PART 3 - DOCUMENTATION · ICD-9-CM vol. 1 & 2 (Diagnosis Codes) ICD-10-CM (Diagnosis Codes) 3-5 characters in length 3-7 characters in length Approximately 13,000 codes Approximately

PART 3 - DOCUMENTATION

Presented by

Steve Wirth, Esq., CAC, CACO, CAPO

Dan Pedersen, Esq., CAC, CACO, CAPO

www.pwwemslaw.com

5010 E. Trindle Road, Suite 202 Mechanicsburg, PA 17050

717-691-0100 717-691-1226 (fax)

[email protected] [email protected]

© COPYRIGHT 2015, PAGE, WOLFBERG & WIRTH, LLC. ALL RIGHTS RESERVED. REPRODUCTION BY ANY MEANS EXPRESSLY PROHIBITED WITHOUT

THE WRITTEN CONSENT OF PAGE, WOLFBERG & WIRTH, LLC.

ICD-10 FOR THE

AMBULANCE INDUSTRY

mailto:[email protected]

mailto:[email protected]

2015

Page, Wolfberg & Wirth, LLC ● 5010 E. Trindle Rd., Ste. 202 ● Mechanicsburg, PA 17050

www.pwwemslaw.com ● 717-691-0100 ● Fax – 717-691-1226

Stephen R. Wirth, Partner [email protected]

Steve Wirth is a founding partner of Page, Wolfberg & Wirth, LLC, and is one of the best known EMS attorneys and consultants in the United States. Widely regarded as the nation’s leading EMS law firm, PWW represents private, public and non-profit EMS organizations, as well as billing companies, software manufacturers and others that serve the nation’s ambulance industry. In a distinguished public safety career that spans four decades, Steve has worked in virtually every facet of EMS – as a first responder, firefighter, EMT, paramedic, flight paramedic, EMS instructor, fire officer, and EMS executive – and was one of central Pennsylvania’s first paramedics. Steve brings a pragmatic business-oriented perspective to his diverse legal practice having served for almost a decade as senior executive of a mid-sized ambulance service, helping to build the company from the ground up.

Steve is a dynamic and sought after speaker at regional, state and national conferences on a variety of EMS and public safety subjects. He has authored numerous articles and book chapters on a wide range of EMS leadership, reimbursement, risk management, corporate compliance and workplace law topics. A contributing writer for JEMS, (where he serves on the editorial board), EMS Insider and EMS World, Steve has co-authored the highly acclaimed and popular compliance manuals and video training programs produced by PWW. He enjoys teaching and is an adjunct instructor for the University of Pittsburgh EMS degree program.

Steve graduated cum laude from Duquesne University School of Law and was a member of the school’s national trial and appellate advocacy competition teams. He is admitted to all Pennsylvania state courts, all federal district courts in Pennsylvania, and the United States Court of Appeals for the Third Circuit. Steve also holds a Master of Science degree in Health Services Administration with an emphasis in organizational behavior.

Steve remains in touch with patient and field provider issues as an active EMS provider and nationally certified firefighter with Hampden Township Fire Rescue where he serves as Incident Safety Officer and Medical Officer. He is a life member of the Nippenose Valley Fire Co. near Jersey Shore, PA, where he started his public safety career as a junior firefighter and served as Deputy Fire Chief. Steve has volunteered for many charitable organizations and is currently on the board of the Pennsylvania Fire and Emergency Services Institute and the Pennsylvania EMS Providers Foundation. Steve is a Certified Ambulance Coder (CAC) and a founder of the National Academy of Ambulance Coding (NAAC). He is a past Commissioner for the Commission on Accreditation of Ambulance Services (CAAS), and served as Chair of the Panel of Commissioners. Steve was the recipient of the prestigious James O. Page Leadership Award in 2013.

http://www.pwwemslaw.com/

2015

Page, Wolfberg & Wirth, LLC ● 5010 E. Trindle Rd., Ste. 202 ● Mechanicsburg, PA 17050

www.pwwemslaw.com ● 717-691-0100 ● Fax – 717-691-1226

Daniel J. Pedersen, Esquire [email protected] Daniel Pedersen is a Senior Associate Attorney with the nationally recognized law firm of Page, Wolfberg & Wirth, LLC. The firm represents ambulance services, municipalities, fire departments, hospitals, and other organizations in a wide range of medical transportation issues.

Daniel joined PWW in 2005, after spending several years at a health care firm in Harrisburg, PA. At Page, Wolfberg & Wirth, Daniel concentrates his legal practice in the areas of compliance, Medicare reimbursement, HIPAA, and federal and state regulatory issues that affect ambulance services, including the false claims act and anti-kickback statute. Daniel spends much of his time performing compliance and claim reviews, including on-site visits and training sessions, and handling Medicare appeals on behalf of clients around the country. Daniel is admitted to practice law in Pennsylvania.

A 1998 Graduate of Franklin & Marshall College in Lancaster, PA, Daniel majored in Biology and English before attending law school. While at Franklin & Marshall, Daniel was involved with the yearbook, Pep band, golf team, Biology club, and served as an Orientation Advisor. He earned his J.D. from Pace University School of Law in White Plains, NY in 2002, and spent his third year of studies as a visiting student at Widener School of Law in Harrisburg, PA. While at both Widener and Pace, Daniel was a research assistant for law professors. While on sabbatical from law school in 1999, Daniel worked as a Quality Assurance Analyst for Wyeth-Ayerst Laboratories in Marietta PA. Daniel resides in Hummelstown, PA with his wife and three children. As a family, they enjoy such activities as reading, swimming, playing golf and tennis, and vacationing in Myrtle Beach.

http://www.pwwemslaw.com/

IMPORTANT NOTICE FOR SEMINAR ATTENDEES The information presented in this seminar and these supporting materials does not constitute legal advice or a definitive statement of the law. These materials are for educational purposes only and to provide a general overview of the issues discussed. The information contained in these materials and discussed at this seminar are subject to change at any time by new laws or regulations, repeals or modifications of existing laws and regulations, court and agency decisions, and in numerous other ways. While our materials are, whenever possible, based on official sources of information from Medicare and other government agencies, you must consult the official sources of materials from those agencies – including regulations, manuals, policies, advisory opinions, etc. – for official statements of the law and government policy. Of course, we cannot be responsible to update these materials for you, nor are we responsible for any documentation, billing, compliance, reimbursement, legal or other decisions you make based in whole or in part upon these materials. We use examples of documentation, billing scenarios and other teaching illustrations throughout this seminar, and they are just that – examples. Do not use any wording in your own documentation unless it is truthful and accurate. While we believe the information presented in this seminar and in these materials to be accurate, errors (such as typographical or other content errors) are possible. Ensure that your agency’s legal counsel is aware of any specific legal issues you may have. All materials are the Copyright of Page, Wolfberg & Wirth, LLC unless otherwise noted. No part of this material may be duplicated, reproduced or distributed by any means. No audio, video and/or digital recording of any type is permitted at this conference. By attending this seminar, and/or utilizing these materials, you agree to these terms and conditions.

© Copyright 2015 PWW Media, Inc.

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ICD-10 for the Ambulance IndustryPart 3 of 3: Documentation

May 20, 2015© Copyright 2015 PWW Media, Inc.

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Today’s Webinar New Era of “Documenting for Detail” Clinical Documentation Improvement

(CDI) for EMS Documentation Compliance Checklists

(DCCs) CDI Queries CDI Implementation, Training, Auditing

and Evaluation Documentation Examples


PLEASE NOTE Any examples of documentation used in this

presentation are strictly for illustrative purposes only. These examples should not be used as “templates” or

“scripts.” Your agency’s documentation must be based on an objective assessment of the patient by your crews, accurately reflect the patient’s clinical condition, and should be honest, complete, and

accurate at all times!


New Era of “Documenting for Detail”

Essential with ICD-10


Clinical Documentation

Defined: a digital or analog record detailing the EMS patient encounter to include accurate, timely and specific descriptions of the patient assessment, condition of the patient, and treatments/services provided


The Goal

Clinical documentation that accurately and precisely as possible reflects the patient’s condition and services performed, so we can have…

Billing codes that accurately and precisely reflect that patient’s condition and the services performed


We Are All in This Together!

Partnership between field providers, billing staff, dispatch, quality assurance, training, and management

Develop standards for documentation – then communicate, train, evaluate, provide feedback – and improve!

Communication and training are the key




ICD-10 is not just a coding challenge.

It’s a documentationchallenge.

ICD-9-CM and ICD-10-CM Comparison

ICD-9-CM vol. 1 & 2 (Diagnosis Codes) ICD-10-CM (Diagnosis Codes)

3-5 characters in length 3-7 characters in length

Approximately 13,000 codes Approximately 68,000 available codes

First digit may be alpha (E or V) or numeric; Digits 2-5 are numeric

First digit is alpha; Digits 2-3 are numeric; Digits 4-7 are alpha or numeric

Limited space for adding new codes Flexible for adding new codes

Lacks detail Very specific

Lacks laterality Has laterality

Example: 453.41 Venous embolism and thrombosis of deep vessels of proximal lower extremity

Example: I82.411 Embolism and thrombosis of right femoral vein

21

Identified in the January 16, 2009 – HIPAA Administrative Simplification: Modification to Medical Data Code Set Standards to Adopt ICD-10-CM and ICD-10-PCS Final Rule © Copyright 2015 PWW Media, Inc.

Diagnosis Code Structure

S52.311A Greenstick fracture of shaft of radius, right arm, initial encounter for closed fracture

Root Root Root Site Severity Etiology Extension

S 5 2 3 1 1 A

Injury, poisoning and certain other

consequences of external

causes

Injuries to the elbow and

forearm

Fracture of

Forearm

Radial Shaft

Greenstick Right Initial Encounter

22


“New” Documentation Concepts

Specificity – more detail as to types of injuries, anatomic location, location of incident, etc.

Laterality – accurately describing which side of the body is affected by the insult or injury (left, right, bilateral)


Specificity Example - Fracture

ICD-10-CM ICD-9-CM

S72031A Displaced midcervical fracture of right femur, initial encounter for closed fracture

82002 Fracture of midcervical section of femur, closed



The “Clinical Documentation Improvement” (CDI) Process

for EMS


Why EMS Documentation Is So Difficult

Because each health care consumer has his or her own unique combinations of medical conditions that your EMS agency must somehow standardize for data comparison and to ensure compliant reimbursement


CDI Bridges the Gap!

Field Providers Document in Clinical Terms

Billers Code Claims in Diagnostic Terms


Goal of Clinical Documentation Improvement (CDI)

ICD-10 is an opportunity to improve clinical documentation and enhance patient care for all patient conditions

CDI is a team process that does that – sharpening the focus on obtaining the highest level of documentation possible


What is CDI?

A process for improving the quality of clinical documentation – to facilitate an accurate representation of the services provided through complete and accurate reporting of patient assessment, procedures, and transport performed


Role of CDI

Impacts quality measures and data used in health care reform and other initiatives that requires more specificity in clinical documentation

Improves accuracy of clinical documentation to reduce compliance risks, minimize audit vulnerability, and provide insight into legal quality of care issues




CDI Promotes . . .

Positive patient outcomes through improved continuity of care

Accurate reflection of the level of care provided to the patient

More precise information for quality improvement measures and for public health purposes


In Today’s Audit and Enforcement Climate a Clinical Documentation Improvement (CDI) Program is Absolutely

Essential!


The Key to High Quality PCR Documentation is a Complete,

Thorough and Well Documented Patient

Assessment!


A Systematic Approach to Patient Assessment Leads to a

Systematic Approach to Patient Documentation


Assessment Elements

Scene evaluation and size-up Initial patient assessment

• Identify/assess life threats• General impression of patient’s

condition Rapid Trauma or Medical Assessment


Assessment Elements

Focused History and Physical Exam Detailed Physical Exam Ongoing Patient Assessment




Acronyms Can Help Crews Remember Key Assessment

Elements


A.V.P.U.

A = awake, alert and oriented x4 V = alert to voice but not oriented x4 P = responsive to pain stimulus only U = unresponsive to both voice or

painful stimulus


D.C.A.P. – B.T.L.S.

D = Deformities C = Contusions A = Abrasions P = Punctures or penetrations B = Burns T = Tenderness L = Lacerations S = Swelling


D.O.T.S

D = Deformities O = Open injuries T = Tenderness S = Swelling

• Addressed for each area of the body


S.A.M.P.L.E.for Patient History

S = Signs and symptoms A = Allergies M = Medications P = Pertinent past medical history L = Last oral intake E = Events that led up to the situation


O.P.Q.R.S.T

O = Onset P = Provocation Q = Quality R = Radiation S = Severity T = Time




Documentation Narrative Formats

S.O.A.P. C.H.A.R.T. C.H.E.A.T.E.D.


S.O.A.P.

S = Subjective O = Objective A = Assessment P = Plan


C.H.A.R.T.

C = Chief Complaint H = History (Present and Past) A = Assessment R = Rx or Treatment T = Transport and condition enroute


C.H.E.A.T.E.D.

C = Chief complaint or concern H = History E = Examination A = Assessment T = Treatment E = Evaluation/effectiveness of

treatment D = Disposition


Elements of the CDI Process

Identify Common

Conditions

Define Documentation Requirements

Communicate Documentation

Standards

Constantly Review the CDI Process

Audit Documentation

Practices


1. Identify the Most Common EMS Patient Conditions

ALS and BLS treatment protocols CMS Condition Code list Evaluate historical run data by chief

complaint Statewide or regional protocols




Examples - Emergency

Chest pain Abdominal pain Nausea and vomiting Emergency childbirth Hemorrhage Possible stroke Fall victim


Examples - Nonemergency

Inter-facility transport Discharge from hospital to SNF Transport ESRD patient for dialysis Transport for specific treatments

(rehab, radiation, etc.) Transport from SNF to hospital for

direct admission Psych transports


2. Define the Documentation Requirements for Each Condition

Review national texts, curricula, treatment protocols

Obtain medical review committee and medical director input

Involve field staff


Bottom Line

Develop list of key elements that must be assessed and documented for each primary patient condition encountered

Audit PCRs based on these elements Provide feedback, constructive

counseling and training to promote improvement


If You Don’t Measure It . . .

You can’t MANAGE it You can’t CONTROL it You can’t IMPROVE it


3. Communicate the Documentation Standards

Communicate documentation elements for key patient conditions

Integrate CDI training into all aspects of leadership and staff training• Initial orientation• Continuing education• Remedial education




4. Audit Documentation Practices by Patient Condition

Audit PCRs using standard documentation elements necessary to document each condition

Identify documentation strengths and weaknesses • On an individual basis• On an agency basis using “trends” to target

additional documentation training


Audit Documentation Practices

Provide follow up concurrently –initiate a CDI Query on inadequate PCR documentation

Provide follow up retrospectively –communicate audit stats and model additional training based on common issues of weakness


5. Constantly Review the CDI Process

Evaluate common strengths and weaknesses and modify approach as necessary

Evaluate appropriateness of CDI Queries to ensure focus is on the clinical documentation

CDI Oversight Team to meet quarterly


Developing “Documentation Compliance Checklists” (DCCs)


Develop “Documentation

Compliance Checklists” for

Each Primary Patient Condition


EMS Patient Conditions

Every primary patient condition encountered by a field provider should have an established checklist of issues that must be addressed in the documentation




Example Condition: “Pain”

Issues that should be documented:• O nset• P rovocation• Q uality• R adiation• S everity• T ime


Example Documentation Compliance Checklist –

Abdominal Pain


Abdominal Pain

Initial Assessment?• ABCs and Chief Complaint

Focused History and P.E.?• How and where was patient found?• Skin color, temp, condition• Location and quality of pain

Associated Symptoms PQRST


Abdominal Pain

Abdominal Assessment• Tenderness• Rebound tenderness• Rigidity• Guarding• Pulsatile masses• Surgical scars


Abdominal Pain

Back pain? (location, quality, radiation, etc.)

Female – menstrual period normal? Nausea and vomiting? Bowel movements? Urination (pain, color, amount,

frequency) Position of comfort?


Abdominal Pain

Oral intake and meals? Fever? Other signs and symptoms? Allergies? Medications? Pertinent past medical history? History of present illness? Vital signs




Abdominal Pain

Interventions?• Oxygen• Cardiac monitor• IVs or saline lock• Medication administration• Position of transport

Response to treatments? Condition enroute and at hospital?


Example Documentation Compliance Checklist –Altered Mental Status


Altered Mental Status

Patient oriented to time?• Knows time of day?

Patient oriented to place?• Knows where they are?

Patient oriented to person?• Knows who they are and others around

them? Patient oriented to situation?

• Knows what is happening?


Altered Mental Status

Syncopal episodes? Glasgow Coma Score assessed and

documented at intervals? Neurological assessment completed? HPI and PMH obtained?


Example Documentation Compliance Checklist –Refusals of Transport or

Treatment


Refusals of Transport/Treatment

Complete patient assessment documented?• Past history of mental issues?• Medications that impact mental status?• Suicidal ideations?• Risk to self or others?





Patient’s mental status? (“A&Ox4”?) Glasgow coma score? Attempts to persuade patient and

patient’s response? Communication with family members

at scene?



Patient’s understanding of possible injuries/illness?

Discussion of the risks and consequences of non-transport explained?

Patient’s understanding of the risks? Alternatives for care and transport

suggested by the crew?



Contact with Medical Command? Recommendation to seek medical care

in some way? Offer to return if patient changes

mind? Providing follow-up instruction?



Actual refusal form read to and understood by patient?

Obtain patient/witness signature


DCCs apply to demographic documentation as well as

clinical documentation


Example Documentation Compliance Checklist –Patient Information and

Demographics




Patient Information/Demographics

Full patient name documented accurately

Pt DOB recorded in mm/dd/yyyy format Complete address of P.O.P. and patient

home address documented


Patient Information/Demographics

SSN documented Signature of patient obtained If patient incapable of signing,

specific reason documented and signature of authorized representative obtained


When You Need More:Proper Use of “CDI Queries”


CDI Query Process

Key element of CDI is provider communication

A “CDI Query” is a routine communication and education tool used to advocate complete and compliant documentation and to ensure accuracy of the PCR


Types of CDI Queries

Written Queries• Based on established documentation

elements for specific patient condition• Helps avoid miscommunication on “why”

the query is being made


Types of CDI Queries

Verbal Queries• Usually for elements that are simply

missing or for minor issues• More likely to be “misconstrued”




When to Query?

Lack of clinical indicators of an undocumented condition (e.g., suspected shock as a “provider impression”)

Need for further specificity or degree of severity of a documented condition (e.g., pain)


When to Query?

Clarifying a potential cause and effect relationship

Missing fundamental information necessary for that particular “condition” or “chief complaint”


The Proper Query

When additions, clarifications or amendments are required, it is critical to reinforce that proper documentation is the goal

Avoid even the appearance of “suggestive” documentation


Compare“Suggestive”

“Your PCR fails to document medical necessity. Please document bed confined status so we can bill this.”

Proper

“This PCR does not document whether the patient could ambulate, sit in a chair/wheelchair or get out of bed unassisted. Please complete accurately according to observed pt condition.”


The Effective “CDI Query”

It is critical to be precise, not only in what you say but how you say it

Be sure to communicate these requests in a way that your intent cannot be misconstrued

Always emphasize importance of accuracy and honesty in documentation

Why Must You Emphasize Honesty,

Accuracy and Completeness?




Billing Investigations

Investigators may interview your crew members

This often happens even before your agency knows of the investigation

“Have you ever been asked to change your patient care reports for billing purposes?”

“Have you ever been asked to put down that the patient was bed confined when the patient was not bed confined?”

“Have you ever been asked to write an addendum to add things that you knew were not true?”

“Have you ever been told never to write that a patient walked to the stretcher?”


Points for Providers

Being asked to clarify, amend or append your documentation does not mean you are being asked to falsify documentation

Providers should never be told to document anything that isn’t true, and they should not be directed on what to write for billing purposes



The focus of any documentation query must be on improving clinical documentation

If a PCR is incomplete or unclear, field providers should be asked to make it complete and accurate – that is the provider’s job



Having a complete and accurate PCR that paints a clear picture is an essential part of patient care

If you didn’t do that the first time, we have every right to ask you to do it the second time


SAMPLE “Clinical Documentation Query Form –

Non-Emergency Transport”

Model form only! You will need to decide how to use this form – e.g., part of patient record, or worksheet to be used for crews to complete an addendum

Only implement after you establish a policy on use of queries and you train your personnel



CDI Tips for Implementation, Training, Auditing and Evaluation


Training Must Change!

QA staff and supervisors need to focus on CDI

Communicate the documentation standards for each key condition

Involve front line staff in finalizing the Documentation Compliance Checklists (DCCs) before they are implemented


Training Must Change!

CDI must be incorporated into the feedback and evaluation process –the 360 degree feedback loop

This re-emphasizes the critical importance of CDI in your agency!


Conducting CDI Audits

Consistently track compliance with DCCs over time

These key elements can be quantified into numbers• E.g., “26% of the time, your PCRs with

a chief complaint of “abdominal pain” failed to document whether guarding or rigidity were present”


Conducting CDI Audits

Tracking these objective documentation indicators over time is critical

That which is observed is improved


Evaluating the CDI Program

The CDI program itself must constantly evolve and adapt

Changes in clinical practice, new protocols, new providers, new medical directors, etc. can all necessitate changes in your CDI program




Examples of “Inadequate” and “Adequate” PCR Documentation


Inadequate Narrative . . .


“We had a 56 y/o patient with no chief complaint. Patient states he had chest pain earlier in the day. His wife said she saw him turn blue and called an ambulance. Past history of heart attack. Patient placed on oxygen and transported to hospital. Transport uneventful”


Adequate Narrative . . .


“Dispatched by 911 for a reported possible heart attack. Upon arrival, we found a 56 y/o obese male

C: Chest pain.

H: Patient states the pain began at around 8 a.m. this morning while he was lying in bed. He states the pain felt “crushing” and lasted for about 30 minutes. He states the pain has subsided somewhat and that it “comes and goes” over the last 4 hours. Pain does not radiate and is centered substernally. He has no SOB, nausea or vomiting, or any other complaints. Wife states that patient appeared to turn blue and she called 911.


Patient states he had a “mild” heart attack 5 years ago and on multiple meds since then. Current meds: Inderal, Lasix, Aspirin and a BP med.

A: Appx. 300 lb. patient found in his recliner laying back, in no obvious distress, but appeared ashen in color holding his chest. Paramedic assessment was performed by Paramedic Jones. Pt was A&O x4. Skin was moist to touch. Capillary refill delayed. O2 saturation 90% room air. Lungs clear in all fields. No tenderness to the chest or abdomen.




Rx: Patient placed on cardiac monitor which revealed atrial fibrillation. Placed on O2, IV established (see treatment section). Litter was brought to the side of recliner and patient was lifted onto stretcher by 2 person lift.

T: Patient loaded into ambulance and vital signs monitored enroute to ABC hospital. Patient complained of a 5 minute episode of chest pain while enroute, described as “dull” and non-radiating with pain level an 8 on a 1-10 scale. Skin color improved enroute. Patient had no other complaints. Patient was transferred to Bed 10 and report given to Sally Jones RN.


Specificity - Trauma

Inadequate Specificity

“Pt has possible fracture to the right tib/fib”

Adequate Specificity

“Pt has possible fx of R tibia after falling down approximately 6 steps at home. Pt has a 3” hematoma mid right anterior lower leg, appx. 2” above the ankle. No angulation or deformity. Distal pulses intact. Good skin color and capillary refill above and below injury site and sensation. Pain upon movement rated 8 on a 1-10 described as sharp


Specificity – Mobility


“Pt found in bed. Transferred pt from bed to stretcher. Moved pt via stretcher to ambulance and transport to hospital uneventful”


“Pt found in hospital bed in living room supine with oxygen running at 2 lpm via nasal cannula. Pt unable to sit up without passing out. Pt moved to stretcher via 3 person sheet pull with pt unable to assist due to severe weakness. Transported pt supine to hospital with no change in pt condition”


Specificity – Mobility


“Pt was transported in position of comfort”


“Pt was transported in a semi-seated position and denied any pain or discomfort during transport”


Specificity - Medical


Pt complains of chest pain and says the pain comes and goes


Pt complains of chest pain. Pain started 3 hours ago while mowing grass. Describes pain as “dull” centered under sternum. States pain comes and goes at intervals of 10-15 min and does not radiate to arms or neck. Severity 8 on a 1-10 scale. No complaints of SOB, nausea or vomiting


Specificity – Non Emergency


Pt was found in bed and transferred from bed to stretcher


Pt was found in hospital bed in hospital room in supine position unresponsive to voice with arms and legs flaccid. Pt was log rolled onto side and then back onto a sheet. Moved to stretcher via a sheet pull and secured in a supine position on the stretcher with four cot straps




Specificity – Abdominal Pain


Pt complains of abdominal pain since 8 a.m. this morning.


Pt complains of abdominal pain since 8 a.m. this morning. Pt states pain is in the right lower quadrant and is sharp in nature. Describes pain as very severe at 10 on a 1-10 scale. Pt denies nausea, vomiting or fever


Specificity – Decubitus Ulcers


Pt has a decubitus ulcer on left side of buttocks


Pt has a decubitus ulcer on left side of buttocks that is bandaged. SNF staff state the wound is Stage 3 approximately 4 inches across. Staff state that severity of wound and pain upon movement make it impossible for patient to sit up in a chair or wheelchair


Non-Emergency Specificity

MLN Matters Number: SE1514, “Overview of the Repetitive Scheduled Non-Emergent Ambulance Prior Authorization Model”

What needs to be addressed in “medical documentation” to support the PCS

A preview of things to come!


What CMS is Looking For . . .

“Only conditions specific for the beneficiary should be noted and all applicable comments should concern the beneficiary’s current condition”

“…a clear picture of the beneficiary’s current condition requiring ambulance transport”



“Capture the “what” and “why” of a beneficiary’s condition that necessitates the transports”

“Support the diagnosis or the ICD codes on the PCS with clinical assessment data and objective findings”



“Documentation must contain statements that capture the “what” and the “why” (for example, if a patient’s condition is bed confined, documentation must indicate why the patient is bed confined”

“Documentation should not contradict the PCS (for example, patient is indicated as bed confined on PCS, however medical records document the patient uses a wheelchair”




What Can We Learn from the Following Example? . . .

“Patient is an 80 y/o white male with history of ESRD being treated with hemo-dialysis at ABC Dialysis Center. Wegener’s Disease, Atrial Fibrillation, severe osteoporosis, and spinal stenosis all treated by Dr. Smith. Recently, patient has had “bouts” of pneumonia. Patient has extremely fragile bones, to the point that any lifting of the patient even with a “Hoyer Lift” can and has resulted in dislocations and fractures. Patient has a bilateral elbow fusion of 30 degrees, reduced plantar strength with a max of 1 out of 5 bilaterally and 0 degree max hip flexion bilaterally. Bilateral knee flexion is 0 degree. Patient is alert and oriented x4 at baseline with a GCS of 15.

Patient requires assistance in the areas of bathing, dressing, toileting and cleaning himself, transferring, unable to get up from bed, and feeding. Patient does not exercise any control over urination or defecation.”


According to CMS, This Documentation Identifies the

“What” and “Why” of the Patient’s Condition that

Necessitates Ambulance Transport!


Summary

Specificity in documentation and ICD-10 coding go “hand in hand”

Key to success is a renewed focus on “CDI for EMS”

Top down commitment is essential Renewed documentation training is a

must - And PWW can help you with that!


Happy EMS Week!

We salute you for all that you do for your communities!

“EMS is truly among the most noble of all professions.”

- James O. Page

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May 20, 2015© Copyright 2015 PWW Media, Inc.



New Features:

-Ambulance ICD-10 Codes-Common EMS abbreviations-Medicare appeals info-Revalidation tips-MAC-specific info

And all ambulance codes, modifiers, definitions and

billing tips!

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abcQuikGuideNow Available!

Order on www.pwwemslaw.com


Questions Submit your

questions. Use the “Question

and Answer” feature on your GoToWebinar control panel.

Or, fax them to (717) 691-1226.


Need Help? Contact PWW -We Can Help With Your

Documentation Training Needs!

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1) In what physical location (room, department, etc.) did you find the patient at the point of pickup?

(Examples: Hospital room, ED bed, bedroom, waiting room)

2) Please provide a description of the position the patient was in when you found the patient.

(Examples: Supine in bed, sitting on edge of bed, sitting in wheelchair, standing with assistance of a walker)

3) Please describe the patient's mobility status in more detail:

Is the patient able to walk/ambulate? Yes No

Please describe:

Is the patient able to sit in a chair or wheelchair? Yes No

Please describe:

Is the patient able to get up out of bed without assistance? Yes No

Please describe:

4) Please describe how the patient was moved to the stretcher:

5) Please describe any physical limitations or patient conditions that would require transport by ambulance:

6) Please describe any medical conditions (including pertinent medical history and current medications) of the

patient that would require transport by ambulance:

7) Please describe any medical treatments provided to the patient during transport (Examples: oxygen,

suctioning, wound vacs, splints, IVs etc.):

8) Please describe the specific reason that the patient was being transported from the point of pickup to the

destination:

Crew Members:

A review of the PCR for this incident revealed that pertinent information may be missing or is incomplete. A complete

and accurate PCR of the patient transport is essential for a complete patient record. Please review the PCR attached

and provide additional information or clarification as indicated by the sections checked below. Please ensure that all

responses are complete, accurate and honest. Do not make anything up and do not provide information that is false

or untrue. If you do not remember or cannot recall then indicate that as appropriate. If you have any questions

please contact ________________________________________.

Documentation Requirements

©Copyright 2015, Page, Wolfberg & Wirth, LLC. This Form Does Not Constitute Legal Advice.

Clinical Documentation Improvement (CDI) Query Form ‐ Non‐Emergency Transport

User Bears All Responsibility for Proper Documentation and Billing and Releases PWW From Any and All Liability for Use.

Call/Run #: Call Time:Date of Query: Date of Incident:

Page 1 of 2

9) Please describe the patient's level of consciousness and mental status upon arrival and during transport:

10) Please describe any relevant patient assessment or current patient condition/medical history that related to

this transport:

11) Do you have any other additional information about the transport of this patient that would be helpful to

other healthcare providers who will care for this patient?

I verify that the information I have provided on this form is accurate, complete, and truthful to the best of

my knowledge.

Signature: _________________________________________________ Date: _________________________

Name: (Please print) ____________________________________________________

Credentials/Certification Level (EMT‐B, EMT‐P, etc.) ___________________________

Page 2 of 2

this

CCeerrttiiffiiccaattee ooff CCoommpplleettiioonn is presented as evidence of completion, by the Certified Ambulance Coder®, Certified Ambulance

Compliance Officer™ or Certified Ambulance Privacy Officer™ whose Signature and Certification

Number appear below, of the NAAC® approved Continuing Education course entitled

PWW - 2015 - ICD-10 Part III - Documentation

Course ID: 1579 Vendor Code: 6 Topic Code: 2 CEU Units: 1.5

Education Provider: Page, Wolfberg & Wirth Presenter: PWW Staff

Jason J. Leet NAAC

® Program Coordinator

5/20/2015 Date of Training

I hereby certify that I have completed the continuing education training as represented on this certificate.

Signed: ______________________________________________________ NAAC® Certification Number ________________________________

Certificate is invalid without the signature and certification number of the attendee.

Documents

PART 3 - DOCUMENTATION · ICD-9-CM vol. 1 & 2 (Diagnosis Codes) ICD-10-CM (Diagnosis Codes) 3-5 characters in length 3-7 characters in length Approximately 13,000 codes Approximately