Friday, November 1, 2013

Discovering the Weakness about “Weakness”

Common Scenario
If we earned a dollar for every “weakness” response we’ve handled over the years, collectively we could more than adequately fund every EMS system in the United States with the newest trucks, latest equipment and all providers would be driving some expensive European luxury car.

But, now that we’ve awakened from the dream we all realize that while weakness is one of those very vague runs, it’s also a very weak (no pun intended) scenario to establish medical necessity and eventually collect reimbursement.

“What are we supposed to do… ?”
During a recent documentation training we conducted for a client the discussion moved to weakness.

The Medicare Administrative Contractor (MAC) for the jurisdiction where we were conducting training had previously issued a billing alert noting that the ICD-9 code for weakness showed up on their radar screen for suspected diagnosis codes not supporting adequate medical necessity to justify payment.

When we shared this information with the attendees, there was the typical moan and groan throughout the room. The collective group comment went something like this…
The billing office doesn’t understand. Sometimes the patient only complains of weakness and we don’t really have much else to go on. So what are we supposed to do when we write our PCR narrative if that’s all we have?
Saved by the Command Physician…
On this day, the host department’s command physician was seated in the front row. As he listened to the providers’ complaints that day he asked us if he could speak to the issue.

Certainly, we graciously gave the floor to the doc.

His comments were insightful. He relayed to the staff that he is faced with the same scenario in the ER that they face in the field. However, instead of taking the glass half empty view he offered the opposite.

Our doctor friend coached those in attendance that day about an assessment and questioning technique he learned that proves vital at getting at the heart of the matter when the complaint is weakness.

He recommended that the providers consider asking questions during their assessment and treatment of the patient that begins to establish the patient’s normal baseline activity.

Using probing questions he recommended that pre-hospital providers follow his lead to determine what the patient does on a normal day. This would include such questions for the patient and/or family, caretakers, friends, neighbors, etc. about the patient’s normal routine.

What’s a normal day look like for this patient? How did today differ from what the patient normally does or differ from how the patient thrives on a regular basis? What caused you to activate the EMS system today?

Baseline Creates Contrast
He explained that by questioning to establish a baseline of “normal” activity for these patients, even though today’s scenario may appear to be vague there is a lot that can be learned about this patient. A lot of information can be collected for later documenting the scenario by clearly establishing how the patient’s overall condition differed today to the point that the EMS system was activated.

In addition, this information will be vital once providers hit the ER door in saving time and effort for the physicians at the ER regarding the next step in treatment to resolve the patient’s complaint(s).

Your documentation may look something like this:
MICU 92 arrived on scene to find a 75 year old female complaining of overall weakness of about 1 hour in duration. Patient stated that she just had no energy and felt “washed out.” Per family on scene, this patient normally has a morning routine that involves arising early without wake-up prompting, showering and grooming, fixes and eats a hearty breakfast while reading the morning newspaper. However today, it was noted that the patient was difficult to arouse having slept for at least two additional hours past her normal awakening time. The patient appeared to have a slightly altered mental status, did not shower as normal and without eating breakfast returned to her room where the family found her slightly incoherent in her bed.
Certainly, documenting such detail helps to paint the picture regarding the patient’s overall condition at the time of the EMS scenario.

Other Contributing Factors
Of course, establishing a baseline deviation is only one of the factors that needs to be documented.

Other details you would assess and then document in your PCR would potential include vital signs, checking sugar levels, noting if the weakness is reported to be limited to any one particular area of the patient’s body, associated signs and symptoms such as accompanying shortness of breath or unusual pains, etc.

In addition, it will be quite helpful to collect information and document any medication allergies, medication routine changes (recently new or recently discontinued medication regimens, for example), possible environmental factors such as potential poisonings (inhalation, ingestion or absorption) or any socially-related stresses or changes that could have triggered or contributed to the patient’s weakness condition.

If suspecting internal causes, of course assessing and documenting the results of a Cincinnati Stroke Scale assessment and/or even any notable past medical history factors must be collected and passed on via documentation for an ongoing record of this patient’s medical necessity (or lack thereof).

Not So Cut and Dried
It’s these scenarios, especially in the routine transport arena, that drive ambulance crew members and administrators crazy. Sometimes there just is no easy cause and effect to be extracted.

This makes documenting these scenarios even more challenging than others.

Plus we know that almost all of the MAC’s, States’ Medicaids and even some Commercial payers have issued cautions regarding their suspicions concerning the medical necessity viability when the ICD-9 code for “generalized weakness” is presented to the payer as justification for reimbursement for the resulting insurance claim.

Of course, we’ve stated in past blogs about the detail that ICD-10 coding will require of your documentation next year. Weakness scenarios will be one of those issues that will drive EMS billing offices crazy when the time comes. The detail that we are recommending for your documentation will be more important than ever when the 10th round of ICD diagnosis codes are finally in play.

What Are Your Department’s “Weaknesses”?
Is the documentation that your providers are completing as part of the run on weakness calls lacking in substance?

Regularly review your completed PCR’s for weakness scenarios. Where are your weaknesses with regards to that same documentation?

Enhanced clients are used to our questions regarding vague documentation. Our staff works with clients all the time to help brush-up on PCR writing that comes from coaching regarding techniques used to adequately assess and record the results of the assessments.

A potential client just told us the other day that they never hear from their current billing contractor regarding documentation issues. My comment is that either this department is tops in their field regarding documentation (denied by the administrators) or the billing company just isn’t doing the job they should be doing.

Enhanced does more than bill. We are the documentation coach and ambulance claim biller. If your department’s billing office isn’t giving you necessary feedback about weakness calls and other common scenario’s, then it’s time to consider a change.

We’re ready to serve you. Contact Chuck Humphrey today at chumphrey@enhancedms.com or toll-free at (800) 369-7544. Strengthen your position on “weakness” once and for all!
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