Accurate and complete clinical documentation of the patient encounter is an essential aspect of providing patient care. The patient care report (PCR) becomes a part of the patient’s medical record and will be relied on by other health care providers treating the patient. It is also the key evidence, other than your own testimony, in a case of negligence brought against you or your EMS agency. The PCR also serves an essential purpose in determining whether an ambulance transport is medically necessary for reimbursement purposes.
In preparing a PCR it is your responsibility to document everything pertinent to the care the patient may need and your assessment of the patient’s condition. This allows the billing professionals to determine if the medical necessity requirements are met for the respective payer of the ambulance service – whether that is Medicare, Medicaid or other insurance when insurance is the payer. That includes documenting the pertinent positive findings as well as the pertinent negative findings, ensuring that the PCR is “completely accurate,” as well as “accurately complete.” The PCR documentation must be an objective and honest description of the patient’s condition that allows the reader to visualize an accurate picture of the patient.
It is not the EMS practitioner’s job to construct a PCR to “document medical necessity.” No PCR should ever be completed with false or misleading statements just to get a claim paid for an ambulance service. Medical necessity for an ambulance service is a determination made after a careful review of the clinical documentation. that determination is made by the billing professionals familiar with the standard for medical necessity for the patient’s insurance.
Those standards may vary from payer to payer, and EMS practitioners cannot be expected to know the standards for every payer. That’s not your job. Your job is to be thorough, objective, clear, descriptive and honest in documenting patient assessment information. That allows others to make a medical necessity determination for an ambulance transport as accurately as possible. If the PCR documentation is thorough, objective, clear, and descriptive, and it supports medical necessity – fine. If it does not, so be it.
Of course, you want your organization to be compensated for the ambulance service it provides. If the patient is insured, and your documentation clearly establishes the medical necessity for the ambulance transport, the organization will be paid for the transport by the insurer if all other conditions of payment are satisfied. If later there is an audit of the claim for the ambulance service, neither you nor your organization should be concerned.
The reality is that some ambulance transports will not be medically necessary. If, upon assessing a patient’s condition you believe that an ambulance transport is not medically necessary, you should follow your company policy and treatment protocols on how this situation is to be handled. In some EMS systems, the decision may be to transport the patient anyway, because there are no viable options at that time and transporting the patient is in the patient’s best interest.
But transporting a patient by ambulance doesn’t always mean your EMS agency is able to bill Medicare or another insurer for that service. Often in these cases, an EMS agency cannot submit a claim for service and either the patient gets billed or the claim gets “written off.” So, in situations where it seems clear to you that the patient did not require an ambulance, alert a supervisor to your concerns.
If suit is brought against you and your organization, and you are called upon to testify a few years after you attended to the patient, you may have little or no recollection of the patient encounter. In that event the PCR can become your “substituted memory” – but only if it paints a complete picture of the patient’s condition. If your PCR documentation responsibilities are met, your PCR will be your best friend – it can not only be used to refresh your memory; it will document that your assessment was complete and support the decision on medical necessity made by your agency’s billing professionals.
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Ken Brody has been an attorney with Page, Wolfberg & Wirth, LLC for almost 10 years. Prior to joining PWW, he served as a health care and regulatory attorney for the Commonwealth of Pennsylvania for more than 30 years. Ken was Counsel for the Pennsylvania Bureau of EMS for more than 15 of those years, where he was instrumental in development of Pennsylvania’s EMS System Act and the regulations adopted under that act. He has authored or co-authored numerous articles and blogs on EMS regulatory and compliance issues and has litigated several EMS cases in state court. Ken can be reached at: [email protected]
For over 20 years, PWW has been the nation’s leading EMS industry law firm. PWW attorneys and consultants have decades of hands-on experience providing EMS, managing ambulance services and advising public, private and nonprofit clients across the U.S. PWW helps EMS agencies with reimbursement, compliance, HR, privacy and business issues, and provides training on documentation, liability, leadership, reimbursement and more. Visit the firm’s website at www.pwwemslaw.com.