Friday, January 10, 2014

Documenting and Billing “Brain Attacks”

CVA- Cerebral Vascular Accident or what we most commonly refer to as a “stroke” can be one of the most challenging and life threatening emergencies that we handle in EMS.

The scenario is literally a “brain attack.” When part of the brain is damaged or destroyed because it’s deprived of blood, it can present an emergency for the patient that may, at the very least, alter the quality of life or in the most extreme cases steal life from the patient altogether despite our best efforts to mitigate the circumstances.

What’s happening right now?
One of the things we continually remind those who read this space and the clients we serve on a daily basis, is when documenting our treatment and transport scenarios we must always remember to focus on “What’s happening right now?”

Stroke scenarios are one of those things that we work with both in an emergency and then later, following an acute event, on the non-emergency or routine transfer side, as well.

All providers are naturally in tune with the fact that anything related to stroke is a “perk-your-ears-and-pay-attention” type of deal. So somehow it becomes engrained in us to think that anything with the word stroke in it must be legit.

Well that can be the case but depending on what we’re doing today, some stroke-related issues that are what we call “late effect” can prove to be more difficult to establish medical necessity for an insurance payer than we providers may think.

So, once again, please allow me to remind each and every one of you to focus on the here and now when documenting these runs- emergency or non-emergency alike. CMS (Medicare and extension to Medicaid) categorically reminds us over and over that they are not interested in the past history. They are not that interested in even the “late effects” of a past event, but are mostly focused on whether or not their programs should pay for ambulance transport based on the condition of the patient at the time of each and every individual transport.

Therefore, when documenting your ambulance run in order to establish medical necessity, you must use the written word to paint a picture with those words that adequately describe the patient’s need for transportation by ambulance- RIGHT NOW AND IN THE PRESENT MOMENT!

The past is the past…
Because strokes can be so severe in nature, we want to think that we have to recall the past in order to make the case for medical necessity. We’ve read many patient care reports, here in the Enhanced billing office, that recount the past CVA and the resulting effects on the patient.

That’s fine.

However, what we typically find is that’s where the explanation ends; especially for the more routine transports and non-emergency scenarios.

But, what the documentation often lacks is a concise explanation of the patient’s condition right now, in the moment.

Remember, you must answer for Medicare and other insurance payers, why your patient could not be safely transported by any other means other than your fully-staffed and fully-equipped ambulance with the resulting highest transport costs of any other means of moving that patient from Point A to Point B.

It’s your burden as the caregiver to make that case on behalf of the department you serve. To do so involves concisely explaining why your patient needed your services which included stretcher transport and medical assessment with monitoring, instead of any other type of less-intensive transportation such as in a van or a car.

Emergencies are much easier
Certainly, you get a break on the emergency side….well at least a tiny break, because emergencies are much easier to document. The event is happening now, the signs and symptoms are presenting now and your treatments follow a narrow protocol set so you can focus on documenting that in-the-moment stuff more clearly.

Emergencies lend to better documentation focus than non-emergencies do because we typically have more information available to us and we don’t have to drill down so far to find that vital information.

There’s no doubt there will be quite a bit to write about your emergency scenario if you are also doing a good job with properly hands-on assessing the patient in the field.

We really like when providers turn in a PCR with a full recount of a Cincinnati Stroke Scale assessment. Why? Well, frankly it’s a good set of indicators and is easily recorded as one of the tests, so to speak, that can be done in the field that would lend credence to the possibility the patient is in the throws of a CVA. The assessment clearly establishes the patient’s deviation from his/her normal baseline when completed properly.

But there are so many other signs, symptoms, assessments and values you can record in your PCR for the emergency call involving a possible stroke.

Noting such items as numbness (especially when the numbness or even tingling is limited to one specific side of the body or the other), severe headaches (remember, it’s a pain so ask the patient to rate it on a 1-10 scale), blurred vision (tested by a simple “number-of-fingers” assessment), notations of slurred speech, facial drooping, specific sudden-onset paralysis, falls and balance problems, and maybe even sudden unusual memory problems.

Of course there are even more detailed assessment findings such as pupil size and reactivity, fixed gazes and staring issues and don’t forget the seizure patient may even be suffering a stroke as part of the blood-flow interruption to the brain especially when the seizure if prolonged and without return of consciousness within a reasonable amount of time following the seizure and/or without a history of seizure activity.

All these items must be noted in your PCR.

And then there is the litany of treatments that arise from your assessment. You’ll be documenting anything from IV therapy initiation to aspirin administration to oxygen use along with reports provided to the receiving facility and any changes in the patient’s overall condition physically and cognitively.

Time passage is important
Of course, while gathering information about your patient you’ll want to note the approximate time of onset of symptoms. This is especially useful if the CVA turns out to be an ischemic stroke in nature so the receiving facility can determine if thrombolytics or “clot busters” can be administered quickly to resolve the blockage and minimize any long-term effects for the patient following the event.

Non-Emergency Documentation
The most severe stroke suffers may require transportation from either home or form a long term care facility for some time following the stroke. It is important to document these transports very carefully and precisely when painting the word picture to establish medical necessity.

Paralysis is one of the most common long-lasting side effects causing a patient with stroke history to require the use of an ambulance for transport after the emergent event has passed. The key question to ask, however, when arranging the transport is to ask the patient or patient’s representatives regarding the normal baseline activity for that patient.

If the patient is able to safely sit in a chair or even a wheelchair for the same time of potential duration of the ambulance transport, then what makes the transport require an ambulance vehicle instead of a wheelchair or paratransit van?

Where CMS raises the hairy eyeball is when they conduct a review and find in the nursing notes from the skilled nursing facility or inpatient charting that the patient was able to sit up without ill effect for the same amount of time he/she would need to sit for transport to and from treatments, etc.

Insurance payers especially like to question the medical necessity of a patient who is able to ambulate in any manner.

Also, we’ll need to determine and then adequately explain why the patient could not receive whatever treatment or evaluation is required within the confines of his/her home or as part of the treatment and care plan that exists within the physical boundaries and location of the long term care facility where he/she currently is staying. Even if medical necessity is established for your patient, if the transport does not meet the destination requirements for payment of the transport (such as when the patient is transported to a doctor’s office) then even explaining adequate medical necessity for your patient won’t make a difference in the payment determination. However, it may fall upon you, as the provider, to make notations of these issues so your billing office can sort out who they will ultimately send the bill for payment after your run is completed.

Of course, always document the obvious such as severe paralysis requiring stretcher transport, contractures, severely altered mental status and/or negative levels of consciousness, demonstrated inabilities to sit in chairs and/or inabilities to ambulate or self-transfer. All those things, including your explanation of why the patient meets the bedbound criteria (unable to sit in a chair, unable to ambulate, and unable to get up from bed without assistance) is critical toward your end-goal of truthfully and accurately explaining your patient’s need for ambulance transport for the safety and security of your patient on that day and for that treatment and transport scenario.

Finally…don’t forget the basics
Lastly, remember to record the basics.

Full sets of vital signs are always to be documented- emergency and non-emergency alike. Diagnostic values must be recorded in your PCR such as blood pressure readings and dextrose levels as determined. Cardiac monitoring results are also important, especially if it is found that the patient has or has suffered from atrial fibrillation which could be an indicator in embolic brain attack events.

Your turn to apply…
CVA or stroke, either in the moment or for the resulting late effects, is one of the events that can trigger the need for ambulance treatment and transport.

Our goal today is to remind you of all the variables that can factor into your documentation as you’re preparing your Patient Care Report to establish medical necessity for your patient. We encourage you to apply what you’ve hopefully learned here today to elevate yourself to a new realm of documentation.

We’ll be glad to answer any questions you may have and we welcome your input and comments on this or any other subject we’ve blogged about.

Enhanced clients can reach out to our Client Services staff for assistance.

Readers of this blog space who are affiliated with an EMS department that is not yet an Enhanced client but recognize that your billing office may not be providing you with this type of in depth guidance, are urged to talk to Chuck Humphrey today for more information about the benefits of becoming an Enhanced client.

Chuck can be reached by e-mail at or by phone, toll-free at (800) 369-7544, Extension 108.
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