EMS documentation

[Swatrous]

Do you think that it is ok for a ambulance company to force EMT's to make chances to their charts after they are submitted ?

 

[Flying]

Do you think that it is ok for a ambulance company to force EMT's to make chances to their charts after they are submitted ?

No. But it happens. If you have a problem with your company, bring it up with your state.

 

[Swatrous]

The company is using EMS charts and flagging PCRs and stating that we have to go back and fix or change information. I'm pretty sure that once a chart is locked it should not be re-opened.

 

[Flying]

I've screwed up a few times when inputting patient info and have had charts flagged and reopened via my admin for correction. That's fine.

If your company is trying to make a grab for fraudulent insurance money, we're skirting trouble with the billing/legal world and that's where your state and its laws, and not advice from the internet takes precedence.

 

[LACoGurneyjockey]

I think it's relevant to ask what exactly they are asking you to change? If they want you to correctly input the patients demographics, that's different from falsely stating the patient could not stand without assistance.

 

[chaz90]

We do 100% QA/QI peer chart review but don't bill anything, and I have to unlock charts and fix errors somewhat frequently. Either an erroneous set of VS that I didn't fix correctly when it was transferred from the LP15 (HR of 300 or BP of 184/178), incorrectly entered incident numbers, forgotten procedures that I did but didn't document. There are plenty of non fraudulent reasons to fix charts.

 

[Smitty213]

I believe it is OK for Clinical QI to " strongly encourage " you to make an edit; charts are legal documents and should be thorough. Also, realizing that you made an error can make you a better provider in the future; to quote an old FTO; "proper care should result in proper documentation and improper documentation is improper care".
What I do disagree with is Billing QI who will try and make you edit something to their specifications to prove nonexistent medical necessity...

 

[Swatrous]

I believe it is OK for Clinical QI to " strongly encourage " you to make an edit; charts are legal documents and should be thorough. Also, realizing that you made an error can make you a better provider in the future; to quote an old FTO; "proper care should result in proper documentation and improper documentation is improper care".
What I do disagree with is Billing QI who will try and make you edit something to their specifications to prove nonexistent medical necessity...

 

[Swatrous]

You hit the nail on the head. Billing QA wants to match the assessment with the medical necessity. And picking apart the assessments in the process. They have unlocked charts over and over again demanding that I change an assessment or how I documented something.

 

[Smitty213]

My partner and I used to take great pleasure in stonewalling them... Eventually they called our supervisor to make us report to their office; we did so with a union steward who politely informed them on our behalf that we would be falsifying no documentation and all assessments had been reviewed and were accurate as they stood. Haven't gotten flagged by billing in over a year...

 

[Swatrous]

Very good. I basically reply to the flags saying just that. But I only work there once in a while so I am just wondering if they are doing things leagly or not

 

[Kevinf]

It wasn't their patient, if the assessment is currently accurate then altering it would be fraudulent. You can certainly put in your chart "per the medical necessity by Dr. John Smith patient has this, this, this" even if your own assessment differs. It's certainly possible for a patient condition to change since a med nec has been filled out, and that itself a pertinent finding while documenting patient status and care. Sounds like they want you to change it so it's billable, which has gotten many companies fined or shut down, and landed people in jail. Just so you know, if you report an agency to CMS that you believe is fraudulently billing them, you may be able to receive a percentage of funds withdrawn in an audit. Something to think about.

 

[Gurby]

We do 100% QA/QI peer chart review but don't bill anything, and I have to unlock charts and fix errors somewhat frequently. Either an erroneous set of VS that I didn't fix correctly when it was transferred from the LP15 (HR of 300 or BP of 184/178), incorrectly entered incident numbers, forgotten procedures that I did but didn't document. There are plenty of non fraudulent reasons to fix charts.

I usually leave the wacky numbers that were downloaded from the machine, and then put in sets of manual VS and mark them as such... Is this bad? Should I be just removing the machine's BP from the documentation, and only leaving accurate numbers?

(this is for situations where the machine can't get a good reading... IE any actually sick patient, anyone with AFib, anyone with a SBP under 90 or over 160, etc...)

 

[usalsfyre]

You hit the nail on the head. Billing QA wants to match the assessment with the medical necessity. And picking apart the assessments in the process. They have unlocked charts over and over again demanding that I change an assessment or how I documented something.

The question being, were you asked to falsely document or did you just not take the time to actually assess whether the patient had the condition or not? I saw both sides, billing who couldn't fathom patients getting better and providers who's laziness was screwing the company out of legitimate reimbursement.