Friday, February 12, 2016

Effectively Documenting Cold Weather Emergencies

Here in PA
This weekend is going to be the coldest weather we’ve experienced here in the area of our home office in Pennsylvania, so we're taking a break from our 'Billing for ALS 2' series. We'll pick back up with Part II in next week's blog. Considering the extreme temperatures we're about to face, we agreed that it would be a timely topic for this week’s blog post to resurrect portions of a post we featured two years ago during a similar cold snap.

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.

The Ambulance Billing Services blog is brought to you as an educational tool by Enhanced Management Services, Inc. Enhanced Management Services, Inc. is an all-EMS third-party billing contractor serving Fire/EMS agencies across the United States. To learn more about who we are and what we do, please visit our website at www.enhancedms.com and click on the “Get Started” button on any landing page.

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