The International Classification of Diseases (ICD) is a system of codes designed by the World Health Organization to standardize the way health care professionals and scientists record and report diseases and other health problems. The concept has existed since the beginning of the 19th century, and it undergoes continual revision. In the United States, ICD-10 went live on October 1, 2015. Emergency medical services (EMS) providers, like other health care professionals, are likely most familiar with ICD as it relates to billing and claim submission for any patient covered by the Health Insurance Portability and Accountability Act.
Although EMS providers may be aware of ICD and perhaps have heard some of the hype about the complexity of ICD-10, they may not understand the impact it can have on patient care reports. Documentation is not always first on the list for initial or continuing education, and it often takes a back seat to honing life-saving skills. However, gone are the days when we could accept scantly completed charts, checkboxes that do not paint a picture of the call, and misspellings that can be fixed with the click of a button.
Our success as EMS providers depends on more than just clinical care. If your department falls behind in revenue recovery, income will decrease and eventually result in a loss of budget dollars that will affect clinical patient care. It is imperative that you understand the rules that regulate your reimbursement so your documentation supports the level of service provided. ICD-10 will most certainly impact your financial reimbursement if providers do not excel in clinical documentation.
In the age of electronic patient care records, the process of creating a chart has been simplified. This has happened for many reasons, some good and some bad. The desire for consistency in patient care reports for analytic purposes has influenced the number of checkboxes, dropdowns, and prefilled fields. It is nearly impossible at the department level to develop a report on runs involving chest pain using free text statements such as “CP,” “pain in the chest,” “intercostal pain with inspiration,” “pleuritic chest pain,” “chest pressure,” or “discomfort.” Checkboxes and prefilled fields serve to code presenting problems in a standardized fashion so that reports can be produced without having to manually sort through hundreds or thousands of records.
The National Emergency Medical Services Information System has introduced a slew of data points over the years, which has transformed the Subjective-Objective-Assessment-Plan note to consistent and standardized field values. Yet, the evolution of dropdowns and checkboxes has created an army of providers who write almost identical charts with only small variances.
Consequently, ICD-10 has made the narrative more important than ever. It will no longer be acceptable to complete a chart using dropdowns to explain that a patient has a laceration to the right thumb, without a foreign body and without damage to the nail. A clear and concise narrative is needed to provide this level of detail for ICD-10. Yes, there is a specific code for laceration of the right thumb without a foreign body and without damage to the nailbed in ICD-10. Now imagine you work in your department’s billing office and you have to find that code!
There are thousands of ICD-10 codes that apply to EMS. Descriptions of pain and trauma require detailed documentation about the location and extent of injury. The Center for Medicare and Medicaid Services (CMS) released a set of codes specifically related to the ambulance industry for billing coders to identify an ICD-9 code and cross it over to the new ICD-10 list (Table 1). There are some limitations to this crosswalk because it does not account for the specificity of some injuries or illnesses. Table 1 shows a few examples from the CMS crosswalk.
The level of specificity is apparent in the CMS crosswalk manual and demonstrates the necessity for accurate and detailed descriptions of the chief complaint. There are several ways EMS providers achieve success in documentation, and it starts well before writing a chart.
To succeed in writing clear and concise patient care reports, initial and continuing education needs a “shot in the arm.” Every training opportunity should challenge providers to use correct medical terminology when discussing or identifying specific areas of injury or illness. Encourage providers to be specific when identifying injuries or symptoms. For example, when discussing stroke symptoms, providers should discuss specifically where the deficits are occurring, whether they affect the patient’s dominant or nondominant side, and other pertinent findings. Once the skill of specifically describing a condition has been emphasized, practice documenting findings. This may seem tedious and unnecessary, but it will commit to memory the skill of evaluating specific patient details, and then it will document those details.
Providers are very good observers. It is amazing what a seasoned medic can observe during a call, but rarely do all of those details make it to the chart; this is partially the fault of the evolution of EMS documentation because it has boxed providers into needing checkboxes and dropdowns. With ICD-10, however, we need to transition providers into writing detailed narratives about the chief complaint, the history of present illness or injury, and their physical assessment findings.
Quality assurance and improvement (QA/QI) programs typically focus on the clinical aspects of charts and occasionally include billing information. It may also be beneficial to involve QA/QI in improving medical terminology. Over time, providers can adapt their documentation to use appropriate medical terms instead of layperson level descriptors such as “liver failure” or “kidney infection.”
The billing office must play a role in the development and improvement of provider documentation. A coder deciphers what the provider documents and then applies the appropriate level of service and ICD-10 code to the claim. This becomes burdensome to the coder, who lacks the extensive medical knowledge of a provider. Consider the time and effort required to find the medical terminology for “liver failure” and the corresponding appropriate billing code of “K70.10: Chronic hepatic failure without coma.” The margin for coding error increases when the coder is made responsible for translating a general medical condition to a more specific medical condition
As a department, give consideration to the time spent researching medical terminology and codes and deciphering charts. Feedback from the billing office directly to the EMS provider can be helpful, but this is sometimes interpreted as an attack. To overcome this perception, departments should use billing reports to help identify trends in data input.
Billing reports can be structured to detail the time billers spend researching codes and the quantity of charts requiring additional information from the EMS provider. Reports can further detail time spent by coders deciphering layperson terms into medical terminology, which can be converted into minutes or hours spent over the week and, ultimately, into payroll dollars.
Internal billing reports can also detail how your coders are doing. A report analyzing the usage of codes that are ambiguous or generic could serve as a red flag for the provider or coder. Administrators must also be aware of the numbers of rejected or denied claims for selected codes and why those codes were selected. Tallying this information could delay claim submissions, but in the long term the billing reports can help identify trends useful for training and quality improvement.
You should also report the positive things EMS providers are documenting. Consider making the process not seem so arduous by instituting a contest between shifts that inspires poor documenters to dust off the textbook and read during their downtime. Keep a tally of documentation benchmarks and compare one group to another-tap into competitive instincts. QA/QI can have more of an impact if it does not appear to be a personal attack.
Last, communicate with local emergency medical technician and paramedic educators on the importance of teaching documentation throughout their classes. The vitality of the EMS industry requires a full commitment to documentation starting on the first day of training.
The impact that EMS providers have on billing revenue cannot be overstated. A single unpaid claim by each of your EMS providers can add up to thousands or even millions of dollars in lost revenue.
As with everything in our industry, do any training on improving documentation with an eye toward compliance. Patient care reports must be truthful and accurate. Providers should not feel pressured to write their charts in a specific fashion that ensures payment. Instead, an EMS provider’s documentation should convey to readers what was actually seen and done.
Most of the strategies discussed here are long term and require commitment from both administration and billing staff, but providers can immediately improve the biller’s ability to apply the correct code to a claim by considering the following tips while documenting their next chart:
- Clearly define the chief complaint.
- Thoroughly document a full assessment.
- Use medical terminology often and appropriately.
- Mention drug classifications when naming drug or medication overdoses.
- Document a thorough history of the present illness.
Proper claim submission begins at the time of dispatch and continues until payment has been applied and the claim has been closed. Everyone involved in the process is responsible not only for the successful payment of the individual claim but also for the long-term vitality of the department. By devoting time and attention to documentation and subsequent reimbursement efforts, providers can ensure that the financial resources are available to their department to allow them to continue doing what they do best-offering high-quality patient care.
Reference
JOHN LESTER is the director of business integration at MultiMed Billing in Baldwinsville, New York. He has been a firefighter and paramedic with multiple departments since 1999. Prior to joining MultiMed in 2014, Lester was the director of business administration and a paramedic for Finger Lakes Ambulance in New York State, where he started in 2006.
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