Proper documentation for emergency and non-emergency EMS transports begins at the time of dispatch. This is because for Medicare purposes, how a call is dispatched and responded to are the key events when distinguishing between billing for an emergency and non-emergency transport. Therefore, it is paramount that ambulance services have proper dispatch protocols in place and crews have proper training on how to document the dispatch information and their response mode in the PCR.
A Brief Bit of History
It’s important to acknowledge past practices in EMS, because the field can be slow to adapt in some ways and crews who have been in the industry for a long time may have learned old documentation forms that are no longer applicable. Being able to identify these misunderstandings can help create better documentation practices for your service.
In the past, “lights and sirens” were the key distinguishing feature of whether a call was an emergency or a non-emergency transport. This practice was based on the CMS payment rules in place prior to April 1, 2002, which stated that an emergency transport was determined based upon the patient’s condition at the scene. However, as response systems have evolved and the definition of an emergency response has changed, the use of lights and sirens does not influence how a transport is billed and the focus on the patient’s condition on scene has shifted to the condition at dispatch.
After April 1, 2002, CMS implemented the Ambulance Fee Schedule and changed the definition of an emergency response. The new definition can be found at 42 CFR § 414.605 and is as follows:
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.
This definition changed the focus of an emergency response from the patient’s condition on scene to the patient’s condition reported at the time of dispatch. The key take away is CMS is now paying for the resources ambulance services need to be prepared to respond to emergencies immediately.
Keys for Documenting Emergency and Non-Emergency Responses
Reviewing the current definition of an emergency response, we can take away two key things to document: the type of dispatch and the immediacy of the response. Lets review these concepts:
- Dispatch Type: An emergency response requires a 911 or 911-like call. This means the crew must document how the dispatch came in. In its easiest form, when a call comes in from the 911 dispatch center, the crew may simply document that they received the call from that 911 dispatch center to meet this requirement. However, in cases where the 911 center was not used, either because there isn’t one in the area, or the caller contacted the ambulance service directly, the call-taker should review the service’s dispatch protocol and use that protocol to dispatch the call as an emergency or non-emergency. In this instance the crew would document how the call was received and whether it was dispatched emergently or not. As a final note, the dispatch protocol should at a minimum be consistent with the local or closest comparable 911 dispatch center protocol. We recommend that all ambulance services review their 911 dispatch center protocols against their internal dispatch protocols to ensure consistency.
- Response: The second element of an emergency response is the documenting of the response itself. As the definition above states, once a 911 or 911-like call is dispatched, the crew should respond immediately. The definition then goes on to say this includes the service taking steps to respond to the call as quickly as possible. The term immediate can cause some confusion, especially during non-emergency transports. This is because crews may document they responded immediately in all cases. In training the crews, it can be helpful to explain that in the context of the emergency response definition, non-immediate is consistent with non-emergent and for clarity of the response urgency, they may document that they responded non-immediately or non-emergently even though the run times will show they left as soon as the call came in.
A Note About Medical Necessity
We find many services, especially 911-only services, can sometimes conflate a 911-response with meeting Medical Necessity. This is not the case and emergency responses are to be reviewed and documented as separate criteria from medical necessity. As the more detailed emergency response definition in Medicare Benefit Policy Manual – 30.1.1 states:
The nature of an ambulance’s response (whether emergency or not) does not
independently establish or support medical necessity for an ambulance transport.
Rather, Medicare coverage always depends on, among other things, whether the
service(s) furnished is actually medically reasonable and necessary based on the
patient’s condition at the time of transport.
We recommend all services who are self-auditing or following a QA process separate the review of emergency documentation from their review of medical necessity if they are not already doing so.
Some Examples
Now that we have a basic understanding of the emergency response definition, lets review a few examples of its application:
- You are dispatched to a nursing home to take a patient to their regularly scheduled dialysis appointment. Once on scene the patient is experiencing chest pain and you divert to the ER. Should this transport be billed emergently? No. The call was dispatched as a non-emergent transport and responded to accordingly, therefore the patient’s different condition on the scene does not change the non-emergency response.
- You get a 911 call but have no available ambulances at the time. You call a crew who are just about to finish another transport and after 5 minutes they become available and leave for the emergency call. Assuming all other criteria are met, should this transport be billed as an emergency? Yes. The call was received through the 911 system and is properly dispatched as an emergency and though the truck was unable to leave at that exact moment, the service took the steps necessary to respond to the call as quickly as possible.
- You are dispatched for a 911 call where the patient is experiencing chest pain. You respond to the scene immediately. Upon assessing the patient, who is bed-confined, you determine that they are having heartburn and downgrade to a non-emergency transport. Assuming the patient otherwise meets program criteria for ambulance transport, should this run be billed as an emergency? Yes. The condition of the patient at the time of dispatch was chest pain and the crew responded immediately. Despite the patient’s condition not being an emergency upon arrival, the response still meets the emergency definition.
Emergency vs. non-emergency responses can be a little more complicated than people may think. We hope this blog has helped clarify the main issues involved in properly documenting emergency and non-emergencies in the PCR. Please feel free to email us with any questions about this topic or suggest another area of EMS documentation for us to cover in the future. Not a client? Contact us today to get started with our suite of EMS Compliance offerings.
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