validates the reason and level of response.
Example: Unit 1 responded to report of chest pain with dizziness.
☑ Patient demographic information
Make sure to include the patient’s full name, current address, phone number and date of birth in order to bill the insurance company and receive reimbursement for services.
☑ Patient insurance information
Collect all insurance information for billing in one go by obtaining copies of insurance cards. Having a scanner on your rig would prove a sound investment to obtaining these copies. Obtain copies of the patient’s insurance card from the receiving facility if you were unable to collect it during transport.
☑ Chief complaint
What medical conditions did the patient indicate upon arrival? When did the symptoms start?
Example: 62 y.o. male states onset of chest pain with dizziness approximately 15 minutes before calling 911. Patient states he was mowing the yard when he had the onset of chest pain.
☑ Detailed primary and secondary assessment information
What signs and symptoms did the patient communicate during your assessment? What were your clinical findings?
Example: Patient indicates no pain on palpation during examination of sternal and chest areas. Patient states chest pain radiates to right arm and denies difficulty breathing at this time. Patient’s skin is cool, pale, and moist to touch. Pulse is equal on both wrists at 85, and is irregular.
☑ Detailed information about medical procedures performed and their outcome.
Example: IV established in left hand with 18 gauge rate TKO. Patient received three aspirin (324 mg) P.O., nitro sublingual. Patient indicates no pain relief after nitro. ECG established shows sinus rhythm as irregular with a rate of 86 and multifocal PVCs.
☑ Your impression
Using the information obtained, what do you think is clinically going on with the patient?
Example: chest pain cardiac related, cardiac dysrhythmia, dizziness
Link to part 2: How to Write Good Patient Care Reports Part 2 (of 5): Avoiding Vague Terminology in Patient Care Reports
We know you take good care of your patients. You know you take good care of your patients. But insurance companies reimbursing your claims don’t know how well you take care of your patients. It’s up to you to tell them.
What’s the best way of doing this? A detailed assessment of the patient AND the patient’s chief complaint during transportation. Part of this process is completely and accurately documenting the patient’s pain.
Following these tips when documenting patient pain does double duty:
it allows the receiving facility to get a complete and accurate picture of the patient’s pain in order to give quality continued care, and
it increases the likelihood of your claims getting paid by insurance companies.
Tip 1: Document the SEVERITY level of pain
On a scale of 1-10 (with 10 being the worst), how much pain does the patient report experiencing?
Tip 2: Document what causes VARIABILITY of pain
What increases the pain (movement, palpation, bearing weight, etc.) and what reduces the pain (ice, elevation, not moving the affected area, etc.)?
Tip 3: Document the MOVEMENTS of the patient at pain onset
What was the patient doing at the onset of pain (e.g. mowing lawn before onset, climbing a ladder and fell down, sleeping and was awakened by pain, etc.)?
Tip 4: Document the LOCATION of pain
What is the specific location of the pain? Be as specific as possible and include the laterality of the pain (which side of the body, and which specific body part is experiencing pain: e.g. pain is in the lower right arm, instead of just saying “arm pain”). Medicare and several other insurances require laterality when coding for insurance claims. If patient is experiencing abdomen pain symptoms, document which quadrant of the stomach is the pain is located in (e.g. patient is experiencing pain in the lower left quadrant of the stomach).
Tip 5: Document the TIME of pain onset
What time or how long ago did the patient report the pain starting? Remember to be specific!
Tip 6: Document your EVALUATION of the pain site
What did you find at the pain site? Was there swelling, deformity, bruising, tenderness, etc.? Was the patient guarding the area of pain?
Last week, Wisconsin Physician Services (WPS) hosted the Medicare Part B provider meeting. Some of the information provided at the meeting serves to benefit all EMS providers- topics including dispatch information and protocols, provider impressions, and Physician Certification Statement (PCS) legibility.
Dispatch information in patient care reports (PCRs) serve to give reviewers enough information to determine the level of response required and coordinating reimbursements. Recently, Medicare reviewers are not getting a clear picture of why EMS is being called to the scene. Not enough information results in the Centers for Medicare & Medicaid Services (CMS) requesting a refund. Emergency dispatchers should be using established dispatch protocols to assist in determining emergent or non-emergent response. They need to be able to gather enough information to determine if Advanced Life Support (ALS) or Basic Life Support (BLS) is needed. This is key in getting fast, accurate payment and avoiding audits.
The WPS reviewers indicated that some of the pull down boxes used for “dispatch reason” did not provide enough information to justify care level. One example provided was the use of the selection sick person in the pull down box for “dispatch reason for transport”. There could be many different situations for a sick person in which some would require an emergency response and others would not.
Insufficient provider impressions continually are an issue with WPS’s post payment audits. Many times, the information provided within the PCR does not accurately describe the patient’s medical condition at transport. The use of vague terms such as “weakness” or “fall” is not considered an adequate impression for reimbursement.
The impression indicated on a PCR should be obtained after a complete patient assessment is performed. Using your medical expertise, provide a sound medical impression of the patient’s condition using descriptive words. Instead of “patient has fallen” an accurate impression might read, “patient complains of pain to the right hip and discomfort upon movement and palpation”.
Be aware that the pull down boxes for the provider impression may not dictate enough information to prove medical necessity. If providers are using pull down boxes in their PCRs, follow up with more detailed information describing the patient’s assessment in the narrative.
The issue of legibility centers on manual PCRs and the completion of the Physician Certification Statement (PCS) form. The handwriting on some of these forms is difficult to read and knowing who signed the form can prove to be impossible. WPS’s recommendation is to either clearly print or type the name and the credentials of the person that signs the PCS form below their signature.
In addition, EMS providers should review the PCS form before transport to assure the appropriate signatures are legible. As a side note, some EMS agencies have found it beneficial to have the requesting facility fax the PCS form to them prior to transport. This allows them to review the form to assure medical necessity requirements are met and legibility is not an issue.
If you have any questions about your agencies patient care reports or documentation, contact us today to learn more about our helpful webinars and billing service.
To read more about this issue, download WPS’s “Rolling with Medicare Ambulance Requirements”.