documentation and billing. ems documentation uses legal record continuity of care with hospital...
TRANSCRIPT
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Documentation and Billing
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EMS Documentation Uses
• Legal record• Continuity of care with hospital• Internal quality assurance• Billing record
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Today’s Environment
• Government focus on fraud• Increased audits• Legally collecting every dollar • EHR—privacy vs. access• Increased litigation
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Important Areas
• Dispatch• Medical Necessity and Reasonableness– Why was an ambulance needed?– What was the level of service provided?
• Mileage• Destination• Forms
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Dispatch
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Dispatch Documentation
• “Emergency” status:– How were you dispatched– How did you respond
• Reported condition of patient– ALS assessment
Example: Dispatched 911 and responded immediately to report of difficulty breathing
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Dispatch Documentation
• Date and time• Point of pick-up with zip code– Payment based on pick-up location
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Medical Necessity
• Definition of medically necessary:– Transport by any other means is contraindicated
• Document why an ambulance was needed• Medicare will only pay for medically necessary
transports
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Medical Necessity
Medical necessity is presumed if the record adequately documents one or more of the following:
• Unconscious or in shock• Hemorrhage• Acute stroke or myocardial infarction• Accident or injury or acute illness
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Medical Necessity
• Immobilization of possible fracture• Required oxygen (not self-administered)• Required emergency measures or treatment• Required restraints• Stretcher required• Bed confined
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Documentation Goals
• Provide accurate information on the patient’s condition and your findings
• Provide sufficient information for a proper billing decision to be made
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Bed Confined
Definition: All 3 must be true!• Unable to safely get out of bed; and• Unable to safely ambulate; and• Unable to safely sit in a chair
Example: Pt unable to get out of bed or ambulate without assistance due to extreme vertigo and was unable to sit unassisted…
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Documenting Level of Service
• BLS• ALS 1• ALS 2• Specialty Care• Deceased on scene
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BLS
• Service can be emergency or non-emergency• EMT-B level of care• Often harder to document than ALS
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ALS-1
• Patient condition requires EMT-I or EMT-P interventions
• Document your assessment and interventions• ALS dispatch downgraded to BLS transport– Dispatch documents ALS crew required– ALS crew provides a hands-on assessment
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ALS-2
• Same as ALS-1 plus any ALS-2 procedure– Manual defib/cardioversion– Endotracheal intubation– Central venous line– Cardiac pacing– Chest decompression– Surgical airway– Intraosseous line OR…
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ALS-2
• Same as ALS-1 plus 3 or more IV medications– Must be 3 separate full doses of one drug, or– 3 different drugs
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Specialty Care
• Interfacility transport• Patient is critically ill or injured• Service level is beyond the scope of EMT-P
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Deceased on Scene
BLS level of service can be billed if:• Patient was pronounced deceased after
dispatch• Patient was not transported
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Mileage• Only charge for loaded miles• New fractional mileage rules• Acceptable documentation– Odometer readings– Trip odometer– GPS device
• Medicare pays to closest appropriate facility– diverted
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Destination
• Name of hospital/facility• Limit abbreviated names• Destinations that are not payable:– Physicians office– Rendezvous with another ground ambulance
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Forms
• Patient signature• Hospital face sheet• EMT Signature• Physician Certification Statement (PCS)• Advanced Beneficiary Notice (ABN)
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Documentation and Billing
Systems Design
Thank You!