Friday, November 14, 2014

Grading the Documentation Pop Quiz-Scenario 1

How did you do?
Last week in this space we began a 3-part series that we entitled “Our Documentation Quiz.” If you missed it, we suggest that you skip down and read the post or you’ll be lost by reading this week’s post.

We presented two hypothetical EMS scenarios and then we asked a few questions to make you think how you would handle the documentation in the Patient Care Report (PCR) if you were the EMS provider on the incident.


Grading to Documentation Quiz
Now it’s time to grade your quiz. How’d you do?

This week we’ll discuss Scenario 1 and next week we’ll tackled Scenario 2.


Scenario 1…

Scenario 1 involved the 85 year old male patient who was reportedly bedbound for which you picked up a Physicians Certification Station (PCS) at the nurse’s station which also documented the patient as bedbound. However, you arrived at the patient’s room to find him sitting in a wheelchair ready for his return ride back to the skilled nursing facility (SNF) where he normally is a guest.

We asked these questions.


Is the patient bedbound?

The correct answer here is “No.” Our patient is NOT bedbound.

We can hear some of you saying, “But, the PCS says he’s bedbound!”


Unfortunately, that PCS is pretty much a worthless piece of paper because you found the patient seated in a wheelchair. Do you remember the bedbound criteria set forth by CMS? What are those criteria? There are three bullet points and if the patient is able to do any one of the three he cannot be bedbound. Those three criteria are…

  1. Patient is unable to sit in a chair
  2. Patient is unable to get up from bed without assistance
  3. Patient is unable to ambulate
Simply, our patient is sitting in a wheelchair. He’s not bedbound.

Is there a potential problem with medical necessity?
The correct answer is “Yes.”

Establishing medical necessity for ambulance transport and later seeking payment from Medicare is suspect because this patient’s overall condition begs for an explanation why at least a wheelchair capable vehicle cannot be used to transport this patient. If you are going to establish medical necessity for this patient there must be some good reason. That reason must be documented in your overall findings within the PCR to prove that transporting this patient by any other means other than an ambulance would jeopardize the patient’s health and well-being.

How will your documentation answer the question…?
We posed the next question in our little quiz like this…
  • “How will your documentation answer the question; ‘Can this patient be safely transported in another vehicle other than an ambulance?’ “
Obviously, there is no yes/no answer to this question. This one requires a bit of an essay approach.

We’ll guess that you kicked around some similar scenarios in your brain, remembering a dozen or so such patients who weren’t bedbound but had a real legitimate reason to be transported by ambulance.


We believe that the majority of PCR’s we read for guys like our hypothetical patient really aren’t medically necessary and no amount of creative documentation will make them medically necessary. That is unless you want to go to a place where no EMS documentation should ever go…to that place of half-truths or outright dishonesty. There’s just no place for that in our business!


What discussion will you have…?

Our final question was this…
  • “What discussion will you have with the call-intake and/or supervisor once you return from your run? And…we followed with…
    • Should you consider a conversation with your supervisor before you take this run and why?
We’ll answer here by suggesting that there be continual dialogue between street providers and office staff at all levels. We suggest, in this case, that the folks back at the station be made aware of this patient so there can be follow-up communication with the facility staff and even the doctor that signed-off on the “bedbound” PCS document.

On the follow-up and sub-question, the answer is “maybe.”


Are you empowered by your EMS agency to notify senior staff and/or administration regarding a questionable transport scenario? We hope you are. To avoid the possibility of completing this run and not being able to collect reimbursement it would be favorable to discuss this patient with your superiors before transporting to avoid reimbursement failure in the billing office.


However, if you choose to proceed with the transport then, given our scenario, we’d suggest that you fully assess the patient and determine the patient’s compelling medical necessity reason- a reason that you are willing to stand-by with effectively documenting the scenario in the PCR you complete following the run. You must provide clear clinical documentation in your PCR to make a case for the patient’s transport by ambulance to justify subsequent reimbursement for said transport.


Before you document the first word in your PCR narrative, there’s a strike against you because your PCS does not accurately reflect the patient’s condition (he’s not bedbound!) You’re faced with an uphill battle. And maybe, just maybe, the person doing the call-intake could have smoked this one out before you even arrived on the scene. That’s a whole blog in itself- another time another post!


The Ambulance Billing Services blog is brought to you as an educational service of Enhanced Management Services, Inc. Enhanced Management Services, Inc. is a full-service, all-EMS third-party billing contractor with Fire/EMS clients located across the United States. For more information about the EMS billing features to benefit your EMS agency, visit our website at www.enhancedms.com and click on the “Get Started” button.
Post a Comment