CMS
Three words
with impactful meaning anchor our discussion today. The Center for Medicare and
Medicaid Services (CMS) sets the definition of medical necessity of an
ambulance patient that all of us in the ambulance billing industry strictly adhere
to.
The definition
centers on the clinical requirement “where
the use of other methods of transportation is contraindicated by the
individual’s condition.” The direction we receive from “The Feds” includes
the warning that EMS Patient Care Reports (PCRs) must include clear clinical documentation detailing
the ambulance transport incident verifying that the patient truly met the
clinical requirement.
Thus, once
explained in the PCR, Medicare, Medicaid and most other insurance payers will
reimburse the claim that your billing office submits for payment to cover the
costs for you to provide an EMS service to your patient.
So let’s
quickly breakdown our three key words.
Clear
The word
clear is used as an adjective, adverb or verb. The overriding definition in the
dictionary defines the word as denoting transparency or defining something as
easy to perceive, understand or interpret leaving no doubt or ambiguity.
The medical
necessity definition uses it as an adjective. So, clear clinical documentation
calls for the documentation in your PCR to be easily interpretive to describe
your patient’s medical necessity leaving no doubt or ambiguity that other
methods of transportation were contraindicated (or not) for your patient given
the condition they were in at the time of the transport.
It’s a very
simple concept when you think about it and yet we, in EMS, struggle with it
because many of us are just not good with words.
Remember
your PCR does not have to be a best-selling novel, but the words in your PCR
must be precise and clearly demonstrate why there was no other way to transport
your patient without endangering or further exacerbating the patient’s medical
condition.
If there
were another way to transport the patient without further endangerment of your
patient, then the decision can be made based on the clarity you’ve written into
your PCR as to whether it is best to bill to the insurance payer or direct to
the patient.
Clinical
Something is
clinical when it coincides with and involves the actual observation and treatment
of a patient. Of course we know that payment for ambulance is based on
transportation but observation and treatment happens in the transporting
ambulance, so the two go together.
This is
where the focus of your documentation is placed.
When we are
directed to support medical claim billing for ambulance transports by providing
clear clinical documentation in the PCR, the clinical part calls for EMS
providers to document that observation and treatment in such detail that it
paints a picture in words regarding everything that happened on the scene, in
the ambulance during transport and upon arrival at the facility leading to
patient transfer.
Clinical is
objective. Clinical involves numbers, readings and interpretations such as
vitals with numeric values, readings from medical instruments in the ambulance
with accompanied objective and scientific interpretations of the instruments’
values. The result is written statements about the patient’s medical condition
such that the reader of your documentation clearly has a laser view into the
patient’s condition in that moment of time.
It’s clear
that the authors of the ambulance medical necessity definition were
anticipating that every single ambulance transport that is billed for
reimbursement will be supported by a PCR that is written in adequate detail to
spell out the clinical relevance of the incident.
Documentation
And finally
after two adjectives, we arrive at the noun to anchor the phrase.
Documentation
is official information and/or evidence that comprises a record of an event or
happening. We use documentation to classify (such as choosing a procedure code
to denote the ambulance level of care- ie. Emergency vs. Non-Emergency, ALS vs.
BLS, etc.)
We also use
documentation to support the all-important ICD-10 diagnosis code that spells
out the patient’s condition at the time of transport. Here text is primarily
used to describe the patient’s condition and chisel in time the definitive
historical clinical record of this one ambulance event.
Because the
documentation is clear and clinical, the reader will be able to review the PCR
and gain a full understanding of why this patient, in this moment of time used
the ambulance for transport from one place to another in either an emergency or
routine non-emergency event.
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
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