non-emergency coding clinic · ©2015, page, wolfberg & wirth, llc ... list of facilities and...
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Non-Emergency Coding Clinic
Day Two
Claim Documents
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2015-2016 Program Materials
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Assisted Living Dialysis Center
Community Hospital
Arendelle 99918
Elementary School
General Hospital
Neverland 99915
Holy Spirit Hospital & Select LTACH
Medical Center Apartment
Fantasyland 99916
Power Plant
Radiator Springs 99912
Frontierland 99913
Tomorrowland 99911
©2015, Page, Wolfberg & Wirth, LLC
Golden SNF
Outpatient Center
Monstropolous 99917
United Church
Hotel Magic SNF
Good Samaritan Hospital
MAP OF MAGIC KINGDOM
List of Facilities and Locations
Medical Center Trauma Center and 1,000 Bed Hospital 1 Magic Kingdom Way, Fantasyland 99916 General Hospital 500 Bed Hospital w/ ER 10 Atlantica View Rd., Neverland 99915 Good Samaritan Hospital 200 Bed Hospital w/ ER 14 Randall Dr., Monstropolus 99917 Holy Spirit Hospital 150 bed hospital w/ separate specialty center 100 14th St. Frontierland, 99913 Community Hospital 25 Bed Hospital and ER 6467 Race St., Arendelle, 99918 Select LTACH 10 Bed SNF, 20 Bed Hospital inside Holy Spirit Hospital (4th Floor) 100 14th St. Frontierland, 99913 Golden SNF 75 Bed SNF, with Hospice Care 2319 Sock Dr., Monstropolous, 99917
Magic SNF 100 Bed SNF and Assisted Living Facility 1501 Oswald St., Fantasyland, 99916 Assisted Living Personal Care Home, no skilled services offered 42 Wallaby Way, Atlantica, 99914 Dialysis Center Dialysis Center (not hospital based) 7878 Creek Run Road Frontierland 99913 Outpatient Center Ambulatory surgery & diagnostic services 14 Granite Dr. Radiator Springs 99912 Apartment Complex 150 Units 500 Dwarf Street, Fantasyland 99916 Power Plant 2320 Atlantica View Rd., Neverland 99915 Hotel 99 Olaf St., Arendelle, 99918 Elementary School 2004 Incredible Dr., Tomorrowland, 99911 United Church 1001 Acorn Way, Fantasyland, 99916
Magic Kingdom Department of Health - Approved ALS Drugs
1. Activated Charcoal 2. Adenosine 3. Albuterol 4. Amiodarone 5. Aspirin 6. Atropine 7. Calcium Chloride 8. Diazepam 9. Dilaudid 10. Diltiazem 11. Diphenhydramine HCL 12. Epinephrine 13. Fentanyl 14. Furosemide 15. Glucagon 16. Intravenous solutions (Dextrose, NaCl, Lactated Ringer’s) 17. Lidocaine 18. Lorazepam 19. Magnesium Sulfate 20. Midazolam 21. Morphine 22. Naloxone HCL (Narcan) IV 23. Nitroglycerin 24. Ondansetron 25. Sodium bicarbonate
+ EMT-B scope of practice includes transport of a patient with an existing IV lock, O2 administration, BGL check, and Narcan administration IM.
Signed:
Walt Disney, MD Medical Director, Magic Kingdom Department of Health
Effective Date: 7/1/2015
Mickey Mouse Ambulance Abbreviation List A&O Alert and Oriented
ALOC Altered Level of Consciousness
AMS Altered Mental Status
AOS Arrived on scene
ASA Aspirin
BVM Bag valve mask
CA Cancer
CAD Coronary Artery Disease
CC Chief complaint
CMS Circulation, motor, sensory
CP Chest pain
CVA Cerebrovascular Accident
CXR Chest X-ray
DC Discharge
DM Diabetes Mellitus
DOA Dead on Arrival
ECT Electroconvulsive Therapy
ED Emergency Department
EKG Electrocardiogram
EtCO2 End tidal carbon dioxide
ETOH Alcohol
HEENT Head, Eyes, Ears, Nose, Throat
HOB Head of Bed
HTN Hypertension
ICU Intensive Care Unit
IV Intravenous
JVD Jugular venous distension
LLE Lower left extremity
LS Lung sounds
MS Multiple Sclerosis
NC Nasal cannula
NIDDM Non-insulin Dependent Diabetes Mellitus
NKDA No known drug allergies
NRB Non-rebreather
NSS Saline
N/V Nausea/Vomiting
O2 Oxygen
O/S On scene
PEA Pulseless Electrical Activity
PERRL Pupils Equal, Round, Reactive to Light
PIV Peripheral IV
P/M/S Pulse/Motor/Sensory
POV Privately Owned Vehicle
PRN As Needed
P/W/D Pink/Warm/Dry
Q.D. Every day
SNF Skilled Nursing Facility
SOB Shortness of breath
SpO2 Pulse oximetry
TBI Traumatic Brain Injury
TKO To keep open
UOA Upon our arrival
UTO Unable to obtain
VS Vital signs
WNL Within normal limits
Y/O/(m)(f) Year old (male) or (female)
Note: This list of abbreviations is for illustration purposes only to provide a “key” for the abbreviations used on the PCRs in the Coding Clinics. These are not necessarily universally accepted or approved abbreviations that must be used on actual PCRs used by your ambulance service. This is not an exhaustive list of commonly used abbreviations, but just provides a sampling of abbreviations used in the Coding Clinics.
ICD-10 Codes
Note: These are just a small number of ICD-10 Codes listed for purposes of the coding clinics. This minimal list is for educational purposes only and does not suggest that these are the only (or best) ICD-10 Codes that should be used for ambulance billing purposes.
ICD‐10 ICD‐10 Code Definition
F29 Unspecified psychosis not due to a substance or known physiological condition
G89.29 Other chronic pain
I26.02 Saddle embolus of pulmonary artery with acute cor pulmonale
I46.9 Cardiac arrest, cause unspecified
I49.9 Cardiac arrhythmia, unspecified
I50.9 Heart failure, unspecified
I67.89 Other cerebrovascular disease
I69.954 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side
J96.00 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia
L89.100 Pressure ulcer of unspecified part of back, unstageable
L89.309 Pressure ulcer of unspecified buttock, unspecific stage
R06.02 Shortness of breath
R07.9 Chest pain, unspecified
R09.2 Respiratory arrest
R09.89 Other specified symptoms and signs involving the circulatory and respiratory systems
R10.8 Other abdominal pain
R10.84 Generalized abdominal pain
R10.9 Unspecified abdominal pain
R11.2 Nausea with vomiting, unspecified
ICD‐10 ICD‐10 Code Definition
R11.2 Nausea with vomiting
R40.241 GCS 13-15
R40.242 GCS 9-12
R40.4 Transient alteration of awareness
R41.82 Altered mental status, unspecified
R41.89 Other symptoms and signs involving cognitive functions and awareness
R51 Headache
R52 Pain, unspecified
R53.1 Weakness
R68.89 Other general symptoms & signs
R69 Illness unspecified
S09.90XA Unspecified injury of head, initial encounter
T14.80 Other injury of unspecified body region
V16.9XXA Unspecified pedal cyclist injured in collision with other nonmotor vehicle in traffic accident, initial encounter
W10.1XXA Fall (on)(from) sidewalk curb, initial encounter
W37.0 Explosion of bicycle tire
Y82.8 Other medical devices associated with adverse incidents
Z49.0 Preparatory care for renal dialysis
Z74.01 Bed confinement status
Z74.3 Need for continuous supervision
Z76.89 Persons encountering health services in other specified circumstances
Z78.1 Physical restraint status
Z99.11 Dependence on respirator/ventilator status
Z99.81 Dependence on supplemental oxygen
Z99.81 Dependence on supplemental oxygen dependence on supplemental oxygen
Z99.89 Dependence on other enabling machines and devices
ABC360 Coding Clinic – Checklist – Non‐Emergency
Run # Med
ical Necessity
Documen
ted?
(Y/N
)
Reason
ablene
ss M
et?
(Y/N
)
Transport to Co
vered
Destination?
(Y/N
)
Mileage Re
corded
? (Y/N
)
PCS Crite
ria M
et? (Y/N
)
Signature Va
lid fo
r Claim
Subm
ission?
(Y/N
)
Coding Comments 001 NE
002 NE
003 NE
004 NE
005 NE
006 NE
007 NE
008 NE
009 NE
010 NE
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Physician Certification Statement for Non-Emergency Ambulance Services
SECTION I – GENERAL INFORMATION
Patient’s Name: Mal Eficent Date of Birth: __6/28/1939_________
Transport Date: 9/30/15 (PCS is valid for round trips on this date and for all repetitive trips in the 60-day range as noted below.)
Origin: Medical Center Destination: Magic SNF
Is the pt’s stay covered under Medicare Part A (PPS/DRG?) YES NO
Closest appropriate facility? YES NO If no, why is transport to more distant facility required?
If hosp-hosp transfer, describe services needed at 2nd facility not available at 1st facility:
If hospice pt, is this transport related to pt’s terminal illness? YES NO Describe:______________________________________________
SECTION II – MEDICAL NECESSITY QUESTIONNAIRE Ambulance Transportation is medically necessary only if other means of transport are contraindicated or would be potentially harmful to the patient. To meet this requirement, the patient must be either “bed confined” or suffer from a condition such that transport by means other than ambulance is contraindicated by the patient’s condition The following questions must be answered by the medical professional signing below for this form to be valid:
1) Describe the MEDICAL CONDITION (physical and/or mental) of this patient AT THE TIME OF AMBULANCE TRANSPORT that requires
the patient to be transported in an ambulance and why transport by other means is contraindicated by the patient’s condition:
Bed confined, unresponsive, decreased GCS
2) Is this patient “bed confined” as defined below? Yes No To be “bed confined” the patient must satisfy all three of the following conditions: (1) unable to get up from bed without Assistance; AND (2) unable to ambulate; AND (3) unable to sit in a chair or wheelchair 3) Can this patient safely be transported by car or wheelchair van (i.e., seated during transport, without a medical attendant or monitoring?) Yes No 4) In addition to completing questions 1-3 above, please check any of the following conditions that apply*:
*Note: supporting documentation for any boxes checked must be maintained in the patient’s medical records
Contractures Non-healed fractures Patient is confused Patient is comatose Moderate/severe pain on movement
Danger to self/other IV meds/fluids required Patient is combative Need or possible need for restraints
DVT requires elevation of a lower extremity Medical attendant required Requires oxygen – unable to self administer
Special handling/isolation/infection control precautions required Unable to tolerate seated position for time needed to transport
Hemodynamic monitoring required enroute Unable to sit in a chair or wheelchair due to decubitus ulcers or other wounds
Cardiac monitoring required enroute Morbid obesity requires additional personnel/equipment to safely handle patient
Orthopedic device (backboard, halo, pins, traction, brace, wedge, etc.) requiring special handling during transport
Other (specify)
SECTION III – SIGNATURE OF PHYSICIAN OR HEALTHCARE PROFESSIONAL
I certify that the above information is true and correct based on my evaluation of this patient, and represent that the patient requires transport by ambulance and that other forms of transport are contraindicated. I understand that this information will be used by the Centers for Medicare and Medicaid Services (CMS) to support the determination of medical necessity for ambulance services, and I represent that I have personal knowledge of the patient’s condition at the time of transport. If this box is checked, I also certify that the patient is physically or mentally incapable of signing the ambulance service’s claim and that the institution with which I am affiliated has furnished care, services or assistance to the patient. My signature below is made on behalf of the patient pursuant to 42 CFR §424.36(b)(4). In accordance with 42 CFR §424.37, the specific reason(s) that the patient is physically or mentally incapable of signing the claim form is as follows: Minnie Mouse, RN 9/30/15
Signature of Physician* or Healthcare Professional Date Signed (For scheduled repetitive transport, this form is not valid for
transports performed more than 60 days after this date). Minnie Mouse Printed Name and Credentials of Physician or Healthcare Professional (MD, DO, RN, etc.) *Form must be signed only by patient’s attending physician for scheduled, repetitive transports. For non-repetitive, unscheduled ambulance transports, if unable to obtain the signature of the attending physician, any of the following may sign (please check appropriate box below): Physician Assistant Clinical Nurse Specialist Registered Nurse Nurse Practitioner Discharge Planner
This is a sample only and does not constitute legal advice. User bears all responsibility for compliance with all applicable laws and regulations.
Run 008-NE
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