Friday, August 31, 2012

EMS Patient Care Report Writing | Documentation 101 | Part 4b - Level of Service

Welcome to Part 4 b in our continuing blog series “EMS Patient Care Reporting Writing/Documentation 101”.

    Part 1: EMS Patient Care Report Writing
    Part 2: Field Notes
    Part 3: Patient Demographics 
    Part 4a: Nature of Dispatch - Emergency vs. Non-Emergency
    Part 4b: Level of Service

It's the fifth installment but we've labeled it "Part 4b" because it's the second part of a multi-post discussion on documenting the Nature of Dispatch.

In this post we'll be dealing with the importance of recording the dispatch in order to back up ALS Emergency level of service billed for the incident.

Dispatch sets the tone for billing…
Documenting the nature of dispatch of your call is vitally important for many reasons, but it’s especially important to support the billing of the level of service of the call.

Last week’s installment focused on the Emergency versus non-emergency definition and how dispatch contributes to the billing of the call.  This week we’re focusing on documenting the emergency dispatch level or priority to determine billing ALS versus BLS and we’re going to center our discussion on billing the call for ALS services this time around.

At what level is the call dispatched?
When the pager activates and you receive your dispatch, be sure to record the dispatch exactly as it’s given to you.  The level of service you are presented with when the emergency is relayed to you by the 9-1-1 center will go a long way in determining how the emergency is eventually billed.

If your 9-1-1 center uses a priority system, then be sure to record the initial priority as provided to you by the dispatcher.  Those priorities (example, Alpha, Bravo, Charlie, Delta or Priority 1, 2, etc.) have specific meaning and those definitions are documented at your dispatch center to label the determination of the call taker when making the decision on whether to send BLS or ALS ambulance responders to the emergency.

Medicare and almost all other insurance payers rely on this documentation to determine if your billing office has billed the call at the correct level, given the events of the incident as they unfold and as those events are documented to support the medical necessity of the call.  This documentation is key to setting the tone for the incident on the operations side and also for the later task of billing and collecting reimbursements dollars after the run is completed.

Possible ALS Scenarios
Below we’ll list a few scenarios that can take place and the documentation that must be included to support the billing of the claim.

ALS Emergency-
Your incident is dispatched as a possible heart attack.  The 9-1-1 center dispatches your MICU crew to the incident and announces that this is an…ALS Emergency, Alpha Response, Priority 1.  RECORD THIS!  You respond, treat the patient and transport.  Your documentation includes something to the effect “MICU 100 dispatched Priority 1 via ABC County 9-1-1 for a possible heart.”  The ALS responder provides care, patient is transported to the hospital and medical necessity and all treatments are documented.  The call is now billed at the ALS Emergency level.

ALS Emergency/Two-Tiered-
Let’s say your system is two-tiered where a BLS ambulance responds along with an ALS responding unit (MICU, Chase Truck, Fly Car, etc.).  Your dispatch would most likely announce, “Ambulance 20 with Medic 100 respond to a possible CVA, ALS Emergency.”  The documentation on both the ALS and the BLS run report should note this fact along with any priorities that may be part of your dispatch protocol. “Ambulance 20 dispatched Alpha Response simultaneously together with Medic 100 for male patient, possible CVA.”

BLS Emergency-Upgraded-
As an ALS ambulance or a BLS ambulance without ALS providers you may be dispatched to a BLS Emergency that then, based on the condition of the patient, need an upgrade in the care level.  Obviously, your documentation would include that you were dispatched BLS in nature.  However, upon arriving you determine that ALS services are needed.  Your documentation must include that the patient’s condition warranted ALS interventions and/or document that a separate ALS responding unit was called for and responded to upgrade the call.  Here is where dispatch and then results of the dispatch, your “arrived to find” documentation becomes very important.

How can we bill?
Let’s break down the scenarios above and determine the documentation required to support billing the claim in these situations.

Dispatched ALS, incident remains ALS (MICU)-
First, there’s the ALS Emergency that responded to by the MICU or ALS transport vehicle.  The crew arrives, finds the ALS emergency, treats the patient and transports.  Obviously, this call can be billed as an ALS Emergency and the dispatch and treatment/transport remains consistent.

Dispatched ALS, incident becomes BLS (MICU)-
Of course, we can always be dispatched ALS and a full ALS crew responds.  However, when the ALS provider assesses  the patient it is determined that the patient does not require ALS treatment and the BLS provider takes over patient care.  THIS CALL CAN STILL BE BILLED AS AN ALS!  Remember, the dispatch sets the tone for billing.  ALS Assessment is allowed for ALS billing by Medicare and most other insurances (there are some exceptions, read provider billing guides carefully).  However, it is important that the dispatch center clearly provides levels of dispatch otherwise ALS Assessment-only does not apply and the condition of the patient would default for billing.

Two-Tier Dispatch Similar to Above-
Similar rules apply to the two-tier scenario when separate BLS and ALS units respond to the same emergency.  However, there are a few wrinkles.

ALS arrives and assesses only- The BLS ambulance arrives on scene and the ALS response unit arrives, as well.  The ALS provider assesses the patient and determines ALS treatment is not needed.  BLS continues with patient care and transport while the ALS unit goes back in service.  THIS CALL CAN BE BILLED AS AN ALS due to the fact that the dispatch was recorded as requiring an ALS provider and the ALS provider arrived and assessed.  Assuming a Joint Billing Agreement exists between the two responding entities (BLS and ALS) the call is billed as an ALS emergency.

ALS arrives and commits to the call- This is cut and dried.  Dispatch, response, arrival and treatment is recorded in the PCR and the call is billed as an ALS.

ALS is cancelled by BLS prior to patient contact-  In this scenario, BLS arrives on the scene before ALS and it is determined that the nature of the incident does not require ALS level skills.  BLS returns ALS to service prior to arrival on the scene and/or patient contact.  THIS CALL IS BILLED BLS!!  In this scenario, even though the run was dispatched ALS, if the ALS provider never establishes patient contact then there is no assessment and the “Assessment-Only” provision does not apply and the call cannot be upgraded for ALS level billing by the BLS company which is billing the call.

BLS is BLS . . . but . . .
There is one final note to leave you with.  We’re often asked about BLS dispatches that involve an ALS or MICU crew responding by default.  Let’s say your ambulance staffs a full ALS crew but takes a BLS dispatch by default.  JUST BECAUSE AN ALS CREW RESPONDED TO A BLS CALL AND EVEN IF THE ALS PROVIDER TREATS THE PATIENT…if the patient’s condition remains BLS in nature and the patient requires no ALS treatment, then the call is BILLED AS A BLS Emergency.

But…should that ALS crew arrive on the scene of a BLS dispatched call and the crew determines that the patient’s condition has worsened or the call was not correctly dispatched and now the patient is documented as requiring ALS care, immediately upon initiating the ALS intervention the call becomes available to be billed as an ALS Emergency.  BE SURE THAT YOUR DOCUMENTATION FOR THIS TYPE OF SCENARIO IS DETAILED, PRECISE AND CLEARLY EXPLAINS THE NEED FOR ALS CARE!  Auditors will look for upgrade scenarios as part of their overview during billing review exercises.

Now it’s up to you!
Wow!  We don’t know about you but our collective brains hurt!  Did you ever realize that this documentation thing could get so technical?  Well, it’s part of what we do and the quicker you grasp these basic concepts, the faster you’ll be on the road to writing effective Patient Care Reports!

We hope the picture has begun to make sense for you as we piece this puzzle of effective Patient Care Report writing together in easily understandable and manageable parts.  Feel free to print these blog postings and share with your friends.  If you have any questions, be sure to e-mail your contact here at Enhanced.  My e-mail address is

Let me know what this series is doing to help you become a better Patient Care Report writer.  E-mail me with any suggestions you may have for topics we can cover as part of this series.

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