Our “Documentation Review as a Habit” series rolls into Part VI with a discussion about capturing timing in the Patient Care Report’s (PCR’s) documentation.
Not only is there an importance placed on documenting the correct date and time of the incident, chronologically, but there is even more importance placed on the timing of the illness or injury in relation to normal versus abnormal life events and the very trigger for the activation of the EMS system for the EMS incident being recorded.
The relational factors have a direct impact on the ICD-10 diagnosis coding of the EMS incident which is where much of today’s discussion will land.
Date of Service
It seems like a “no-brainer” but you’d be surprised at the number of PCRs that arrive in our billing office with an incorrect Date of Service.
How does this happen?
Quite simply, a PCR with an incorrect Date of Service is probably a product of the author’s procrastination. The EMS incident occurs today but today has been busy. The EMS provider and author of the PCR ends his/her shift having not completed the PCR and returns tomorrow (or the next day…) and completes the PCR in the ePCR program.
However, because tomorrow is not the day of the incident guess who forgot to change the default date of the incident from today (which is “tomorrow) back to yesterday (which is the today of the incident.) Your billing office most likely does its pre-billing check and notices that the patient signed the authorization form and dated his signature with yesterday’s date but you turn in the PCR completed containing today’s date.
Other ways of picking up on incorrect dates of service also include a mis-match of dates on the hospital face sheet or differing dates between the Physicians Certification Statement (PCS) and the PCR.
Time of Day
Don’t miss the importance of documenting the correct chronology of the events that took place as part of your EMS incident in the PCR.
It is extremely important in both the QA/QI realm plus proving to insurance payers that the payment they are about to make is justified, to document the events that took place at what time and in relation to other events, treatments and interventions.
For operations, protocols are established on the “if this, then that” criteria. Following them may lead to the billing arena, especially when determining the level of service and the application of the correct HCPCS procedure code (Emergency, Non-Emergency, ALS, BLS, SCT, etc.)
Your Incident Described in Relevance
Where diagnosis coding is concerned, many incidents must be described by documenting timing intervals of the injury or ailment itself.
Here is a good lesson in the proper use of appropriate wording in the written narrative portion of your PCR.
As EMS providers we must use words that capture the patient as he/she describes his/her need to call for your help. We document that the medical emergency was a “sudden attack” or was a “flare-up” or “eruption” and can be a convulsion or a seizure that has “recurred.”
We label the incident as acute, chronic and we etch the treatment and transport scenario in time with relation to other previous and coming events as either post- or pre- .
Describe the patient’s need for ambulance services as regular or irregular. Patients will tell you that their pain is occasional, periodic, cyclical, rhythmic, “here and there” or “on and off.” Or, the patient may describe and you subsequently document the scenario to be constant, permanent, regular or continual.
All of these word combinations denote time in the sense of relevance and are important in assisting your EMS billing office in choosing the most appropriate ICD-10 diagnosis code to describe the EMS incident when billing to a payer source.
Final Word- An Example
We close with the example of the myocardial infarction (MI) which is one of the most common scenarios that EMS providers deal with almost daily.
Consider that an MI can be coded and reported by duration such as I21.3 (acute with stated duration of 4 weeks or less). There is a code for an MI that is “healed and old” (I25.2) and there is a code to capture when the patient dials 9-1-1 while experiencing distress following recent cardiac surgery (I97.190). Also applicable can be the “subsequent” MI (recurrent in nature) which applies the code I22.9.
Of course, this list is not all-inclusive but used to emphasize the point that time and relevance are extremely important in light of the coding decisions made by your billing office following the incident.
The Ambulance Billing Services blog is brought to you as an educational tool by Enhanced Management Services, Inc. Enhanced Management Services, Inc. is an all-EMS third-party billing contractor serving Fire/EMS agencies across the United States. To learn more about who we are and what we do, please visit our website at www.enhancedms.com and click on the “Get Started” button on any landing page.