What is an appropriate CC for CPK and increased wbc?

[ogonzalez3]

I had a call where my patient was not complaining of ANYTHING at all the day I arrived on scene. This pt was to be transported from a nursing home to the ER for increased wbc and a cpk test. It was my very first day as an emt in the field, my partner was a month into the job as well and had trouble deciding what the CC would be. The patient had a very long Hx, pages of Rx and had a fever for a week with dysuria but was totally fine that day as I said. I gave the RN my report, but seemed to look at me as if i was stupid for writing in fever & dysuria as my CC. and I also told the RN that the pt was here for an increase of wbc and a cpk.

I would appreciate any feedback, I want to learn from my mistakes and grow from them to perform a better job.

 

[JPINFV]

"Abnormal labs" or the specific lab(s) that were elevated would work as a CC in a situation like this.

 

[NomadicMedic]

I would always write "SNF requested ED evaluation following abnormal lab values".

That was what the "documentation specialists" asked us to use as a CC for these "no acute complaint" transports.

 

[sirengirl]

I would always write "SNF requested ED evaluation following abnormal lab values".

This. Forcibly reminds me of the lady (AOx4, ambulatory) who called 911 (while her AOx4 husband and AOx4 son-in-law {who had a car} and AOx4 home nursing aide {who, strangely, also had a car} stood in the background watching me invterview her) because she wanted the doctor to do a followup on her endoscopy from 2 days ago.

I believe that one was listed as "request for eval at ER..." only because "cars out of gas" isn't an option :glare:. I kid, I kid.... But no, really. "Request for eval."

 

[exodus]

Abnormal labs is what I always went with.

 

[WestMetroMedic]

My QA group has run into this issue. We only transport critical lab values, and turf vanilla abnormal labs to a BLS service.

Its difficult to bill a government payer for abnormal lab values and any minor complaint you can get from the patient increases you ability to bill exponentially. Sometimes it may be something regarding the patients inability to stand without assistance, or something as bland as weakness. Sometimes, your service will just end up eating the cost.

This is just how we do it and we have checks and balances in place to ensure we dont cross the fraud line, but it has proven decent for us...

 

[Handsome Robb]

If the patient has no complaint my CC entry in our ePCR is "no acute complaint". Then I explain the reason behind the transport in my narrative.

ie "PT denies any acute complaint at the time of transport. Per RN at the sending facility recent labs show an elevated WBC and CPK, PT being transported to xxx for further evaluation, observation and diagnostic capabilities not available at the sending facility".

Obviously the narrative has more than that, that's just a quick example.