Friday, December 13, 2013

A “Fractured” Tale

That time of year…
The weather alerts started hitting the phone early this morning. Starting overnight, those of us here in Northeastern Pennsylvania will be anticipating a blanket of 4-6 inches of snow come tomorrow. Depending on where you are located as your reading this post, you may or may not be headed for the same thing or maybe even worse.

So, as all of us know in EMS, snow and ice bring fractures. Bones are ripe for breaking when we slip and fall during adverse weather events and so forecasts like the current one bring to mind what we need to remember when documenting these events in our Patient Care Reports.

ICD-10 Will Make It More Intense
If you regularly follow our posts, then you know that we have begun to include ICD-10 connections in many of our posts. A few weeks ago we provided an entire blog to introduce ICD-10 to our followers. If you haven’t read that piece, feel free to check it out in our blog post archives.

One of the things that ICD-10 will usher in is a level of drill-down into specifics that we’ve never before seen in healthcare. As you read in our previous blog on the subject, ICD-10 includes over 55,000 additional codes compared to the current ICD-9 for diagnosis reporting when filing medical claims of all types, ambulance included.

The codes that those of us in the billing office will be using are organized by anatomical site and injury categories and they are even separated by body system which will in turn require pre-hospital EMS PCR’s to become more detailed and clinical in nature than ever before in the history of the tie-in between treatment, transport and documentation that will lead to eventual payment of the claim.

ICD-10 makes this whole process more intense when it comes to documenting our scenarios.

You’re dispatched to a fall victim on the ice. The dispatcher announces via radio that you have a 72-year-old female patient who has fallen outside and she has a possible fractured leg. Your geographical coverage area is in the middle of a snow storm and the steering wheel and brake application on your rig tells you that footing is a bit uncertain both on the roads and especially on the sidewalks.

You arrive at the scene to find your patient had been outside trying to shovel some snow on her porch steps and she had slipped landing with her left leg underneath her when she fell. Upon your initial assessment, you learn that the patient is complaining of considerable pain which she loudly complains of in the lower part of her left lower extremity just below the knee. Swelling and bruising has already begun to set in and there is the appearance of slight angulation in the proximal portion of the tib/fib section of the extremity.

Of course, you take all the necessary precautions by straightening the extremity carefully, quickly apply the appropriate splint to the extremity and use a long board and c-collar to move the patient just in case there are other complications.

There was a time…
There was a time when one could describe this scenario a bit more broadly. Your documentation would probably include a mention about the fact that the patient fell, was alert and oriented when you encountered her, that the suspected injury possibly involved a fracture via traumatic injury to the lower left leg and then you would describe the treatment and packaging.

We’re sure you did a good job painting the overall picture but was it enough to satisfy the new, upcoming coding requirements…..ummmm…..probably not.

A New Mindset Requiring a New Level of Specificity
Moving forward into the ICD-10 world and to keep your billing office happy (unhappy billing people are not usually pleasant people…I can say that….I am one!) you need to pull out the stops and document your scenario with a new level of specificity. Doing so will require you to adopt a new mindset about documentation following your ambulance run.

So, rather than just mentioning the potential for injury to the leg, let’s explore what we need to do.

Location, Location, Location
Focusing on the injury itself, we must now remember we need to include not just that it’s a leg but what anatomical part of the leg injury.

So our new mindset will require us to document something to the effect…
“Upon palpation of the affected lower left extremity, the patient was found to have considerable stabbing pain which she rated as a “10” on a 1-10 scale in the proximal area of the tibia/fibula section of the extremity just below the knee area. Upon examination, we found the area to be slightly angulated and asymmetrical with the same area of the right lower extremity. There was notable swelling and bruising to indicate that the traumatic injury most likely involved the potential for fracture in the general area described.”
Notice with just a few lines in our subjective narrative, we were able to adequately pinpoint the exact area of the injury, the suspected anatomical location of the injury, the pain level with a numeric qualification and a quality description of the pain in the patient’s own words along with the suspected type of blunt force trauma the patient experienced as a result of her fall from a standing position.

Sans this kind of focused specificity in your documentation, the billing office will potentially be unable to pick the appropriate ICD-10 code beginning next October, because there will be no generic or “catch-all” code for simply a “broken leg.”

Other things to consider…
We focused on an extremity injury as our example for our purposes today, but consider all the other types of injuries and fractures that can result.

Mid-torso fractures such as rib cage and even, by extension, hip and pelvic fractures bring a whole larger more complex realm of potential injuries by extension to our documentation. Such items as pain radiation, multiple anatomical and system involvement, the possibility of circulatory system inclusion with potential hemorrhaging and internal organ complications all warrant that we be aware of multiple system treatments with the documentation of associated signs and symptoms that may stray from the primary injury site.

Our documentation now must include specifics about the various locations involved and systemic interaction and inclusion. Always remember, when your done writing your PCR someone else in the next step of the billing loop has to be able to match that scenario up with a very specific code that will represent the entire scenario to the insurance payer source.

Of course, bad weather also brings trauma from vehicle accidents, both motor vehicle and recreational vehicle in nature. If your service has any type of winter recreation areas within your primary response territory, such as ski resorts, ice skating rinks, parks with winter play areas….those kinds of places put you right smack dab in the middle of a plethora of winter weather events.

And….in another blog sometime we can even extend the conversation to the effects of extreme cold to such things as treatment, transport and subsequent documentation of hypothermia frost bite scenarios.

Get in the Habit!
Now’s the time to get in the habit of writing a better PCR.

Each time you sit down to document your runs, put yourself in the billing chair. Think about how your chart will pass through QA/QI for operations and then think further about whether or not your chart “paints a picture” in words to adequately describe your run to an insurance payer such that transport by any other means for this patient would be contraindicated.

If you read over your trip sheet and it’s clear that the patient could only have been safely treated and transported by EMS, then you’ve passed the test.

Of course, we advocate that you be truthful and also adequately describe those scenarios that involved your being called to a scene where maybe the patient didn’t quite need an EMS response and involvement. When that happens, your billing office will appreciate your candor as it will assist them in protecting your department from unnecessarily billing a claim for payment where the patient could have probably made another choice to seek attention for his/her injury outside of activating the EMS system.

Looking Ahead…
Everyone, here at Enhanced, is committed to getting the word circulated about the ICD-10 transition and what it means for our billing clients. It is our belief that we can make this important switch easily and efficiently with minimal effect to your department’s bottom line if you start to tweak up your documentation today.

Our Client Services folks are ready to answer current clients’ questions on these or similar subjects.

Readers of this blog who are part of a department that does not use Enhanced as a billing solution, can contact Chuck Humphrey to learn more about how your company can participate in the Enhanced discussion by becoming a part of our client nation. Talk to Chuck today at, by completing the “Get Started” area on our website or by calling him toll-free at (800) 369-7544, Extension 108.

Until we get together again next week, be careful out there and stay upright!!
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