Friday, February 14, 2014

The “Heart” of the Matter

Affairs of the Heart
Today is February 14th. It’s the day that we traditionally celebrate love.

Valentine's Day GiftsIt’s Valentine’s Day, named in honor of the patron Saint of Love Valentinus who was martyred on this day late in the third century A.D. But then again history records that there may have been about a dozen men that carried the moniker “Valentinus” as it is derived from the Latin word for worthy, strong or powerful so there are references to various popes of the time period calling each “Valentinus.”

Personally, I think that a guy named “Hallmark” teamed up with a florist and Milton Hershey of chocolate fame to fleece a whole lot of money out of guys like me.

Anyway, since today is a day when we think of love and when thinking of love we characterize the day with a big red heart. So, we thought it appropriate to blog about documenting cardiac or “heart” scenarios.

Coronary Events
We have many names for coronary events in EMS. Attempting to document the nature of the scenario using the closest terminology is a good start. We refer to MI (myocardial infarction), heart attack or CHF (congestive heart failure). Then there’s ACS (acute coronary syndrome) and a bunch of drill downs into related terms such as A-Fib (atrial fibrillation), SVT (supraventricular tachycardia), unstable angina, the dreaded STEMI (ST Elevation MI)…and the list goes on.

As we know, many of these scenarios are life threatening. They require quick action in the field and there is very little time to think.

So when it comes to documenting these events, following the treatment and transport scenario we must rely on good notes and prints of the field “machines” to give us the data necessary to paint a word picture describing the medical necessity for billing purposes.

Well drilled…
Fortunately, we’re well drilled in these events. As providers, we practice these scenarios on a regular basis as part of the job. Therefore, the protocols are familiar to us and we can easily remember many of the steps we take while we are treating and transporting these patients.

Standard protocol in acute coronary events for both the ALS and BLS provider is to begin a cardiac run where the patient presents with, most likely, chest pain or discomfort accompanied by unstable tachycardia or bradycardia. Document those initial findings.

Then next we will bet that you are going to begin to mention your actions, typically beginning by administering oxygen and probably noting the oxygen saturation values delivered via pulse oximetry.

The ALS provider notes that treatment most likely began with the application of a cardiac monitor and most likely will include in detail the findings of a 12-lead ECG in the field.

Chest Pain
With pain we always recommend recording the pain rating on a 1-10 scale. That’s an important part of the documentation process. In addition, you will be recording if your patient relates that he/she has radiating pain such as pain radiating to the jaw, left shoulder or left arm. Female patients may also complain of referred pain into left upper back.

In addition are there any secondary complaints that may or not be cardiac in nature accompanying the primary complaint of chest pain?

Continuing with the emergency scenario, documenting treatments is extremely important.

What treatments did you perform as part of the cardiac emergency? You will obviously document the steps you took to follow the appropriate EMS system protocol for your practice location.

At the billing office, we’ll anticipate seeing the administration of low dose or “baby” aspirin and the quantity administered (typically four 81 mg chewable tabs or 324 mg total), IV initiation, and most likely the introduction of nitroglycerin sublingually.

Of course, depending on the scenario you may be also given orders to administer at least a first dose and possible follow-up doses of narcotics analgesic (fentanyl or morphine sulfate.) It goes without saying that it is important to record the number of administrations, the dosages and it’s every bit important to record from whom and when the order was given for those administrations (if applicable within the protocol.)

BLS documentation either before or without ALS in the picture, should document those items that are appropriate and within the scope of practice for a BLS provider, including recording vital signs, oxygen administration, attempts to calm the patient and even possibly your assisting the patient to self-administer pre-prescribed medications, typically nitroglycerin.

BLS should note if ALS was part of the initial dispatch or was requested upon arrival on the scene. In a two-tiered, joint billing system it is important for the BLS transporting entity to note the ALS providing the assistance so the billing office can accurately bill and later split the reimbursement dollars appropriately per the written ALS Intercept agreement that is in place between the ALS and BLS entities.

It’s a no brainer that your documentation will include vital signs. Many billing offices love to see cardiac monitor strips appended to the Patient Care Report. Pulse oximeter readings come into play. And, by extension there are other values such as glucometer readings to be recorded too.

When nitroglycerin is administered it is vital to have recorded multiple blood pressure readings in order to note that such administration was warranted and did not place the patient into a relative but potentially fatal hypotensive episode.

And…should the patient move into cardiac arrest, your documentation will now unfortunately turn into a mini-novel that should document every portion of the events leading up to, relative to the arrest event and, of course, the outcome.

Routine Transports
There are times when cardiac-related events can be routine in nature, such as in chronic conditions such as ongoing Congestive Heart Failure (CHF).

These patients we see sometimes more than once. We typically transport them for diagnostic testing and ongoing evaluations. Many of these people wind up being institutionalized, so it’s important to have effective call intake procedures and forms to relay the relevant nature of the need for transport.

Of course, while CHF and cardiac events may sound serious and most times they are, in the chronic patient is the patient’s condition at the time of transport such that moving the patient using any other mode of transportation other than an ambulance would be detrimental to the health and well-being of the patient.

Also, as part of the routine event we must clearly explain the exacerbation of the chronic cardiac event and the nature of that exacerbation above and beyond the patient’s daily baseline that triggered the need for ambulance transport.

In our world, most significant is answering the question to the insurance payer- most importantly to Medicare and Medicaid- why the payer should pay a claim for a patient that has CHF or chronic coronary events as part of their ongoing long term care plan.

Ambulatory Patients
This discussion could actually go on for many more pages, but we’ll begin to wrap up by reminding our readers that in emergent scenarios coronary events are one of a handful of events where recording that the patient walked to the ambulance may not affect medical necessity. Typically a patient who can ambulate is not necessarily the easiest candidate to establish medical necessity for your post-scenario documentation in the PCR.

However, we’re sure you can relate many emergency dispatches that involved a very ill patient walking to your ambulance clutching his chest and you find that an acute coronary event, even life-threatening, is taking place.

Of course, always truthfully document how the patient presented to you and the events leading to your care and transport of the patient. If the patient walked to the ambulance, then your documentation should note that he/she walked to the ambulance.

Give us enough information at the billing office level and we’ll effectively be able to outline your event to make our best attempt to collect the correct level of appropriate reimbursement.

How to Show Your Billing Office the “Love” They Deserve
Since today is the “love” day of the year; how can you show your billing office the “love” they deserve?

The easiest way to do this is to help make their job easier. It’s a two-way street.

Members of the billing office are rarely also on the street. Therefore they need you to document what you see, hear and do in the field to make their job easier. Remember to provide clear, clinical documentation that adequately presents a medical necessity picture of your patient.

It will be fairly easy for your billing office to complete their duties if you do yours by providing a killer PCR.

We love our Enhanced clients. And, they show us love by writing top-notch PCR’s.

But, maybe you are sitting there thinking… “My billing office doesn’t deserve the love!”

Why? We ask.

You continue, “They give us no guidance. They don’t teach us the fine points of documenting our trips. We never receive feedback from them and frankly we’re not sure if they understand what they are doing when they receive our PCR’s.”


It appears that it’s time to take a good look at your billing solution if these words could have come from your mouth.

Call Enhanced Management Services today. Chuck Humphrey is standing-by to learn more about your EMS department and how Enhanced can provide you the support to gain top reimbursement dollars.

You can reach Chuck by calling our toll-free number at (800) 369-7544, Extension 108 or why not e-mail him today at

From all of us here at Enhanced, we wish you a Happy Valentine’s Day!
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