Friday, February 7, 2014

Effectively Documenting Cold Weather Emergencies

Thanks to an unusual shift in the jet stream resulting in a prolonged visit from the phenomenon known as the polar vortex, much of the United States, including even such unlikely places as the deep South have seen one of the coldest winters ever to be recorded.

When prolonged weather events like this take place, EMS is faced with the presentation of emergencies arising from the cold, icy, wintery weather that accompanies such anomalies.

We thought it would be a timely topic for this week’s blog to focus on the documentation that’s necessary to capture the medical necessity of the effects of the cold on our patients in our Patient Care Reports (PCR’s).

Hypothermia and Frostbite
One of the common outtakes from prolonged cold is an uptick of emergencies arising from hypothermia.

In this environment, a simple fall victim lying outside on the icy tundra can turn into a much more serious emergency given the added complications from the patient experiencing prolonged exposure leading to hypothermia.

Consider grandma who ventures outside to walk the dog and winds up slipping and falling on the ice in her backyard. Her neighbors on each side are at work and no one notices that grandma has fallen, probably fractured a hip, leg, arm and is unable to get up to call for help. Consider that grandma may potentially lie outside in sub-freezing air temperatures for several hours, most likely lying in wet, inadequately layered clothing resulting in grandma’s core temperature plummeting to dangerous levels over time.

After several hours, grandma is discovered and her condition is now critical.

So to explain the medical necessity in your PCR for this hypothetical scenario you obviously are going to explain several key bullet points. You will be documenting…
  • Nature and mechanism of injury
  • Length of downtime and exposure to the elements
  • Patient’s condition upon initial assessment
    • Was there positive loss of consciousness?
    • What are the obvious injuries you observed?
    • Color, appearance and “feel” temperature of the patient’s skin
      • Are there signs of frostbite evident by discoloration?
    • If the patient is able to communicate with you, does the patient have feeling in the most distal portions of her extremities? If there is feeling, describe what the patient indicates to you (ie. numbness, tingling, cold, hot…)
    • Is the patient experiencing pain?
      • If “yes”, always include a 1-10 scale pain rating
      • If “no”, document especially if there is obvious injury as the lack of pain could indicate either an interruption in circulation to the affected area or could even indicate a potential spinal/cervical injury that has resulted in interruption to the nerve responses
    • Also it is important to not look at the obvious and miss the hidden. For example, be sure to document if the patient suffers from any chronic, ongoing medical conditions that can be exacerbated by this cold weather emergency on the surface such as any cardiac events, past history of MI’s, stroke, respiratory compromise such as COPD, asthma, etc.
    • Document if the patient is on any medications that could hasten the cold weather emergency side effects such as blood thinning medications or other medications that affect the patient’s circulatory system.
Unusual Accidents
As field providers, we are often presented with a host of unusual accident-related events as part of prolonged cold weather events.

Consider things like snow-related recreational vehicle accidents and the resulting injuries. There have been a few times in our memory where we have been presented with amputations, especially finger amputations from mishaps involving snow removal equipment. There are increases in falls from standing positions from walking, skiing, snow shoeing, ice skating…you name it. How about increased motor vehicle accidents resulting from slick roadways and black ice? Not only does the potential for increased mechanism of injury come into play, but once again the added complication of cold weather exposure following the accidents only complicate matters beyond what the normal mechanism of injury presents in its own right.

From the billing office, we ask that you “write books” about these scenarios. Many times, the billing office must sort out who the responsible party is before we can even bill out the claim.

For example, Mr. Smith pulls into his church parking lot on a Sunday morning. He gets out of his car and falls in the parking lot fracturing his hip. Who is billed for this event?

The answer to this question will hinge on what you, as the provider, tell us about this event. Be sure to adequately describe the scene and ask the following questions while documenting the answers to these questions….
  • Was there ice on the surface in the parking lot?
    • If ice, did you observe that there were attempts to spread anti-skid material?
  • Was the parking lot plowed of all snow cover?
  • Did the patient indicate he tripped and fell as a result of the potentially slippery condiations?
  • Did the patient or someone accompanying him who may have witnessed the event state that he suffered a near-syncopal episode prior to the fall which caused him to fall resulting in injury secondary to the medical event?
Questions like this with resulting clear, concise and detailed answers to those questions documented in your PCR written narrative will allow the billing office to make a decision as to what payer source is billed for this event. Will it be the church’s liability insurance or the patient’s medical insurance that receives the bill? Ultimately, your description and information in the PCR will determine the billing action that happens back in the office.

Work Related?
Also, always be sure to describe when such events are work related. If your patient suffers injury or illness that is weather related while employed (ie. shoveling snow, operating a plow or snow-removal equipment, repairing a boiler or heat source, working clearing tree limbs that have fallen due to ice build-up….you name it), then it’s important that you document that fact and attempt to collect contact information for the employer as your scenario has now turned into a potential workman’s compensation claim.

Packaging, Treatment, Moving, Transporting
Whatever you do in documenting your cold weather emergency scenario, don’t forget to document how you packaged, treated, moved and ultimately transported the patient.

Remember, as providers we must make a  case for why transportation by any other means would be contraindicated for your patient resulting in an eventual bill to an insurance payer source which we expect to be paid by who we sent the bill to and ultimately receive (or don’t receive) payment from.

Always record the treatments provided in the field and be specific. Record how you packaged the patient. Record how you moved the patient and ultimately transported the patient.

For example, your patient falls and fractures his right femur while cross-country skiing. He called 9-1-1 on a cell phone from somewhere approximately two miles from any paved roads. The patient indicates there is a fair amount of bleeding from the wound. You employ a specially equipped recreational vehicle from the neighboring department to access the patient, however there was a delay in reaching your patient due to the distance and the challenge of the terrain minus a convenient, direct access route. Be sure to document in your PCR that delay in reaching the patient and explain that special off-road equipment was required to access the patient. Remember, special handling and packaging explanations go a long way toward solidifying the medical necessity of your patient. 

You document that upon arrival you found the open fracture mid-shaft area of the femur. You will document that you were able to control the bleeding with direct pressure and elevation and was able to immobilize the fracture by whatever means and with whatever equipment you chose to use that was available to you. You further explain that once the fracture was immobilized you placed the patient on a long spine board with a cervical collar and CID’s in place and the patient was moved into a stokes basket using a six-person lift with the basket containing the patient then moved onto and secured to the four-wheeler and transported the distance from the wilderness to the waiting ambulance.

Once inside the ambulance, you document your efforts to begin warming the patient using heat packs in strategic body locations, you document your secondary survey and document in detail the events of the transport to the hospital. Of course your documentation will include that you assessed vital signs and monitored the patient’s overall condition including his level of consciousness while continuing to assess any complications from his prolonged exposure to the cold while lying on the snowy ground prior to your arrival. Certainly, ALS providers will document the establishment of IV therapy, application of cardiac monitoring and there would be expected to be notes in the PCR regarding the hemodynamic stability of the patient and the presence and/or absence of signs and symptoms of shock.

These details are necessary to “paint a picture” in words regarding this scenario and will adequately provide the billing office with the information it needs to properly prepare and code the claim for submission to the payer source.

ICD-10 Tie-In
Remember, all of this gets more intense as we move toward the October 1, 2014 transition to the use of the ICD-10 diagnosis codes. As in all previous discussions on this topic, it is very important that your billing office receives detailed, clear, clinical, concise documentation following each and every incident.

We remind all providers that ICD-10 will require the highest level of specificity you can apply to your documentation. For injuries, we must see exact, pinpointed descriptions written in your narratives in order that we, in the billing office, can apply the correct level of coding.

Remember, it’s important that a leg fracture now be documented as left or right. Injury location should be described as simple, compound, distal, proximal, medial and/or lateral. Complications must be recorded such as hemorrhaging, referred pain, secondary injuries, medical complications and all must be very, very specific.

The very nature of the ICD-10 coding sets are to pinpoint the exact location and derivative of the mechanism with a look toward the outcomes of your treatments in the end.

You get the picture…
By now we’re sure that you’ve read enough to get the overall picture of what your billing office will need to turn your PCR into cash.

As you can see these cold weather scenarios can be complicated with “a lot of moving parts.” Your adequate documentation of all these events in sufficient detail in order to paint a word picture describing your scenario will relieve the stress of the billing office in making sense of just what did happen out there, while determining which payer source is ultimately responsible to pay the bill.

Current Enhanced clients can lean on the many educational opportunities and dialogue that we conduct back-and-forth on a regular basis with our clients. Help is as close as a “Live Chat”, an e-mail or a phone call to Client Services away.

If you’re reading this blog and your billing office has never attempted to provide you with information to help you document cold weather or other complicated events, then it’s probably time to look for a billing office solution that will provide you with that kind of guidance. You’ve found the right place to start. Contact Chuck Humphrey today by e-mail at or call toll-free at (800) 369-7544, Extension 108.

And….stay warm!!! Spring will be here before you know it!
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