Friday, December 15, 2017

Winter Weather, Injuries and EMS Documentation for Billing

‘Tis the Season!

Here in the Northeast we experienced the first significant snowfall of the year. Additionally, last week saw an unprecedented ice and snow event roll through even the Deep South.

Winter Weather, Injuries and EMS Documentation for Billing
Of course, all of us in EMS know that snow and ice bring falls. Bones are ripe for breaking when your patients slip and fall in the midst of adverse weather events. This time of year brings to mind that it’s time to review some tips for documenting these events in the Patient Care Reports (PCRs) we prepare to document the ambulance run.

Think Coding

When preparing your PCR following a weather-related incident, think coding.

ICD-10 diagnosis coding has ushered in a level of specifics that requires more detail to be documented about our EMS incidents. The codes that we use in the EMS billing office are organized by several criteria including anatomical location, injury categories and mechanism plus taking into consideration affected body systems.

Then there are the finer details such as the relational aspects of laterality. 

ICD-10 has made the entire process more intense and requires a level of field documentation that is more detailed than ever.

Example

You are dispatched to a fall victim located outside his residence. The dispatcher relays that you patient is an elderly male patient who has fallen outside and has a possible leg fracture. Your coverage area is in the middle of a present snow storm and as you make your way to the scene, the driving is fairly hazardous and slippery.

All ground surfaces are covered with a dangerous layer of ice.

You arrive on the scene to find your patient lying on the sidewalk. He had been trying to shovel the snow and slipped landing with his left leg underneath the weight of his body. Your initial assessment finds the patient complaining of considerable pain (a “10”) in the lower part of his left lower extremity just below the knee area.

You note swelling and bruising has already occurred and there is notable angulation in the distal portion of the tib/fib area.

Of course, you take all the necessary precautions, applying a splint to the extremity and move the patient to a long board having applied a c-collar before moving the patient.

Once upon a time…

Once upon a time, an EMS provider could document this scenario a bit more broadly. That documentation would have probably included a mention about the fact that the patient fell, was alert and oriented upon patient access and that the suspected injury involved a possible leg fracture.

We’re sure you did a good job painting the overall picture then. But, would the documentation of yesterday measure up to today’s requirements? 

Probably not.

Today

The ICD-10 reality that we live in today, requires so much more detail to be recorded in the PCR. Plus, every one of you wants to keep your billing office happy- right?

Let’s explore what we need to bring in from the field by way of documentation to meet the requirements of today.

Location, Location, Location…

Focusing on the injury itself, we must now remember we need to include not just that it’s a leg but what anatomical part of the leg injury.

So our new mindset will require us to document something to the effect…
“Upon palpation of the affected lower left extremity, the patient was found to have considerable stabbing pain which she rated as a “10” on a 1-10 scale in the distal area of the tibia/fibula section of the extremity just below the knee area. Upon examination, we found the area to be slightly angulated and asymmetrical with the same area of the right lower extremity. There was notable swelling and bruising to indicate that the traumatic injury most likely involved the potential for fracture in the general area described.”
Notice with just a few lines in our subjective narrative, we were able to adequately pinpoint the exact area of the injury, the suspected anatomical location of the injury, the pain level with a numeric qualification and a quality description of the pain in the patient’s own words along with the suspected type of blunt force trauma the patient experienced as a result of her fall from a standing position.

Sans this kind of focused specificity in your documentation, the billing office will potentially be unable to pick the appropriate ICD-10 code.

Other things to consider…

Of course, our example focused on an extremity injury but there are tons of other scenarios that can happen when bad weather strikes ranging from falls, exposure incidents to motor vehicle accident injuries. Consider the potential for injury from winter recreation activities like skiing or ice skating.

Now we’re thinking not only extremity injuries but also head injuries, chest and abdominal trauma ushering all kinds of injuries that go beyond fractures and may include circulatory and/or respiratory compromise.

Are you prepared to document these incidents with the correct level of detail? If not, time to brush up and get ready because the Winter of 2017-2018 is here!

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