4 Things You Need for Proper Documentation

In the EMS industry, it’s common to find ambulance services mistakenly billing Basic Life Support (BLS) transports as medically necessary, or billing them as Advanced Level Service (ALS) transports — even though the documentation that they’ve prepared states otherwise. 

Because of this, EMS providers tend to be fined and penalized for not billing these transports correctly. But the truth is, these financial and reputational consequences are relatively easy to prevent. So the question is, just where should you start?

The answer is to start from the very beginning — and that’s with proper documentation upon your first response. After all, ensuring that your documentation is coded accurately and comprehensively is vital — especially since ambulance coding has become increasingly complex due to the guidelines set forth by the Centers of Medicare and Medicaid Services (CMS). 

To prepare the proper documentation, here are 4 things you should keep in mind while writing up your report:


Is It an Emergency or Non-emergency?

According to the CMS, an emergency response is when an ambulance supplier responds immediately with BLS or ALS1 to a 911 call or the equivalent in areas without a 911 call system. This isn’t to be confused with their definition of an immediate response, which is when the ambulance supplier begins as quickly as possible to take the necessary steps to respond to the call. Remembering the difference between them is key, especially when it comes to framing your documentation within the correct context.  

The purpose of a higher payment here, as the CMS states, is to also recognize any additional costs required. This is so that EMS providers will be more prepared to respond immediately to a 911 call when it is received — regardless of the condition of the patient. This allows the ambulance supplier to bill at a higher level when the ambulance is dispatched as an emergency response due to an accident, illness, or injury. 

It’s also important to note that the beneficiary’s condition is used to determine whether the ambulance dispatch was medically necessary. As a result, not all emergency dispatch services are considered medically necessary

Non-emergency transports are considered when the ambulance supplier is providing transportation services due to any condition requiring stretcher transport. This can include being discharged from the hospital, transportation to and from physician’s offices, and even some inter-facility hospital transfers where the patient was stabilized prior to transport.


What Is the Level of Service?

The level of service provided should be considered based on the care that was provided to the patient, and if it was reasonable and necessary. The level of care, on the other hand, is determined based on state and local regulations that govern your EMS agency and your staff. 

BLS is defined as a ground transport in which the patient’s condition requires the need for BLS treatment and interventions, while an ALS is defined as a ground transport in which the patient’s condition requires an ALS assessment or intervention. An ALS assessment is one that is performed by an ALS crew as part of an emergency response, but it does not necessarily determine whether the patient requires an ALS intervention. Both are also defined in accordance with state and local laws. 

To apply the ALS Assessment Policy to your organization, your EMS agency must utilize a standard dispatch protocol, such as the Emergency Medical Dispatch (EMD). If, however, a standard dispatch protocol is absent, then the level of service provided to the patient must be used instead. 

It’s also worth noting that Medicare has, in recent articles, cited fraudulent billing practices when an agency chooses to bill all of their calls at an ALS level since all ambulances are staffed as ALS. Additionally, it is also inappropriate to establish protocols for patient care based solely on the fact that the billing rate is higher. An example of this would be establishing an IV on all of the patients that you transport, just so you can bill at a higher ALS level. 


Is it A Medical Necessity?

As stated by CMS regulations, medical necessity is established when the patient’s condition is such that any other means of transportation are contraindicated and could endanger their condition. However, this definition can be vague and is usually subject to interpretation by Medicare contractors, auditors, and EMS agencies. 

To assist with this vague and generic definition, the CMS published the Ambulance Medical Condition List in 2006. While this list might not be all in-inclusive, mandatory, or even a guarantee for medical necessity, this list can assist EMS providers in establishing the necessary benchmarks required. The Ambulance Medical Condition List can also be used in the case of an audit to determine if your documentation has met the intentions of the Condition Code as published by the CMS. 

It’s imperative that EMS providers review the patient’s condition to determine whether they require ambulance transportation. Most Medicare and Medicaid contractors do not review documentation for ambulance services prior to processing their claims, and they do not have edits in place to deny certain ICD-10 codes on their initial claim submissions. 

These contractors instead place the responsibility of establishing medical necessity on the ambulance supplier to bill only those services that meet the requirements for coverage. Then, they will conduct audits on a post-payment basis to determine which services should not have been covered. 

Everyone speaks of the proverbial “stubbed toe” example, in which the patient does not have a reason to be transported by ambulance. This would represent a transport in which the ambulance provider should submit the claim as a non-covered service using the GY modifier. 


Is Your Narrative Field Sufficient?

It’s crucial that EMS staff document a narrative field that provides a detailed account of the patient’s condition as well as the care provided. This is so you can make necessary, accurate decisions for coding. Listed below are three examples of narrative fields that illustrate the need for documentation:

  1. Insufficient Narrative
    • Chief complaint of abdominal pain. Transported to Hospital A without incident. 
  2. Sufficient Narrative of Medically Necessary Ambulance Transport 
    • Chief complaint of abdominal pain x 6 hours with worsening of symptoms x 1 hour. Patient appears to be in obvious distress with sharp stabbing pain to the lower left quadrant of the abdomen. Patient has associated nausea and vomiting. Patient rates pain as 8/10 on the Pain Scale. 
  3. Sufficient Narrative on Non-Medically Necessary Ambulance Transport
    • Chief complaint of abdominal pain x 6 hours. Patient does not appear to be in any distress. Patient is ambulatory to the ambulance with his bag in hand and puts on his coat without grimacing. Patient rates pain as 8/10 on the Pain Scale and wishes to be transported to the Emergency Department for a refill on pain medications.

The Importance of Proper Documentation  

Preparing the proper documentation upon your first response is more than just a professional responsibility — it ensures that critical, potentially life-saving information is transcribed on record for all relevant authorities to see. 

But these records do more than just paint an accurate picture of your patient’s condition. In the event of an audit or any adverse legal outcomes, proper documentation is one of your agency’s greatest tools for risk management, playing a crucial role in protecting your agency against any detrimental repercussions. 


How Crew Analysis® Can Help 

As a tool that provides measurable data on crew member documentation practices, EMS|MC’s Crew Analysis® can help you quantify how often your crew members are documenting specific data points on their PCRs.

Review your crew’s documentation scores, and see how they fare in comparison to the EMS|MC National Average. Depict documentation trends for your crew members over a specific date range with the Crew Member Trend Chart, or view your trips by ordering facility. With Crew Analysis®, these in-depth data analytics can be captured and used to incentivize your crew’s progress and drive training programs.

Want to get your crew started on proper documentation and more compliant collections? Request a demo for Crew Analysis® with us here, and read our eBook on how to strengthen your EMS compliance here

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