2012 Claims Coding Clinic - Arkansas Ambulance Association

Transcription

2012
Arkansas EMS Expo
Emergency
and
Non-Emergency
Coding Clinic
© Copyright 2012, Page, Wolfberg & Wirth, LLC. All Rights Reserved.
Emergency
and
Non-Emergency
Coding Clinic
Background
Documents
Page 1 of 8
IMPORTANT NOTICE
The information presented in this coding clinic 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.
Attending this program is only one part of a formal, comprehensive corporate
compliance program, which we urge all ambulance services to implement.
The information contained in these materials and discussed at this conference 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 based on official sources of information from Medicare, OIG 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 billing,
compliance, reimbursement, legal or other decisions you make based in whole or in part
upon these materials.
We use examples of documentation, coding scenarios and other teaching illustrations
throughout this conference, 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 conference and in these materials to
be accurate, errors (such as typographical or other content errors) are possible.
Consult your legal counsel for advice on dealing with any specific legal issues you may
have.
By attending this conference, and/or utilizing these materials, you agree to these terms
and conditions.
Page 2 of 8
Background Information
The examples in the coding clinics were performed by “ABC Ambulance,” a fictional, private, nonprofit ambulance service located in the fictional city of Mountain, in Howard County in the State of
Confusion. ABC Ambulance, through local Mountain Ordinance, is an “ALS mandated” service,
operates three ground ambulances, one air ambulance and has 11 active crewmembers.
ABC Ambulance serves as the primary provider to the municipality, and serves the various facilities
located within the county (three hospitals, two skilled nursing facilities, a dialysis center and an
assisted living facility). For “nearest appropriate facility” purposes, the attached “area map” is deemed
to be the “locality” served by both ABC Ambulance and all of the facilities represented on the map.
ABC Ambulance routinely assists other ambulance services in the surrounding area, including a
separate air ambulance service (Life Flight Team) and a BLS service located in the neighboring state
of Paranoia, known as “Paranoia Ambulance Service (“PAS”). Along with Mountain, other major cities
within Howard County, served by ABC Ambulance are Howard, Ravine, and Valley. Various facilities
are located within these cities and transports occur between such facilities and from various points
within these cities.
ABC Ambulance will also travel to other hospitals outside its immediate service area (e.g. Big Bad
Hospital in the neighboring state of Paranoia) to deliver patients.
ABC Ambulance
P.O. Box 427
Mountain, CF 12345
(426) 433-0434
Alfred B. Carpenter, CEO
Page 3 of 8
ABC Ambulance Crew Member Signature Log
Crew Member Name
Signature Specimen
Certification Level
Natalie Gulbis
Natalie Gulbis
EMT-B
Certification
Number
367
Grace Park
Grace Park
Paramedic
123-P
Dustin Johnson
Dustin Johnson
Paramedic
2345-P
KJ Choi
KJ Choi
694-P(A)
Rory Sabatini
Rory Sabatini
Paramedic with
vent training
Paramedic
Retief Goosen
Retief Goosen
EMT-B
578
Stuart Appleby
Stuart Appleby
Paramedic
3765- P
Luke Donald
Luke Donald
EMT-B
321
Ian Poultier
Ian Poultier
Paramedic
5556-P
Zach Johnson
Zach Johnson
EMT – Intermediate
7124-I
Annika Sorenstam
Annika Sorenstam
Registered Nurse
43401 – RN
8765-P
Paranoia Ambulance Crew Member Signature Log
Crew Member Name
Signature Specimen
Certification Level
Mara Abbott
Mara Abbott
EMT-B
Certification
Number
786
Tyson Chandler
Tyson Chandler
EMT-B
556
LifeFlight Crew Member Signature Log
Crew Member Name
Signature Specimen
Certification Level
Caroline Powell
Caroline Powell
CFRN
Certification
Number
0067
Emmanuel Rego
Emmanuel Rego
EMT-P
982 -P
Page 4 of 8
Area Map
Page 5 of 8
Facility Listing and Details
North Mountain Medical Center (NMMC), Mountain, CF 12345
• Level III Trauma Center
University of Mountain Hospital (U of M), Mountain, CF 12345
• Burn Center
• Level I Trauma Center
• Cardiac Cath Lab
• Neurosurgery
University of Mountain Dialysis (U of M Dialysis) Mountain, CF 12345
• Attached to U of M Campus
St. Agnes Housing, Ravine, CF 78765
• Assisted Living Community
St. Joseph Hospital, Valley, CF 98765
• Critical Access Hospital
Big Mountain SNF, Mountain, CF 12567
LifeFlight Team, Round Top, PN 56776
• Air Ambulance Service
• Ground Critical Care Transport Service
Big Bad Hospital, Psycho, PN 75667
• Psychiatric Inpatient and Outpatient Clinic
Howard County SNF, Howard, CF 48843
Mountain Dialysis Center, Mountain, CF 88765
Quick Check Clinic, Ravine, CF 78675
• Freestanding walk-in clinic
Little Hospital, Psycho, PN 75567
• 50 bed hospital
Page 6 of 8
Response Determinants and Dispatch Codes
Response/Transport Priority
Alpha – BLS Cold
Bravo – BLS Hot
Charlie – ALS Cold
Delta – ALS Hot
Echo – ALS Hot
Dispatch Codes
001 – Cardiac (ALS)
002 – Respiratory (ALS)
003 – Fall – greater than 10 feet (ALS)
004 – Fall – less than 10 feet (BLS)
005 – Animal Bite – with other symptoms (ALS)
005 – Animal Bite – no other symptoms (BLS)
006 – Fracture – with other symptoms (ALS)
007 – Fracture – without other symptoms (BLS)
008 – Gunshot/Stab Wound – dangerous body part/bleeding not under control (ALS)
009 – Gunshot/stab wound – not dangerous body part/bleeding under control (BLS)
010 – Hemorrhage/Bleeding – dangerous body area or 2° symptoms (e.g. vomiting/pain) (ALS)
011 – Hemorrhage/bleeding – not dangerous body area or minor bleeding (BLS)
012 – Seizure Activity (ALS)
013 – Altered Mental State – other symptoms (ALS)
014 – Altered Mental State – no other symptoms (BLS)
015 – Sick Person, Man Down, unknown status (ALS)
016 – Sick Person, known status, minor condition (BLS)
017 – CVA/Stroke (ALS)
018 – Mass/Multiple Trauma (ALS)
019 – Fever – no other symptoms (BLS)
020 – Pain – no other symptoms < 4/10 on pain scale (BLS)
021 – Pain – other symptoms, >4/10 on pain scale (ALS)
022 – Choking – alert, awake, no other symptoms (BLS)
023 – Diabetic Problems (BLS)
024 – Eye Problem (BLS)
025 – Headache (BLS)
026 – Syncope/Vertigo (BLS)
027 – Pregnancy/Childbirth (BLS)
028 – Overdose (ALS)
029 – Psychiatric/Suicidal (BLS)
030 – Heat/Cold Exposure (BLS)
031 – Interfacility Transfer / Palliative Care
Page 7 of 8
Citations and References
Code of Federal Regulations
42 C.F.R. § 410.40
42 C.F.R. § 414.605
42 C.F.R. § 414.610
42 C.F.R. § 424.36
42 C.F.R. § 424.37
42 C.F.R. § 424.40
Medicare Benefit Policy Manual
Chapter 10
Medicare Claims Processing Manual
Chapter 3
Chapter 6
Chapter 10
Chapter 15
Medicare Program Integrity Manual
Chapter 6
Miscellaneous
CMS Program Memorandum AB-02-130 (9/27/02)
CMS Transmittal 327 (03/16/2010)
Social Security Act
Social Security Act § 1879(a)-(c) (42 U.S.C. § 1395pp(a)-(c))
Social Security Act § 1861(s)(7) (42 U.S.C. § 1395x(s)(7))
Social Security Act § 1862(a)(1) (42 U.S.C. § 1395y(a)(1))
Page 8 of 8
Emergency
and
Non-Emergency
Coding Clinic
Slides
Important Notes
2012
Coding Clinic
• All claims are analyzed in accordance
with Medicare guidelines
• U
Use th
the response d
determinants
t
i
t iin your
handouts for dispatch protocols
• Any reference to actual persons is purely
coincidental and/or for comic relief!
© Copyright 2012 Page, Wolfberg & Wirth, LLC
Important Notes
Important Notes
• We are using the Ambulance Condition
Codes for ICD-9 coding purposes
• We are applying post-payment audit rules
for the Coding Clinic
• ICD
ICD-9
9 “A
“As Bill
Billed”
d” may b
be ffrom ffullll ICD
ICD-9
9
Code Book, but “As Audited” will be from
Condition Code List
• W
We use the
th GY modifier
difi to
t show
h
cases
where a trip should not have been billed
(based upon the documentation available)
Important Notes
Important Notes
• You are not required to bill a non-covered
service unless the patient requests the trip
be submitted and/or where a Medicare
denial is required for coordination of
benefits.
• Always use the appropriate non-covered
service modifier (e.g., GA, GY or GZ)
when submitting a claim for a non-covered
service
1
Important Notes
• When preparing your claims, and you
find certain requirements (e.g.,
signatures) are not met, you can simply
hold the claim until you fulfill the
requirements
Whenever you determine that
you have been overpaid, be
sure that refunds of all
overpaid amounts are made to
Medicare in accordance with
your MAC’s refund
procedures.
All refunds must be made
within 60 days.
Run 201E
As Billed
Important Notes
• However, because the Coding Clinics are
post-payment audits, we are reviewing
claims that have actually been submitted,
and we use non-covered
non covered service
modifiers (like GY) to indicate it should
not have been billed for payment
Run 201E
George Washington
Run 201E – Emergency Response
• ABC Ambulance dispatched for 001Cardiac
A0427 HH
A0425 HH (20.6)
ICD-9: 428.9 (Cardiac
monitoring required)
• Delta
D lt (ALS H
Hot)
t) R
Response
• 5 minute interval between dispatched and
enroute times
2
• An “emergency response” means
responding immediately at the BLS or
ALS1 level of service to a 911 call (or the
equivalent in areas without a 911 call
system)
• An immediate response is one in which
the ambulance entity begins as quickly as
possible to take the steps necessary to
respond to the call
Run 201E – Medical Necessity
• Patient required cardiac services not
available at origin due to:
– Fl
Fluctuating
t ti cardiac
di enzymes
– Heparin infusion
Run 201E – Origin and Destination
Run 201E – Reasonableness
• “Patient required cardiac services not
available at origin.”
• D
Documentation
t ti could
ld b
be iimproved
d tto
better clarify exactly why the patient
required the transport
Run 201E – Mileage
• Both the origin and destination were
hospitals
• Crew documented fractional odometer
readings from the origin to destination
• “H” modifier
difi appropriate
i t
• 20.6
20 6 lloaded
d d miles
il
• Destination was covered
3
Run 201E – Forms
• AOB
Run 201E - Documentation
• Documentation should include that the
patient was transported to the closest and
most appropriate facility
– Signed by the patient on the date of service
– Witnessed by a crew member
• If not,
not should document rationale why closer
facilities were bypassed
– Diversion
– Witness also recorded address
– Specialized services
• A0427/ALS1-E vs. A0434/SCT
– A0434/SCT transport defined as facility to
facility transport of critically ill patient requiring
services beyond the scope of a paramedic (in
accordance with state protocols)
• A0427/ALS1-E vs. A0434/SCT (cont’d)
– Thoroughly and carefully document the
rationale why the patient needs a transfer
from a particular facility
– A nurse on board does not guarantee
definition of SCT was met
– Clearly indicate why a crew member with
higher level of training than a paramedic was
needed for the trip (physician orders, beyond
scope of practice, etc.)
– A0427/ALS1-E level better supported by the
PCR:
• “Emergency response” with emergency level
dispatch
• Medically necessary ALS interventions
4
Run 201E – ICD-9
• 428.9 (Cardiac monitoring required) was
supported by the documentation
Run 202NE
Martha Jefferson
Run 202NE
Run 202NE – Medical Necessity
As Billed
• 79 year old patient
A0426 HH
• Required cardiac catheterization
A0425 HH (43.6)
ICD-9: 428.9
(Cardiac/hemodynamic
monitoring required
enroute)
Run 202NE – Reasonableness
• Patient with Heparin infusion and cardiac
monitor
• Indicated ALS-level service was needed
Run 202NE – Origin and
Destination
• PCR did not document rationale behind
transport
hospitals
• No support that the services the patient
required were unavailable at the origin
• “H” modifier
difi
• PCR documentation should include this
information to better support appropriate
and accurate coding and billing
• Covered destination
5
Run 202NE – Mileage
• Fractional odometer readings documented
on the PCR
Run 202NE – Forms
• AOB
– Signed by patient on date of service
Run 202NE – Forms
• PCS
– Signed by Dr. Mann on date of service
– Certified that transport was medically
necessary due to hemodynamic monitoring
requirement, Heparin infusion, and that the
patient was unable to administer oxygen
Run 202NE – Documentation
• PCR documentation supported the need
for ambulance transport but did not identify
WHY the transport occurred
• Should document what services the
patient required that were unavailable at
the origin
Run 202NE – Forms
• PCS (cont’d)
– Documented that “St. Joseph doesn’t have a
cath. lab”
– Supported transport and that services the patient
required were unavailable at the origin
– Also documented U of M was the closest and
most appropriate facility
• A0426/ALS1-NE vs. A0434/SCT
– Interfacility transport
– Critically ill/injured patient questionable and not
supported by documentation
– No documentation to suggest that monitoring
EKG or Heparin infusion was beyond the scope
of a paramedic
6
• A0426/ALS1-NE vs. A0434/SCT (cont’d)
– A0426/ALS1-NE better supported and more
appropriate level of billing based upon
documentation
Run 202NE – ICD-9
• 428.9 (Cardiac/hemodynamic monitoring
required enroute) is appropriate and
supported by documentation
– EKG
– Heparin infusion
Run 203E
As Billed
Run 203E
Martha Washington
A0427 NH
A0425 NH (13.0)
ICD-9: 790.21
(Blood glucose)
• Ambulance was dispatched for 026Syncope
• Sudden change/decrease in level of
consciousness
• Delta (ALS Hot) Response
• Responds only to painful stimuli
• 2 minute interval between dispatched
and enroute times
• Speaking with incomprehensible words
7
• Patient would require evaluation and
treatment with equipment not available at
a SNF
• Origin was documented as Howard
County SNF
– “N”
N appropriate for SNF
– Blood gas and chemistries
– Urinalysis
– CT scan of the head
• Destination was University of Mountain ER (U
of M)
– “H” for hospital
• Fractional odometer readings documented
on the PCR
Run 203E – Forms
• AOB
– Crew documented that the patient was
mentally unable to sign due to a decreased
level of consciousness
– PCR supported this documentation
Run 203E – Forms
• AOB (cont’d)
– The crew signature was both timed and dated
BUT
BUT…
Run 203E – Forms
• AOB (cont’d)
– Invalid signature for claims submission
purpose; 42 CFR 424
424.36
36 (B)(6) criteria not
satisfied
– There was no receiving facility representative
signature
8
Run 203E – Documentation
Run 203E – ICD-9
• Documentation included objective findings
and both thorough and detailed physical
exams
• 790.21 (Blood glucose) was not supported by
the documentation because the blood
glucose was not abnormal
• Treatments were documented in
chronological order and supported medical
necessity
• 436 (Neurological distress) was more
appropriate and better supported
– Unable to verbalize
– Responsive to painful stimuli
Run 204NE
As Billed
Run 204NE
James Madison
A0428 HN
A0425 HN (4.4)
ICD-9: 496 (Need for IV
fluid management)
• PCR did not fully describe the patient’s
condition
• Documentation should better describe
MRSA wound
• Two person sheet lift was an indication of
patient’s condition, but did not “paint a
total picture”
• No documentation of a gait or range of
motion
– Open skin breakdown
– Wound leakage
– Location
9
Destination
• Reasonable that a patient that no longer
required an acute care setting would be
discharged to a nursing home for further
rehabilitation and care
• The point of pick up was North Mountain
Medical Center
• IV antibiotics
• The destination was Big Mountain Skilled
Nursing Facility
• No documentation to support that other
methods of transport were contraindicated
Run 204NE - Mileage
• Mileage inappropriately calculated
– “H”
H appropriate for hospital
– “N” for nursing home
Run 204NE - Mileage
• Overpayment based upon incorrect billing
and coding of loaded fractional mileage
– At destination = 4.4
– On scene = 1.2
– Total loaded mileage = 3.2
Run 204NE - Forms
• AOB
– No documentation on the PCR or AOB why
the patient was physically or mentally
incapable of signing
Run 204NE - Forms
• AOB (cont’d)
purpose; 42 CFR 424
424.36
36 (B)(2) criteria not
satisfied
– It is the patient’s inability to sign that “triggers”
a patient representative allowance to sign
10
Run 204NE - Forms
• PCS
– Signed by Dr. Cavell on date of service
– Documented that patient was not bed
confined or that they required monitoring
– No support for ambulance transport
Run 204NE – ICD-9
• 496 (Need for IV fluid management) was
not supported by the documentation
Run 204NE - Documentation
• Crew documented sheet transfer but failed
to have enough support to satisfy medical
necessity
• No indication patient was bed confined or
that they required monitoring
• No indication other forms of transport were
contraindicated
Run 204NE – ICD-9
• 041.9 (Special handling – isolation
required en route)
• S
Supported
t db
by th
the ffactt the
th patient
ti t had
h d
MRSA and sepsis and required IV
antibiotic treatment
Run 205E
As Billed
Run 205E
John Adams
A0433 NH
A0425 NH (4.3)
ICD-9: 789.00
(Abdominal pain)
11
• Dispatched for 001-Cardiac (ALS)
• Patient complained of chest, abdominal,
back pain
• Delta (ALS Hot)
• Required
R
i d nitroglycerin
it l
i ffor chest
h t pain
i
• Responded within 2 minutes of receiving
dispatch
Run 205E - Reasonableness
• Requires further evaluation with
equipment not readily available at a SNF
– Chest radiograph
– Telemetry
• Pain relieved with nitroglycerin
• Origin was Big Mountain Skilled Nursing
Facility (SNF)
– “N”
N appropriate for SNF
• Destination was North Mountain Medical
Center (NMMC)
– Blood chemistries
Run 205E - Mileage
• At destination = 742.5
Run 205E - Forms
• AOB
• On scene = 738.2
– Signed by patient on date of service
• Total loaded mileage = 4.3
– Signature legible
– Did not require a witness signature
12
• Documentation included information to
warrant both emergency level billing
(dispatched condition and response time)
and ALS level billing (ALS assessment
assessment,
medications/interventions, EKG)
• BUT documentation did not support billing
at the A0433/ALS2 level
• A0433/ALS2 vs. A0427/ALS1-E
– PICC line not specifically listed as an ALS 2
intervention
– PICC line was not “performed” by the crew –
existing line was used for medication
administration
– CMS has only clarified the “monitoring” issue with
respect to endotracheal intubation
• ALS assessment was warranted
• Plus, there were ALS interventions
((nitroglycerin
it l
i spray, IV
IV, EKG)
Run 205E – ICD-9
• 789.00 (Abdominal pain) was supported
by documentation
• 786
786.50
50 (Chest
(Ch t pain)
i ) was more appropriate
i t
based upon dispatched condition and
treatments rendered
Run 206NE
As Billed
Run 206NE
A0428 JR
A0425 JR (2.8)
Dolley Madison
ICD-9: 907.2 (Special
handling required to
monitor orthopedic
device)
13
• Trip report did not fully describe the
patient’s medical or physical condition
that required patient to need ambulance
transport
• Billing department faces a challenge
– everything needed for billing
appears to be available – but not from
a PCR prepared by the crew
• Common problem with repetitive
transports – field crew sees patient
routinely and does not fully document the
trip report each time
• Every trip needs a fully documented
PCR in order to be able to bill the
claim
Destination
• Reasonable that a patient would require
transport to a residence after dialysis
treatment
• Origin was University of Mountain Dialysis
• Do not confuse “medical necessity” with
“reasonableness”
• Destination was the residence of the
patient
– “J” for freestanding dialysis clinic
– “R” appropriate
• Odometer readings documented
• Fractional mileage noted
Run 206NE – Forms
• AOB
– Signed by the patient on the date of service
14
Run 206NE – Forms
Run 206NE – Forms
• PCS (cont’d)
• PCS
– Signed by Dr. Breckenridge on 06/20/2011
– PCS noted patient was not bed confined
– Within 60 day window for non-emergency,
scheduled, repetitive ambulance service
– But, PCS also showed that patient was unable to
tolerate sitting in a chair for time needed to
transport
– PCS showed she could not support herself and
was unable to move herself without assistance
Run 206NE - Forms
• PCS (cont’d)
• Crew documentation was poor and not
thorough
– PCR should clearly establish medical
necessity as a stand-alone document
• No
N ““picture”
i t ” off th
the patient
ti t
– PCS supports the trip report (and you can’t bill
without it!)
– PCS should not be used in place of a well
documented PCR to prepare claims
Run 206NE – ICD-9
• What about using ICD-9 codes for:
– ESRD
Run 206NE – ICD-9
• Ambulance codes should describe the
condition that caused patient to need an
ambulance
– CVA
– MI
– Diabetes
15
Run 206NE – ICD-9
• ESRD does not describe a condition that
needs an ambulance
• Patient may have had partial paralysis
ffrom th
their
i CVA which
hi h would
ld necessitate
it t
ambulance but that info was not provided
in PCR
Run 207E
Abigail Adams
• Code with the condition that caused
patient to need ambulance
Run 207E
As Billed
• Dispatched for a Sick Person
A0427 RH
• Bravo (BLS Hot) response
A0425 RH (6.2)
ICD-9: 780.97 (Altered
level of
consciousness)
• Call was dispatched at 12:20 and
ambulance responded at 12:25
• Crew documented that it took another 20
minutes to arrive on scene due to a wrong
address
• Patient complained of weakness
• Here there was an “emergency response”
with documented rationale to explain the
delayed on scene time and NOT delayed
response
• BP = 82/58 and HR = 107
• Difficulty pronouncing words
– Physiologic response to hypovolemic shock
16
• Patient would require services not available
at origin
– Hypotensive/tachycardic
– Nausea
• Origin should be “R” for residence
• Transported to St. Joseph Hospital
– “H” appropriate and covered
– Orthostatic hypotension
– Weakness to “left side of face” (rule out CVA)
• Crew documented the total loaded
mileage
• D
Documented
t d iin ffractional
ti
l miles
il
• Documentation should include the
odometer readings at the point of pick up
and the destination so that the total loaded
mileage can be “tracked”
tracked and supported
• No supporting documentation (no starting
or ending mileage)
Run 207E – Forms
• Electronic Signature Form
– Dated 02/15/2009
– Signed by Steve Adams (on behalf of the
patient)
– Stamped as a “Lifetime Signature”
Run 207E – Forms
• Electronic Signature Form (cont’d)
– Documentation on the PCR would support
why the patient was both physically and
mentally incapable of signing on the date of
service
• Hypotensive, weak, nausea, tachycardic
17
Run 207E – Forms
– BUT there was no documentation to support
why a patient representative was unable or
unwilling to sign on the date of service
Run 207E – Forms
– The “Electronic Signature Form” failed to have
the signature of the patient and also lifetime
signature
i
t
language
l
– Was not established as a “Lifetime Signature”
– Also, no crew or receiving facility
representative signature from the date of
service
Run 207E – Forms
purpose; 42 CFR 424
424.36
36 (B) criteria not
satisfied
Run 207E – ICD-9
• 780.97 (Altered level of consciousness)
was not supported by the documentation
–N
No d
documentation
t ti tto show
h
thi
this patient
ti t was
“altered”
– Also, the relationship between Steve and Abigail
not documented
• Documentation included an emergency
level dispatch, thorough assessment, and
medically necessary ALS interventions (IV,
EKG NSS bolus)
EKG,
Run 207E – ICD-9
• 780.02 (Weakness) more appropriate and
better supported by the PCR
– Chief
Chi f complaint
l i t off weakness
k
ffor 2 d
days,
“weakness of left side of face”
– GCS 15, A&Ox3, able to verbalize the history
of present illness
18
Run 208NE
As Billed
Run 208NE
A0426 HH
James Monroe
A0425 HH (43.2)
ICD-9: 786.50 (Chest
pain)
• Chest pain for 2 weeks
• Patient was being transported from Little
Hospital to U of M for pre-cath work up
• “Pre heart cath work up”
• IV in right arm
• EKG monitoring
Destination
• Cl
Clear that
th t patient
ti t required
i d cardiology
di l
services
• BUT not clear that Little Hospital was
unable to provide cardiology services
hospitals
• Crew documented total loaded mileage in
fractional format
• A
Appropriate
i t tto code
d “H” ffor b
both
th origin
i i and
d
destination modifier
• D
Documentation
t ti should
h ld h
help
l supportt th
the
total loaded mileage by documenting the
mileage at the point of pick up and the
destination
19
Run 208NE – Forms
• AOB
Run 208NE – Forms
• AOB (cont’d)
– “Patient unable to sign”
– No billing authorization signature was
obtained at the time of service
– Does not appear that an attempt was made
after the time of service to obtain a billing
authorization signature
– Even though the signature form documented
why the patient could not sign
– Unless a billing authorization signature is
obtained or a lifetime signature is on file, the
claim should not be billed
Run 208NE – Forms
• AOB (cont’d)
– Someone from the sending facility could have
g
on the patient’s
p
behalf if theyy were
signed
physically or mentally incapable
– Another option – educate facilities to sign the
PCS form indicating they are signing on
behalf of the patient when physically or
mentally incapable
Run 208NE - Forms
• AOB (cont’d)
Run 208NE – Forms
• PCS
– By signing, facility personnel are not
accepting financial responsibility for the claim
– PCS did not document patient going to
closest appropriate facility
– A signature is needed for every claim
– Signed by Dr. Fairchild on date of service
20
• Patient on cardiac monitor and IV; ALS
services were warranted
• N
No iindication
di ti off emergency di
dispatch
t h
• Trip report did not document that patient
was going to the closest appropriate
facility or that cardiac catheterization
services were not available at the sending
facility
• Appeared appropriate to bill as an ALS
Non-Emergency level claim
Run 208NE – ICD-9
• 428.9 (Cardiac monitoring required
enroute) was better supported by the
documentation
Run 209E
Thomas Jefferson
Run 209E
As Billed
• Dispatched for 013- Altered Mental Status
A0427 PHGA
• Delta (ALS Hot) response
A0425 PHGA (1.0)
ICD-9: 427.5 (Cardiac
arrest)
• Dispatched and enroute times are the
same (14:39)
21
• 79 year old patient
• Unresponsive
• “UTO” = “Unable to obtain” blood pressure
• Weak radial pulses
• Point of pick up was “P” for physician’s
office
• Patient was at his doctor’s office but was
unconsciousness with shallow
respirations, weak pulses, and had
pupillary changes
• Would require services found at an acute
care setting capable of in-patient
monitoring and treatment
• Crew documented fractional mileage
• Note though that all mileages end in “.0”
• D
Destination
ti ti was “H” ffor NMMC ER
• Both are covered
Run 209E – Forms
• AOB
– Date of transport 07/11/2011
Run 209E – Forms
• AOB (cont’d)
– Signature required at any point prior to claims
submission
– Patient signed on their own behalf on
07/15/2011 (4 days after date of service)
– Follow up effort to secure patient signature
prior to billing
22
Run 209E – Forms
Run 209E – Forms
• ABN (cont’d)
• ABN
– Advanced Beneficiary Notice of Noncoverage
– ABN was used, BUT
– “P” is point of and covered
– “H” is destination and covered
– Medically necessary trip – unconsciousness
– ABN is not necessary and should not be used
for emergency trips
Run 209E – Forms
• ABN (cont’d)
– ABN is not necessary in this case
– “Reasonable” trip – need services at a
hospital for condition
• PCR objective, thorough
– “Mandatory” uses for ABN are rare
• Included emergency dispatch and
“
“emergency
response”” iinformation
f
ti
– Using this GA code “self denied” the claim and
Medicare did not pay
• Medically necessary ALS interventions
– WRONG – claim was payable!
• Documentation supported billing the claim
at A0427/ALS1-E without the ABN or GA
modifier
– IV, EKG, NSS bolus
Run 209E – ICD-9
• 427.5 (Cardiac arrest) not applicable
– Patient was not in cardiac arrest as evidenced
by the palpation of a pulse and spontaneous
respiratory rate
23
Run 209E – ICD-9
• 780.97 (Altered level of consciousness)
better supported
Run 210NE
– GCS 4 and
d5
Elizabeth Monroe
– Unconscious
– A&Ox0
Run 210NE
As Billed
• Weakness for 2 days in the left arm and
left leg
A0427 NH
• Altered
A0425 NH (13.0)
• Confused
ICD-9: 780.02
(Weakness)
Run 210NE - Reasonableness
• Patient required evaluation and
management of symptoms beyond the
level of care available at the origin
• Weak grip strength
Destination
• Origin was documented as Big Mountain
SNF
– “N”
N for nursing home
• Destination was University of Mountain ER
24
• Fractional mileage documented
Run 210NE – Forms
• AOB
• At destination = 5602.2
– Documentation supported that the patient
g the AOB
was mentallyy unable to sign
• On scene = 5589.2
– Signed by Sophine Mann, RN, on behalf of
the patient
– 42 CFR 424.36 (B)(4) criteria satisfied
Run 210NE – Forms
• PCS
– Signed by Sophine Mann, RN, on date of
service
– Certified ambulance transport was medically
necessary because patient had left sided
weakness that required evaluation
Run 210 - Documentation
• A0427/ALS1-E vs. A0426/ALS1-NE
(cont’d)
– But no documentation of emergency dispatch,
and
– Time between dispatch and ambulance
enroute to patient was 50 minutes
Run 210 - Documentation
– Based on patient’s condition, appeared that
this should have been an emergency call
– Left-sided weakness of arm and leg; left
grip very weak
(cont’d)
– Trip
T i reportt documented
d
t d this
thi was a nonemergency transport
– Charlie (ALS Cold) response
– No evidence of “emergency response”
25
• A0427/ALS1-E vs. A0426/ALS1-NE (cont’d)
– Trip report provided detail of patient’s condition
p
was moved to stretcher
and how patient
– Trip report documented an attempted ALS
intervention
(cont’d)
– ALS level billing warranted based upon
interventions
– ALS1-NE warranted based upon dispatch
information
– IV was attempted without success
Run 210NE – ICD-9
• 780.02 (Weakness) supported by the PCR
documentation
2012
Coding Clinic
26
Emergency
and
Non-Emergency
Coding Clinic
Documents
Run 201E
ABC Ambulance Service
Run Number: 201E
Patient Name: George Washington
Patient Care Report
Date of Service: 07/07/2011
Times
Dispatched:
Enroute:
Response/Outcome Info
10:34
Dispatched
10:39
At Scene:
10:39
To Destination:
11:26
At Destination:
12:24
In Service:
12:50
Mileage
As:
001- Cardiac
Type:
ALS
Priority:
Delta
Location:
St. Joseph Hospital
To Scene:
-
On Scene:
-
Enroute Dest.:
7836.6
At Dest:
7857.2
In Qtrs:
-
Total Loaded
Valley, CF 98765
Miles:
Transported
U of M ER
To:
Mountain, CF 12345
20.6
Transport
Priority:
Delta
Patient Information
Name: George Washington
DOB: 11/28/1930
Sex: Male
Address: 100 Union St
Age: 81
Weight: 140 lbs
Mountain, CF 12345
Initial Information
Pt found: Supine in hospital bed
Chief Complaint: “My chest was killing me!”
Meds: Zocor, Zetia, Ecotrin, Plavix
Allergies: Demerol, Dilantin
Past Medical History: Angina, CHF, MI, HTN
Impression: Cardiac Transport
Narrative
Arrived on scene in response to a 911 call for transport of patient needing cardiac services unavailable at origin
facility. Found patient in hospital bed on oxygen, cardiac monitor, and IV drip with Heparin. Patient is A&O x4.
Pt. complains of anxiety and chest tightness. Cardiac enzyme levels reported as being fluctuating and
abnormal, but cardiac monitor reads a normal sinus rhythm. Patient transported from hospital bed to cot via
draw sheet method. Transport to U of M ER was uneventful and patient was turned over to care of RN.
Vital Signs
Time
11:15
BP
141/80
Pulse
86
Resp
18
Pupils
PERRL
GCS
15
LOC
A&Ox4
Skin
Pink/warm/dry
Treatments
Oxygen @ __2___ LPM via __NC_____
Meds _ Heparin infusion_____________
Pt to Stretcher Via: _________________
Route of Admin: ___IV_________
Other: _EKG_________________
Crew Info
Name: Stuart Appelby
Cert No: 3765-P
Cert Level: Paramedic
Signature: Stuart
Appleby
Name: Annika Sorenstam
Cert No: 43401-RN
Cert Level: RN
Signature: Annika
Sorenstam
Patient Name: _George Washington_______________________ Transport Date: ____07/07/2011_________
______
Privacy Practices Acknowledgment: by signing below, the signer acknowledges that [ABC Ambulance Service (ABC)] provided a copy of its
Notice of Privacy Practices to the patient or other party with instructions to provide the Notice to the patient.
*A copy of this form is valid as an original*
SECTION I - PATIENT SIGNATURE
The patient must sign here unless the patient is physically or mentally incapable of signing.
NOTE: if the patient is a minor, the parent or legal guardian should sign in this section.
I authorize the submission of a claim for payment to Medicare, Medicaid, or any other payor for any services provided to me by [ABC] now, in
the past, or in the future, until such time as I revoke this authorization in writing. I understand that I am financially responsible for the services
and supplies provided to me by [ABC], regardless of my insurance coverage, and in some cases, may be responsible for an amount in addition
to that which was paid by my insurance. I agree to immediately remit to [ABC] any payments that I receive directly from insurance or any
source whatsoever for the services provided to me and I assign all rights to such payments to [ABC]. I authorize [ABC] to appeal payment
denials or other adverse decisions on my behalf without further authorization. I authorize and direct any holder of medical information or other
relevant documentation about me to release such information to [ABC] and its billing agents, the Centers for Medicare and Medicaid Services,
and/or any other payors or insurers, and their respective agents or contractors, as may be necessary to determine these or other benefits
payable for any services provided to me by ABC, now, in the past, or in the future.
If the patient signs with an “X” or other mark, a witness should sign below.
X George
Washington
07/07/2011
Patient Signature or Mark
Date
X Stuart
Appleby
Witness Signature
__07/07/2011________
Date
_P.O. Box 427, Mountain, CF 12345______________
Witness Address
SECTION II - AUTHORIZED REPRESENTATIVE SIGNATURE
Complete this section only if the patient is physically or mentally incapable of signing.
On the line below, explain the circumstances that make it impractical for the patient to sign:
__________________________________________________________________________________________________________________________
I am signing on behalf of the patient to authorize the submission of a claim for payment to Medicare, Medicaid, or any other payor for any
services provided to the patient by [ABC] now or in the past, (or in the future, where permitted). By signing below, I acknowledge that I am
one of the authorized signers listed below. My signature is not an acceptance of financial responsibility for the services rendered.
Authorized representatives include only the following individuals:
 Patient’s legal guardian
 Relative or other person who receives social security or other governmental benefits on behalf of the patient
 Relative or other person who arranges for the patient’s treatment or exercise other responsibility for the patient’s affairs
is a sample only
and
does not
User bears
responsibility
forpayment
compliance
with all applicable
laws and
regulations.
 This
Representative
of an
agency
or constitute
institutionlegal
that advice.
did not furnish
the all
services
for which
is claimed
(i.e., ambulance
services)
but
furnished other care, services, or assistance to the patient
X
______ ________
Representative Signature
_______
Date
__________________________________________________________________________
Printed Name and Address of Representative
SECTION III - AMBULANCE CREW AND RECEIVING FACILITY SIGNATURES
Complete this section only if: (1) the patient was physically or mentally incapable of signing, and
(2) no authorized representative (Section II) was available or willing to sign on behalf of the patient at the time of service.
A. Ambulance Crew Member Statement (must be completed by crew member at time of transport)
My signature below indicates that, at the time of service, the patient named above was physically or mentally incapable of signing, and
that none of the authorized representatives listed in Section II of this form were available or willing to sign on the patient’s behalf. My
signature is not an acceptance of financial responsibility for the services rendered.
______________________________________________________________________________________________________________________
Name and Location of Receiving Facility: _______________________________________________________________________________________
Time at Receiving Facility: ____________________________
X
_______
Signature of Crewmember
_______
Date
__
________
_____
Printed Name and Title of Crewmember
__
B. Receiving Facility Representative Signature
The patient named on this form was received by this facility at the date and time indicated above. My signature is not an acceptance
of financial responsibility for the services rendered to this patient.
This is a sample o
X
____
____ ___
Signature of Receiving Facility Representative Date
______
Printed Name and Title of Receiving Facility Representative
This is a sample only and does not constitute legal advice. User bears all responsibility for compliance with all applicable laws and regulations.
__
Run 202NE
Run Number: 202NE
Patient Name: Martha Jefferson
Patient Care Report
Times
Dispatched:
Enroute:
12:20
Dispatched
12:20
At Scene:
12:25
To Destination:
13:05
At Destination:
13:54
In Service:
14:30
Mileage
As:
031 - Transfer
Type:
ALS
Priority:
Charlie
Location:
St. Joseph Hospital
To Scene:
-
On Scene:
-
Enroute Dest.:
119.2
At Dest:
159.8
In Qtrs:
203.4
Total Loaded
Valley, CF 98765
Miles:
Transported
U of M
To:
Mountain, CF 12345
43.6
Transport
Priority:
Charlie
Patient Information
Name: Martha Jefferson
DOB: 05/13/1932
Sex: Female
Address: 1677 JFK Blvd
Age: 79
Weight: 270 lbs
Valley, CF 98765
Initial Information
Chief Complaint: Cardiac cath. transport
Meds: Lipitor, ASA
Allergies: NKDA
Past Medical History: MI, CABG
Impression: Cardiac catheterization
Narrative
Pt is a 76 year old female found on hospital stretcher AOx3, skin warm and dry, lungs clear, abdomen soft
and non-tender, neuromotor + = all extremities. EKG sinus brady, rate 55 SP O2 on 2L O2 97%
Pt on heparin 10ML/hr. Pt moved to stretcher and then to ambulance. Pt stable during
transport, - CP, - SOB, - change, - C/O. Pt transferred to hospital staff, bed 5214. Report given bedside.
Vital Signs
Time
13:02
13:48
BP
139/64
139/77
Pulse
55
56
Resp
18
18
Pupils
PERRL
PERRL
GCS
15
15
LOC
Alert
Alert
Skin
P/W/D
P/W/D
Treatments
Oxygen @ _2__ LPM via __NC_____
Meds _ Heparin
_______
Pt to Stretcher Via: Sheet lift __
Route of Admin: ___IV______________
Other: _EKG______________________
Crew Info
Cert No:
43401-RN
Name: Luke Donald
Cert No: 321
Cert Level: RN
Signature: Annika
Cert Level: EMT-B
Signature: Luke
Sorenstam
Donald
Patient Name: _____ Martha Jefferson ________________________ Transport Date: ___07/12/11__
______
X
Martha Jefferson
__07/12/11_______
Date
X_____________________________________ __________________________
Witness Signature
Date
___________________________________________________________
Witness Address
__________________________________________________________________________________________________________________________
is a sample only
and
does not
User bears
responsibility
forpayment
compliance
with all applicable
laws and
regulations.
 This
Representative
of an
agency
or constitute
institutionlegal
that advice.
did not furnish
the all
services
for which
is claimed
(i.e., ambulance
services)
but
X
______ ________
_______
Date
__________________________________________________________________________
______________________________________________________________________________________________________________________
X
_______
_______
Date
__
________
_____
__
This is a sample o
X
____
____ ___
______
__
SECTION I – GENERAL INFORMATION
Patient’s Name: Martha
Jefferson
Transport Date:07/12/11
Origin: St.
Date of Birth: _05/13/1932__________ Medicare #:
(PCS is valid for round trips on this date and for all repetitive trips in the 60-day range as noted below.)
Joseph Med/Surg
Destination: Univeristy
Is the pt’s stay covered under Medicare Part A (PPS/DRG?)  YES
Closest appropriate facility?
202NE
X YES
of Mountain Cath Lab
__________________________
X NO
 NO If no, why is transport to more distant facility required?
If hosp-hosp transfer, describe services needed at 2nd facility not available at 1st facility: St.
If hospice pt, is this transport related to pt’s terminal illness?  YES
X
Joseph doesn’t have a cath lab
NO Describe:______________________________________________
SECTION II – MEDICAL NECESSITY QUESTIONNAIRE
Ambulance Transportation is medically necessary only if other means of transport are contraindicated or would be potentially harmful to
the patient. To meet this requirement, the patient must be either “bed confined” or suffer from a condition such that transport by means
other than ambulance is contraindicated by the patient’s condition The following questions must be answered by the medical
professional signing below for this form to be valid:
1) Describe the MEDICAL CONDITION (physical and/or mental) of this patient AT THE TIME OF AMBULANCE TRANSPORT that requires
the patient to be transported in an ambulance and why transport by other means is contraindicated by the patient’s condition:
Patient is on a Heparin infusion and requires ALS monitoring._________________________________
Is this patient “bed confined” as defined below?
X Yes  No
To be “bed confined” the patient must satisfy all three of the following conditions: (1) unable to get up from bed without
Assistance; AND (2) unable to ambulate; AND (3) unable to sit in a chair or wheelchair
3) Can this patient safely be transported by car or wheelchair van (i.e., seated during transport, without a medical attendant or monitoring?)
 Yes
X No
4) In addition to completing questions 1-3 above, please check any of the following conditions that apply*:
*Note: supporting documentation for any boxes checked must be maintained in the patient’s medical records
 Contractures
 Non-healed fractures
 Patient is confused
 Patient is comatose  Moderate/severe pain on movement
2)
 Danger to self/other
X IV meds/fluids required  Patient is combative
 DVT requires elevation of a lower extremity
 Need or possible need for restraints
 Medical attendant required
X Requires oxygen – unable to self administer
 Special handling/isolation/infection control precautions required  Unable to tolerate seated position for time needed to transport
X Hemodynamic monitoring required enroute
 Unable to sit in a chair or wheelchair due to decubitus ulcers or other wounds
 Cardiac monitoring required enroute
 Morbid obesity requires additional personnel/equipment to safely handle patient
 Orthopedic device (backboard, halo, pins, traction, brace, wedge, etc.) requiring special handling during transport
 Other (specify)
SECTION III – SIGNATURE OF PHYSICIAN OR HEALTHCARE PROFESSIONAL
I certify that the above information is true and correct based on my evaluation of this patient, and represent that the patient requires
transport by ambulance and that other forms of transport are contraindicated. I understand that this information will be used by the
Centers for Medicare and Medicaid Services (CMS) to support the determination of medical necessity for ambulance services, and I
represent that I have personal knowledge of the patient’s condition at the time of transport.
 If this box is checked, I also certify that the patient is physically or mentally incapable of signing the ambulance service’s claim and that
the institution with which I am affiliated has furnished care, services or assistance to the patient. My signature below is made on behalf of
the patient pursuant to 42 CFR §424.36(b)(4). In accordance with 42 CFR §424.37, the specific reason(s) that the patient is physically or
mentally incapable of signing the claim form is as follows:
Dr. Mann
07/12/2011
Signature of Physician* or Healthcare Professional
Date Signed
(For scheduled repetitive transport, this form is not valid for
transports performed more than 60 days after this date).
Dr. Mann, MD
Printed Name and Credentials of Physician or Healthcare Professional (MD, DO, RN, etc.)
*Form must be signed only by patient’s attending physician for scheduled, repetitive transports. For non-repetitive, unscheduled ambulance
transports, if unable to obtain the signature of the attending physician, any of the following may sign (please check appropriate box below):
 Physician Assistant
 Nurse Practitioner
 Clinical Nurse Specialist
 Discharge Planner
 Registered Nurse
Run 203E
Run Number: 203E
Patient Name: Martha Washington
Patient Care Report
Times
Dispatched:
Enroute:
10:09
Dispatched
10:11
At Scene:
10:19
To Destination:
10:30
At Destination:
10:49
In Service:
10:59
Mileage
As:
026 - Syncope
Type:
ALS
Priority:
Delta
Location:
Howard County SNF
To Scene:
-
On Scene:
-
Enroute Dest.:
32547.6
At Dest:
32560.6
In Qtrs:
-
Total Loaded
Howard, CF 48843
Miles:
Transported
U of M ER
To:
Mountain, CF 12345
13.0
Transport
Priority:
Delta
Patient Information
Name: Martha Washington
DOB: 02/25/1914
Sex: Female
Address: 601 May St.
Age: 97
Weight: 120 lbs
Howard, CF 48843
Initial Information
Chief Complaint: N/A – pt. unresponsive.
Meds: Unknown
Allergies: NKDA
Past Medical History: Brain cancer, anemia
Impression: Decreased LOC
Narrative
Response to 911 dispatch for report of unconscious person @ SNF. Per staff, pt. is normally up and walking around, but
today unable to walk or verbalize. Pt. responds only to pairful stimuli. no dyspnea; HEENT unremarkable; PERRL; no
JVD; chest= rise and fall; abdomen soft, non-tender; pulse stable; no edema; no signs of trauma; EKG NSR w/PVC pt.
speaking but incomprehensible words. Checked for neuological deficits but pt. not responsive enough. Pt. family states
pt. was not exposed to new drugs or chemicals.
Vital Signs
Time
10:19
10:32
BP
133/77
138/89
Pulse
88
94
Resp
18
18
Pupils
PERRL
PERRL
GCS
LOC
Skin
Treatments
Meds _ N/A
Pt to Stretcher Via: Crew sheet lift
Route of Admin: N/A__________
Other: _EKG, IV, Blood sugar (128)
Crew Info
Name: Retief Goosen
Cert No:
578
Name: Rory Sabatini
Cert No: 8765-P
Cert Level: EMT-B
Signature: Retief
Signature: Rory
Goosen
Sabatini
Patient Name: ___Martha Washington______________________ Transport Date: _______07/08/2011 ______
X
______________ ______________ X_____________________________________ __________________________
Date
Witness Signature
Date
___________________________________________________________
Witness Address
__________________________________________________________________________________________________________________________
is a sample only
and
does not
User bears
responsibility
forpayment
compliance
with all applicable
laws and
regulations.
 This
Representative
of an
agency
or constitute
institutionlegal
that advice.
did not furnish
the all
services
for which
is claimed
(i.e., ambulance
services)
but
X
______ ________
_______
Date
__________________________________________________________________________
______Decreased LOC. See PCR__________________________________________________________
Name and Location of Receiving Facility: U
of M ER ___________________________________________________
Time at Receiving Facility: __10:49__________________________
X
Retief Goosen
_
07/08/2011
Date
__
Retief Goosen, EMT-B
________
This is a sample o
X
____
____ ___
______
__
Run 204NE
Run Number: 204NE
Patient Name: James Madison
Patient Care Report
Times
Dispatched:
15:54
Dispatched
Enroute:
15:57
As:
At Scene:
16:03
To Destination:
16:50
At Destination:
17:08
In Service:
17:22
Mileage
To Scene:
031 Transfer
Type:
BLS
Priority:
Alpha
Location:
NMMC
Big Mountain SNF
To:
Mountain, CF 12567
1.2
Enroute Dest.:
1.2
At Dest:
4.4
In Qtrs:
10.2
Total Loaded
Mountain CF 12345
Transported
On Scene:
Miles:
4.4
Transport
Priority:
Alpha
Patient Information
Name: James Madison
DOB: 07/15/1938
Sex: Male
Address: 905 New Rd,
Age: 72
Weight: 215 lbs
Mountain, CF 12345
Initial Information
Pt found: Supine in bed
Chief Complaint: “I had the MRSA.”
Meds: List with patient
Allergies: NKDA
Past Medical History: MRSA, Sepsis, HTN
Impression:
Narrative
Called to NMMC for transport of 70 year old male pt to SNF for continuing treatment of IV antibiotics after being
treated for sepsis at NMMC since 7/7/11. Pt met lying in bed transferred to stretcher via 2 man draw sheet.
Enroute vitals taken and assessed as noted. Pt rested w/no complaints At Big Mountain, pt brought to room
125 transferred to bed via 4 draw sheet. Papers and report given to RN.
Vital Signs
Time
16:55
BP
110/52
Pulse
76
Resp
16
Pupils
GCS
LOC
Alert
Skin
Treatments
Oxygen @ ___ LPM via ______
Meds ___
_______
Pt to Stretcher Via: Sheet lift
Route of Admin: _______________
Other: _______________________
Name: Ian Poultier
Cert No:
5556-P
Name: Luke Donald
Cert No: 321
Crew Info
Cert Level: Paramedic Signature: Ian
Cert Level: EMT-B
Poultier
Signature: Luke
Donald
Patient Name: ____James Madison_____________________________ Transport Date: _____07/14/2011________
X
______________ ______________ X_____________________________________ __________________________
Date
Witness Signature
Date
___________________________________________________________
Witness Address
__________________________________________________________________________________________________________________________
Patient’s legal guardian
Relative or other person who receives social security or other governmental benefits on behalf of the patient
 This
Representative
of an agency or institution that did not furnish the services for which payment is claimed (i.e., ambulance services) but
is a sample only and does not constitute legal advice. User bears all responsibility for compliance with all applicable laws and regulations.

X
X Lilly
Madison_
_07/14/2011
___Lilly Madison, 905 New Rd, Mountain, CF 12345__
Date
______________________________________________________________________________________________________________________
X
_______
_______
Date
__
________
_____
__
This is a sample o
X
____
____ ___
______
__
Patient’s Name: James
Madison
Origin: NMMC
Date of Birth: _07/15/1938______Medicare #:
204NE
Hospital
Destination: Big
Mountain Nursing Home
X NO
Closest appropriate facility? X YES  NO If no, why is transport to more distant facility required?
If hosp-hosp transfer, describe services needed at 2nd facility not available at 1st facility:
If hospice pt, is this transport related to pt’s terminal illness?  YES X NO Describe:______________________________________________
1)
Describe the MEDICAL CONDITION (physical and/or mental) of this patient AT THE TIME OF AMBULANCE TRANSPORT that requires
Patient ambulates ONLY with a walker
2)
 Yes
 No
3)
Can this patient safely be transported by car or wheelchair van (i.e., seated during transport, without a medical attendant or monitoring?)
 Yes
X No
4)
In addition to completing questions 1-3 above, please check any of the following conditions that apply*:
 Contractures
 Danger to self/other  IV meds/fluids required  Patient is combative
 Patient is comatose
 Moderate/severe pain on movement
 Requires oxygen – unable to self administer
 Hemodynamic monitoring required enroute
 Other (specify)
Edith Cavell
07/14/2011
Date Signed
Edith Cavell, MD
Run 205E
Run Number: 205E
Patient Name: John Adams
Patient Care Report
Times
Dispatched:
Enroute:
01:01
Dispatched
01:03
At Scene:
01:10
To Destination:
01:45
At Destination:
01:53
In Service:
02:43
Mileage
As:
001- Cardiac
Type:
ALS
Priority:
Delta
Location:
Big Mountain SNF
To Scene:
736.8
On Scene:
738.2
Enroute Dest.:
738.2
At Dest:
742.5
In Qtrs:
748.9
Total Loaded
Mountain, CF 12567
Miles:
Transported
NMMC ER
To:
Mountain, CF 12345
4.3
Transport
Priority:
Charlie
Patient Information
Name: John Adams
DOB: 04/04/1941
Sex: Male
Address: Big Mountain SNF
Age: 70
Weight: 152 kgs
Mountain, CF 12567
Initial Information
Pt found: In recliner
Chief Complaint: “I feel really sick in my stomach and my
Meds: Albuterol, Xanax, Coumadin
chest is tight”
Allergies: Morphine
Past Medical History: DM, HTN, Depression
Impression:
Narrative
Upon arrival, pt found lying supine in bed; pt is A+O x3 c/o chest pain and nausea. CP reported as substernal with radiating
pain to L shoulder + back; Pain 8/10 initially, and woke him from sleep. Intermittent but reproducible w/ touch to sternum.
Slight nausea pt believes from nerves. Pt also complaining of pelvic/ back pain unrelated to this CP. Pt reports diff.
breathing due to stuffy nose. Pt has PICC line in R arm. EKG shows SR w/ ectopy; pt. on O2 @ 4 lpm ; to 15 via NRB;
Admin 0.4 mg NTG spray - helped eradicate pain; transport w/o incident.
Vital Signs
Time
01:17
01:42
BP
127/68
130/P
Pulse
75
68
Resp
20
18
Pupils
PERRL
PERRL
GCS
15
15
LOC
A&Ox3
Skin
Pink
Treatments
Oxygen @ __10___ LPM via __NRB_____
Meds _ NSS via PICC; Nitro
Pt to Stretcher Via: Crew sheet lift __
Route of Admin: NSS was via PICC. Nitro via SL
Other: _EKG(NSR), IV, Blood sugar (128)
Crew Info
Name: Zach Johnson
Cert No:
7124-I
Name: Rory Sabatini
Cert No: 8765-P
Cert Level: EMT-I
Signature: Zach
Johnson
Signature: Rory
Sabatini
Patient Name: _____John Adams________________ Transport Date: _07/09/2011___
___________
X John
Adams
_07/09/2011
Date
X_____________________________________ __________________________
Witness Signature
Date
___________________________________________________________
Witness Address
__________________________________________________________________________________________________________________________
is a sample only
and
does not
User bears
responsibility
forpayment
compliance
with all applicable
laws and
regulations.
 This
Representative
of an
agency
or constitute
institutionlegal
that advice.
did not furnish
the all
services
for which
is claimed
(i.e., ambulance
services)
but
X
______ ________
_______
Date
__________________________________________________________________________
______________________________________________________________________________________________________________________
X
_______
_______
Date
__
________
_____
__
This is a sample o
X
____
____ ___
______
__
Run 206NE
Run Number: 206NE
Patient Name: Dolley Madison
Patient Care Report
Times
Dispatched:
Enroute:
Mileage
Dispatched
15:10
At Scene:
15:15
To Destination:
16:00
As:
031- Transfer
Type:
BLS
Priority:
Alpha
Location:
U of M Dialysis
In Service:
481.2
On Scene:
482.3
Enroute Dest.:
482.8
At Dest:
485.6
In Qtrs:
492.7
Total Loaded
Mountain CF 12345
At Destination:
To Scene:
Miles:
Transported
4 Elm St
To:
Mountain CF 12345
2.8
Transport
Priority:
Alpha
Patient Information
Name: Dolley Madison
DOB: 05/21/1940
Sex: Female
Address: 4 Elm St
Age: 71
Weight: 200 lbs
Mountain CF 12345
Initial Information
Pt found: Seated in treatment chair
Chief Complaint: Routine transfer
Meds: List with patient
Allergies: NKDA.
Past Medical History: ESRD, CVA, MI, DM
Impression: Dialysis transport
Narrative
Pt found in TX chair. Pt assisted to W/C, weighed and assisted to stretcher. Upon arrival, pt was assisted to couch and
placed in position of comfort.
Vital Signs
Time
15:53
BP
132/74
Pulse
82
Resp
16
Pupils
PERRL
GCS
LOC
A&Ox3
Skin
Pale
Treatments
Oxygen @ ___ LPM via ______
Meds ___
_______
Pt to Stretcher Via: Sheet lift
Route of Admin: _______________
Other: _______________________
Crew Info
Name: Retief Goosen
Cert No:
578
Cert Level: EMT-B
Signature: Retief
Name: Luke Donald
Cert No: 321
Cert Level: EMT-B
Signature: Luke
Goosen
Donald
Patient Name: ______Dolley Madison__________________________ Transport Date: ___07/15/2011___
______
X Dolley
Madison
___________
07/15/2011
Date
X_____________________________________ __________________________
Witness Signature
Date
___________________________________________________________
Witness Address
__________________________________________________________________________________________________________________________
is a sample only
and
does not
User bears
responsibility
forpayment
compliance
with all applicable
laws and
regulations.
 This
Representative
of an
agency
or constitute
institutionlegal
that advice.
did not furnish
the all
services
for which
is claimed
(i.e., ambulance
services)
but
X
______ ________
_______
Date
__________________________________________________________________________
______________________________________________________________________________________________________________________
X
_______
_______
Date
__
________
_____
__
This is a sample o
X
____
____ ___
______
__
Patient’s Name: Dolley
Madison
Origin: U
Date of Birth: ___05/21/1940________
Medicare #:
206NE
of M Dialysis
Destination: Residence
NO
Closest appropriate facility? YES  NO If no, why is transport to more distant facility required?
 NO Describe:______________________________________________
Is not wheelchair able (should not stand, pivot or ambulate; is unable to safely assist with moving
herself)
2) Is this patient “bed confined” as defined below?
 Yes
X
No
3)
 Yes
X No
4)
 Contractures
 Special handling/isolation/infection control precautions required X Unable to tolerate seated position for time needed to transport
 Other (specify)
Mary Breckenridge, MD
06/20/2011
Date Signed
Mary Breckenridge, MD
Run 207E
Run Number: 207E
Patient Name: Abigail Adams
Patient Care Report
Times
Mileage
To Scene:
Dispatched:
12:20
Dispatched
Enroute:
12:25
As:
016- Sick Person
Type:
BLS
Priority:
Bravo
Location:
18 Sherwood Lane
At Scene:
12:45
To Destination:
13:01
At Destination:
13:50
In Service:
15:19
On Scene:
Enroute Dest.:
At Dest:
In Qtrs:
Total Loaded
Valley, CF 98765
6.2
Miles:
Transported
St. Joseph ER
To:
Valley, CF 98765
Transport
Priority:
Alpha
Patient Information
Name: Abigail Adams
DOB: 04/24/1936
Sex: Female
Address: 18 Sherwood Lane
Age: 75
Weight: 105 lbs
Valley, CF 98765
Initial Information
Pt found: In lounge chair
Chief Complaint: “I’ve been throwing up for days.”
Meds: Nexium, Reglan, Privinil
Allergies: Morphine, Demerol, Tylenol
Past Medical History: Uterine cancer
Impression: Weakness
Narrative
U/A pt. complaining of weakness/syncope upon standing x2 days progressively worsening. Nausea w/o vomiting. Low B/P
and difficulty pronouncing words. Patient also reports slight “weakness on left side of face.” Pt. denies c/p or sob: skin warm
and reddened but normal as per pt.; radial pulse easily palpable; abdomen soft; indwelling urinary catheter in place; 300 CC
NS bolus intro L arm; Delay in arriving due to wrong address given @ dispatch.
Vital Signs
Time
12:49
13:25
BP
82/58
90/47
Pulse
107
100
Resp
16
14
Pupils
PERRL
PERRL
GCS
15
15
LOC
A&Ox3
A&Ox3
Skin
Pale
Treatments
Meds _ NSS bolus
_______
Route of Admin: IV_________________
Other: _EKG(ST), IV, Blood sugar (126)
Crew Info
Name: Zach Johnson
Cert No:
7124-I
Name: Luke Donald
Cert No: 321
Cert Level: EMT-I
Signature: Zach
Johnson
Cert Level: EMT-B
Signature: Luke
Donald
Electronic Signature Form
Run Number: 207E
Patient Name: Abigail Adams
CREW MEMBER SIGNATURE #1
CREW MEMBER SIGNATURE #2
Stuart Appleby
PATIENT SIGNATURE
PATIENT REPRESENTATIVE SIGNATURE
Steve Adams (on behalf of patient)
Steve Adams (on behalf of patient)
Run 208NE
Run Number: 208NE
Patient Name: James Monroe
Patient Care Report
Times
18:12
Dispatched
Enroute:
18:15
As:
031- Transfer
Type:
ALS
Priority:
Charlie
Location:
Little Hospital
At Scene:
18:39
To Destination:
18:50
At Destination:
20:09
In Service:
21:06
Mileage
To Scene:
Dispatched:
On Scene:
Enroute Dest.:
At Dest:
In Qtrs:
Total Loaded
Psycho, PN 75567
Miles:
Transported
U of M Hospital
To:
Mountain CF 12345
43.2
Transport
Priority:
Charlie
Patient Information
Name: James Monroe
DOB: 09/08/1939
Sex: Male
Address: 101 Spring Dr.
Age: 71
Weight: 211 lbs
Psycho, PN 75567
Initial Information
Pt found: Semi fowlers in bed
Chief Complaint:
Meds: Lopressor, ASA, Lipitor
Allergies: NKDA
Past Medical History: HTN, BKA
Impression: Transport
Narrative
Transfer for pre-heart cath work up. Patient was complaining of CP for 2+ weeks. CP was localized to the L interior
costal region–rating pain of 1 on 1-10. Assessment completed noting an 18g in the right a/c. Pt. to cot then unit. Patient
remained at 20◦ HOB and was secured x3 buckles. O2 @ 2 LPM NC SP-O2 95-97 app. Accucheck @ 173, enroute 1030 min to U of M Hospital. Reassessment unremarkable. Pt. denied pain,
Discomfort x 3. VS Xferred to BMC registration. Report given to RN.
Vital Signs
Time
18:42
20:05
BP
130/75
145/75
Pulse
59
64
Resp
18
18
Pupils
PERRL
PERRL
GCS
15
15
LOC
A&Ox3
A&Ox3
Skin
NCTreatments
Oxygen @ _2__ LPM via _NC_____
Meds ___
__________
Pt to Stretcher Via: Sheet lift ___
Route of Admin: _______________
Other: ___EKG(NSR)____________________
Crew Info
Signature: Dustin
Name: Dustin Johnson
Cert No: 2345-P
Name: K.J. Choi
Cert No: 694-P(A)
Cert Level: Paramedic (Advanced) Signature: K.J.
Johnson
Choi
Patient Name: ___James Monroe_________________ Transport Date: ________07/16/2011_____
X
Pt Unable to Sign
______________ X_____________________________________ __________________________
Date
Witness Signature
Date
___________________________________________________________
Witness Address
_______Chest Pain, IV, Monitor_____________________________________________________________
is a sample only
and
does not
User bears
responsibility
forpayment
compliance
with all applicable
laws and
regulations.
 This
Representative
of an
agency
or constitute
institutionlegal
that advice.
did not furnish
the all
services
for which
is claimed
(i.e., ambulance
services)
but
X
______ ________
_______
Date
__________________________________________________________________________
______________________________________________________________________________________________________________________
X
_______
_______
Date
__
________
_____
__
This is a sample o
X
____
____ ___
______
__
Patient’s Name:
James Monroe
Origin:
Date of Birth: _09/08/1939_______
208NE
Medicare #:
Little Hospital
Destination: University
of Mountain Hospital
X NO
Closest appropriate facility? X YES  NO If no, why is transport to more distant facility required?
 NO Describe:______________________________________________
1)
Describe the MEDICAL CONDITION (physical and/or mental) of this patient AT THE TIME OF AMBULANCE TRANSPORT that requires
CP/CAD
2)
 Yes
 No
3)
 Yes
 No
4)
 Contractures
X Medical attendant required
X Hemodynamic monitoring required enroute
 Other (specify)
Helen Fairchild, MD
07/16/2011
__________________
Date Signed
Helen Fairchild, MD
Run 209E
Run Number: 209E
Patient Name: Thomas Jefferson
Patient Care Report
Times
Mileage
Dispatched:
14:39
Dispatched
013- Altered Mental
Enroute:
14:39
As:
Status
Type:
ALS
Priority:
Delta
Location:
Dr. Peirce’s Office
At Scene:
14:45
To Destination:
15:12
At Destination:
15:14
In Service:
15:35
To Scene:
On Scene:
1.0
Enroute Dest.:
1.0
At Dest:
2.0
In Qtrs:
3.0
Total Loaded
Mountain, CF 12345
Miles:
Transported
NMMC ER
To:
Mountain, CF 12345
1.0
Transport
Priority:
Delta
Patient Information
Name: Thomas Jefferson
DOB: 02/25/1932
Sex: Male
Address: 1 Lamar St.
Age: 79
Weight: 285 lbs.
Mountain, CF 12345
Initial Information
Pt found: In wheelchair
Chief Complaint: (from staff) “He just passed out.”
Meds: Unknown
Allergies: Unknown
Past Medical History: Dementia, ETOH abuse, HTN
Impression: Unconscious person
Narrative
911 response to Dr. office for reported 76 year old male who “just went unresponsive;” Pt arrived at physician’s office from
SNF earlier in day for follow-up appointment for cataract surgery; Upon arrival, crew found patient sitting in w/c, with head
being supported by nurse, and patient unresponsive to voice. Pt. was moved to floor and evaluated; Pt. heavily diaphoretic;
unresponsive to voice and pain; skin clammy and cold; RR = 20 but shallow; weak radial pulse x 2. IV established
to administer 250 cc bolus of NS (18 gage in Left forearm); Pupils constricted; airway patent; pt. occasionally moves arms;
no edema; no trauma noted; EKG monitor shows sinus brady; Heart rate increased while en route; patient becomes more
responsive and begins verbalizing during tx.
Vital Signs
Time
14:47
14:52
BP
UTO
UTO
Pulse
64
54
Resp
20
20
Pupils
Sluggish
Dilated
GCS
4
5
LOC
Unconscious
A&Ox0
Skin
Pale, diaphoretic
Pale, diaphoretic
Treatments
Oxygen @ __15___ LPM via __NRB_____
Meds _ NSS bolus
_______
Route of Admin: IV_________________
Other: _EKG(NSR), IV, Blood sugar (206)
Crew Info
Cert No:
43401-RN
Name: Luke Donald
Cert No: 321
Cert Level: RN
Signature: Annika
Cert Level: EMT-B
Signature: Luke
Sorenstam
Donald
Patient Name: _______Thomas Jefferson____________________ Transport Date: _____07/11/2011______________
X
Thomas Jefferson_____
07/15/2011_
Date
X____________________________
Witness Signature
__________________________
Date
___________________________________________________________
Witness Address
__________________________________________________________________________________________________________________________
is a sample only
and
does not
User bears
responsibility
forpayment
compliance
with all applicable
laws and
regulations.
 This
Representative
of an
agency
or constitute
institutionlegal
that advice.
did not furnish
the all
services
for which
is claimed
(i.e., ambulance
services)
but
X
______ ________
_______
Date
__________________________________________________________________________
______________________________________________________________________________________________________________________
X
_______
_______
Date
__
________
_____
__
This is a sample o
X
____
____ ___
______
__
ABC Ambulance Service, Inc
P.O. Box 427, Mountain CF 12345 (426) 433-0434
B. Patient Name: Thomas Jefferson
C. Identification Number: 209E209E
Advance Beneficiary Notice of Noncoverage (ABN)
NOTE: If Medicare doesn’t pay for the ambulance services below, you may have to pay.Medicare does not pay
for everything, even some care that you or your health care provider have good reason to think you need. We
expect Medicare may not pay for the ambulance services listed below.
Services
Ambulance transport
and mileage
Ambulance mileage
ALS Ambulance
Air Ambulance
Non-Ambulance
Services
Reason Medicare May Not Pay:
___ Medicare does not pay for transportation from a residence or a SNF for
services that could more economically be performed at the residence or SNF
___ Medicare does not pay for ambulance service that is not medically necessary
X Medicare does not pay for transports to a doctor’s office or other noncovered destinations
___ Medicare does not pay for transports for the convenience of a patient, family
or physician
___ Medicare does not pay for mileage beyond the closest appropriate facility
___ Medicare does not pay for a higher level of service (Advanced Life Support)
when a lower level of service (Basic Life Support) would suffice
___ Medicare will not pay for air ambulance service if the patient could have been
safely transported by ground ambulance.
___ Medicare does not pay for non-transporting paramedic intercept services
___ Medicare does not pay for wheelchair van or stretcher car services
Estimated Cost
$_350.00_______________
BLS Ambulance Service
$__2.50_______ per mile
$__650.00______________
ALS Ambulance Service
$________________
Air Ambulance Service
$________________
$________________
WHAT YOU NEED TO DO NOW:
•
•
•
Read this notice, so you can make an informed decision about your care.
Ask us any questions that you may have after you finish reading.
Choose an option below about whether to receive the ambulance services listed above.
Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might
have, but Medicare cannot require us to do this.
OPTIONS:
Check only one box. We cannot choose a box for you.
X OPTION 1. I want the ambulance services listed above. You may ask to be paid now, but I also want
Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I
understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by
following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less copays or deductibles.
☐ OPTION 2. I want the ambulance services listed above, but do not bill Medicare. You may ask to be paid
now as I am responsible for payment. I cannot appeal if Medicare is not billed.
☐ OPTION 3. I don’t want the ambulance services listed above. I understand with this choice I am not
responsible for payment, and I cannot appeal to see if Medicare would pay.
H. Additional Information:
This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or
Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048). Signing below means that
you have received and understand this notice. You also receive a copy.
J. Date: 07/11/2011
I. Signature: Dr. Pierce
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed,
and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Baltimore, Maryland 21244-1850.
Form CMS-R-131 (03/11)
Form Approved OMB No. 0938-0566
Run 210NE
Run Number: 210NE
Patient Name: Elizabeth Monroe
Patient Care Report
Times
Dispatched:
Enroute:
18:25
Dispatched
19:15
At Scene:
19:26
To Destination:
19:58
At Destination:
20:22
In Service:
20:38
Mileage
031- Interfacility
As:
Transfer
Type:
ALS
Priority:
Charlie
Location:
Big Mountain SNF
To Scene:
5586.9
On Scene:
5589.2
Enroute Dest.:
5589.2
At Dest:
5602.2
In Qtrs:
5621.4
Total Loaded
Mountain, CF 12567
Miles:
Transported
U of M ER
To:
Mountain, CF 12345
13.0
Transport
Priority:
Delta
Patient Information
Name: Elizabeth Monroe
DOB: 05/06/1916
Sex: Female
Address: 14 Redrum Way
Age: 94
Weight: 165 lbs
Mountain, CF 12345
Initial Information
Pt found: Supine on hospital bed
Chief Complaint: “She needs her weakness evaluated.”
Meds: Namenda, ASA, Fish Oil,
Allergies: Fentanyl
Past Medical History: Alzheimer’s, Dementia, HTN
Impression: Weakness
Narrative
ALS unit called for transfer to ER. U/A found cons. 92 yr old female in nursing home bed. Pt. weakness X 2 days in the left
arm, L leg. Pt. transferred via 2-person sheet transfer to cot to ambulance. Pt rested in POC, semi-fowlers in NAD. Pt.
denied pain. Pt. minimal or no responses to questions or commands, altered and confused. L grip very weak. EKG 3-lead
shows regular sinus rhythm. IV attempt, 18 gauge, R forearm, unsuccessful. Transport uneventful. Pt. transferred via 2person sheet to ER bed and left in care of ER nurse with full report provided.
Vital Signs
Time
19:30
19:35
BP
164/84
170/76
Pulse
80
80
Resp
14
14
Pupils
PERRL
PERRL
GCS
14
LOC
Skin
Treatments
Oxygen @ _10_ LPM via _NRB_____
Meds __N/A_
__________
Pt to Stretcher Via: 2 person sheet lift
Route of Admin: _N/A______________
___
Other: _EKG (NSR)______________________
Crew Info
Cert No: 123-P
Signature: Grace
Name: Stuart Appleby Cert No: 3765-P
Signature: Stuart
Name: Grace Park
Park
Appleby
Patient Name: ______ Elizabeth Monroe __________________ Transport Date: _________07/17/2011_________
______
X
______________ ______________ X_____________________________________ __________________________
Date
Witness Signature
Date
___________________________________________________________
Witness Address
_____________Alzheimers___________________________________________________________________



X
Patient’s legal guardian
Relative or other person who receives social security or other governmental benefits on behalf of the patient
Relative or other person who arranges for the patient’s treatment or exercise other responsibility for the patient’s affairs
Representative
of an
orconstitute
institutionlegal
that advice.
did not User
furnish
the all
services
for which
is claimed
(i.e., ambulance
services)
but
This
is a sample only
andagency
does not
bears
responsibility
for payment
compliance
with all applicable
laws and
regulations.
X Sophie
Mann, RN _____ 07/17/2011
Date
Sophie Mann, Big Mountain SNF Mountain, CF 12567_______
______________________________________________________________________________________________________________________
X
_______
_______
Date
__
________
_____
__
This is a sample o
X
____
____ ___
______
__
Patient’s Name: Elizabeth
Monro________
Origin: Big
Date of Birth: ___05/06/1916_____________Medicare #: 210NE
Mountain SNF
Destination: U
of M ER
Closest appropriate facility?
X YES
X NO
 NO If no, why is transport to more distant facility required?
 NO Describe:______________________________________________
Left sided weakness needs evaluation
2)
X Yes  No
3)
 Yes
 No
4)
 Contractures
 Unable to sit in a chair or wheelchair due to decubitis ulcers or other wounds
 Other (specify)
Sophie Mann, RN
07/17/2011
Date Signed
Sophine Mann
X Registered Nurse

2012 Claims Coding Clinic - Arkansas Ambulance Association

Transcription

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