This blog post is part of a series that addresses ambulance billing best practices. Our ambulance billing blog series highlights tips and insights to help you improve ambulance billing efficiency, lower ambulance claim rejections, and get reimbursed faster.
Common examples of incomplete EMS documentation include missing signatures and missing mileage, both vital pieces of EMS documentation required in order to bill for services.
Examples of inconsistent EMS documentation include things like a patient care report narrative that states a patient has an altered level of consciousness but Glasgow Coma Score is missing/contradictory, or the patient care record narrative states that the patient is complaining of pain but there is no numeric pain scale.
This JEMS article on documentation and patient care is a great post to share with your EMS staff on a full spectrum of common mistakes.
Those responsible for documenting a dispatch record or patient care report need to ask two important questions before finalizing their EMS documentation:
These two questions are key to coding an ambulance transport claim correctly and getting reimbursed appropriately. It is also important to have QA review processes in place on EMS documentation to be sure that all mistakes and omissions are recognized and corrected prior to the EMS documentation being forwarded to EMS billing. As mistakes and omissions are found, the EMS documentation should be sent back to the originator to fix, since they are responsible for that specific patient record.
A good EMS software solution can help with EMS documentation completeness and consistency. This starts with picking a solution that offers strong integration between dispatch, ePCR, and billing. An integrated solution that keeps dispatchers, crews, QA staff, and billers all on the same page and working together to ensure accuracy.
Another must-have in a quality EMS software solution is automated validation checks that prevent missing and inaccurate records.
Lastly, the EMS software solution should have a quality assurance workflow built into the program to ensure your agency isn’t missing any training opportunities.
It would be great if we could just tell dispatchers and crews to make sure they are consistent and complete with their EMS documentation processes, and that’s all it took. However, we must recognize that these folks have a lot on their plate… namely saving lives. So how can we reinforce the value of quality EMS documentation in relation to the important work they do?
From EMS Dispatch, ePCR, and EMS Billing Software, AIM offers a full line of online EMS Software that can handle all of your EMS documentation. Or, if you want a team of EMS billing processional to handle your agency’s billing for you, explore our EMS Billing Services.
To learn more about AIM EMS Software and EMS Billing Services, call 1-800-726-4690, fill out our online information request form, or read more about ambulance billing best practices.