Mental status documentation has become an issue we’ve noticed many services face and many billing and compliance professionals struggle with as well. At MCS our focus is to bring the various elements of EMS compliance (providers, QA, billers, etc.) together to understand each other’s point of view. It is our belief that building this understanding can help set proper expectations for compliant documentation that is fit for billing and is clinically sound. This article will review the common mental status assessments and scales, identify key areas of overlap and inconsistency in mental status documentation, and offer recommendations for more complete documentation. Let’s get started!
Establishing a Baseline
To begin, it’s important that our readers, regardless of whether they are a provider, a compliance officer, or a biller, are speaking the same language when it comes to mental status documentation. So, let’s begin by reviewing three of the most common measurement scales of mental status in EMS: GCS, AVPU, and A&O. Below we will briefly describe what they measure and how they are scored.
What does AVPU Measure?
For a good breakdown of the AVPU scale, check out this article on EMS1. To put it briefly, AVPU is a scale used to describe the patient’s level of consciousness. AVPU stands for the following:
A = Awake – The patient is awake.
V = Verbal – The patient responds to a verbal stimulus.
P = Pain – The patient responds to a pain stimulus.
U = Unresponsive – The patient is unresponsive to stimulus.
This scale basically works in descending order. If the patient is awake, regardless of whether they are also disoriented, fully alert, or lethargic, they are considered an A on this scale. You’d determine that they are awake if they verbally respond to a stimulus you provide.
Next, if the patient is verbal, this means they respond to a verbal stimulus, but not with a verbal response. Using the example from the EMS1 article above, if you say something to the patient and they raise their eyes to you or otherwise physically respond, that is a V.
If the patient doesn’t respond to a verbal stimulus, you would next attempt to provide a pain stimulus, such as a sternum rub. If a patient has a physical response to this, such as pulling away, they would be considered a P.
Finally, if the patient is unresponsive, they have failed to respond to any of the stimuli you’ve provided and would be considered U.
What does A&Ox4 Measure?
Alert and Oriented is an assessment that uses simple questions to determine the patient’s awareness of reality in the moment. Here are the four levels of orientation:
Person – You may ask the patient what their name is. If they can answer this question they are oriented to person.
Place – You may ask the patient where they are. If they can respond to this they are oriented to their current place.
Time – You may ask the patient if they know what day it is, what month, what year. If they can answer this, they are oriented to time.
Situation/Event – Finally, you may ask the patient if they know what is happening to them at the moment. If they can answer this question they are oriented to the current situation.
Depending on how the patient answers these questions, they may be A&Ox1 through 4 or unresponsive (0). It is also important to mention that in some EMS situations crews may also use the A&Ox3 scale, excluding the situation/event assessment.
What does GCS Measure?
According to an article on the National Library of Medicine, The Glasgow Coma Scale (GCS) is used to objectively describe the extent of impaired consciousness for all types of acute medical and trauma patients. The scale assesses patients according to three aspects of responsiveness: eye opening, motor, and verbal responses. Here is a detailed look at how each of these aspects are scored:
Best eye response (4)
- No eye opening
- Eye opening to pain
- Eye opening to sound
- Eyes open spontaneously
Best verbal response (5)
- No verbal response
- Incomprehensible sounds
- Inappropriate words
Best motor response (6)
- No motor response.
- Abnormal extension to pain
- Abnormal flexion to pain
- Withdrawal from pain
- Localizing pain
- Obeys commands
Let’s Bring it Together
You may be looking at these forms of measuring mental status and notice that they overlap with each other. You’d be correct! In fact, you may use the AVPU scale as an initial determination before using the alert and oriented assessment. This is because if the patient is awake (A) in AVPU, then they can be assessed for the alert and oriented questions. If the patient is not awake, they cannot answer any of those questions. Similarly, the AVPU scale and alert and oriented assessment can roll into the more detailed numbering of the GCS scale.
We Have All of These Measurements So What’s the Problem with Mental Status Documentation?
A simple answer is the documentation of mental status has been reduced to numerical data entry without any detail or consistency. At MCS we attempt to put a spotlight on the problem areas in understanding between the different groups involved in EMS documentation and billing. Below we will discuss examples of why simply providing the numbers from these mental status assessments is insufficient for compliant billing documentation.
- There are inconsistencies within EMS agencies on how these scales are used. If you were to ask a group of medics what scale they were trained to use when assessing mental status, you will probably hear some variation of the three scales above. If you were to ask those same medics what their service’s protocol is for documenting mental status, they would likely say there isn’t a specific protocol and they are free to use any of those scales and assessments. It is very common that we see runs from the same service using A&Ox4 and A&Ox3 as the maximum scale. Without knowing when the distinction is made the same patient who is A&Ox3 could be considered fully oriented or slightly disoriented depending on who you ask.
- Another big issue occurs in ePCR programs that may have fields which autogenerate if left blank. We have seen many run reports where a patient’s vitals field shows a GCS of 15 then assessment tabs and the narrative will contradict that number with other mental status scales. This error can lead to the appearance of contradictory documentation of mental status.
- Recently we have also seen the use of the term “patient is at their baseline” for mentally handicapped patients. This is a useful description, however, a patient who is mentally handicapped but who is listed as GCS 15 or fully A&Ox4 “at baseline” creates a contradiction in mental status. The same is true for a patient who is GCS 13 but A&Ox4 at their baseline.
- Finally, we have also seen arguments that a patient can have conflicting scores without it actually being a contradiction, for example a patient who is A&Ox2 can also be GCS 15. The argument being that a patient could sufficiently answer who they are and what date it is but not know who the president is or the year, and then be able to function appropriately within the other GCS response scales.
Our takeaway from these situations and examples are that numbers alone are not sufficient for mental status documentation. Words matter. A provider may read this and think some of these examples can technically be true or correctly documented with those numbers. However, the details of that explanation are most often missing from the narrative. When a QA-er, biller, or auditor looks at those numbers, they don’t see what’s in the medic’s head and this can lead to claims being sent back for review or flagged for an overpayment.
How Does Medicare Want Us to Document?
Glad you asked! The answer, as it so often is when it comes to compliant billing is to paint the picture. In a webinar conducted by CGS in 2021, they focused several slides on documentation of medical necessity in non-emergent transports related to impairments of mental function. Here are some bullet points showing what the narrative should include about mental status:
- How has the disease affected the patient’s function ability as it relates to transport?
- Why would a stretcher be required instead of a wheelchair?
- The impairments must be specifically documented and related to the underlying diagnosis and need for ambulance transport.
- The medical documentation must describe how the specific structural and/or functional impairments together with the activity limitations contribute to the determination that stretcher transport is necessary for the patient’s safety as it relates to their condition.
- Important: Do not just list diagnosis codes.
These issues can further be addressed by using Medicare’s guidelines for medical necessity. Details about a patient’s ability to self-administer O2, a need for restraints, being a danger to themselves or others, an inability to tolerate a seated position for transport, and other examples can be used with the details of the mental status assessments to paint a fuller picture of the patient’s need for interventions and an ambulance.
But this doesn’t just apply to billing. The same inconsistencies in these numbers can be interpreted differently by different providers. We would argue that not only is providing details about the mental status important for compliant billing, but it is also important for clinical documentation. Being able to answer the why? in documentation is the best practice in all cases.
A lot goes into mental status documentation. It impacts medical necessity and patient signatures. Simply entering the numbers taken from the common scale assessments is not enough taken by itself to support compliant documentation. We hope our presentation of the various assessments and scales helps non-providers in EMS gain further understanding of the meaning of those numbers and that crews can see how simply using those numbers by themselves can be confusing without the proper context, even among other providers.
We recommend ambulance services take a close look at their current protocols and policies on mental status documentation and try to develop a uniform process for their agency. We also highly recommend services check the settings in their ePCRs and determine whether any auto-responses are active for different assessment fields and specifically for the GCS assessment. These should be turned off to avoid errors in documentation.
Please reach out to us with questions or concerns about mental status documentation using our contact form on the site!