Q&A: What are the rules for using information from ambulance forms or trip tickets?

Q: Can CDI programs use information on ambulance forms or trip tickets to abstract from if the information is pulled into or reiterated in the ED or history and physical (H&P) documentation? Our staff doesn’t want to miss criteria that would diminish our ability to substantiate the true severity of illness of some patients but I have been informed that coders are not allowed to code from ambulance papers or information.

A: First, coders cannot assign a code based on emergency medical technician EMT documentation.  Although these documents are often included in the health record, they are not owned by the hospital and are usually classified as external correspondence. If the claim is selected for complex review, the EMT trip sheet cannot be released. So it cannot be used to support code assignment.

There is one caveat to this statement, however. In ICD-10-CM, when implemented, the code for Glasgow coma requires a character that indicates when the assessment was made, which can include those made by an EMT. Coding Clinic for ICD-10-CM/PCS, First Quarter 2014 states that it “would be appropriate to use the pre-hospital report containing the EMT’s documentation and other non-physician documentation to determine the Glasgow coma score.”

Second, physicians need to provide a history of present illness (HPI) as part of the H&P. Conditions not related to the current episode of care should not be reported. Documentation by the provider should not simply reiterate EMT finds but needs to clearly show the conditions that exist at the time of admission and reflect the physician’s clinical decision thinking rather than just listing an overall history of the patient’s conditions.

Third, the coder’s perspective is different than a clinician’s regarding what they define as a history of a condition. Often, if a provider fails to carry a diagnosis throughout the health record, and doesn’t include it in the discharge summary, it may not be perceived as reportable by a coder.  Many coders begin the coding process with the discharge summary, because it is the final word of the attending provider. However, it is important to note that Coding Clinic for ICD-10-CM/PCS, First Quarter 2014 states that:

“Documentation is not limited to the face sheet, discharge summary, progress note, history and physical, or other report designed to capture diagnostic information. This advice only refers to inpatient coding.”

Just because the provider doesn’t mention a diagnosis more than once does not mean it isn’t reportable. Often, the provider’s focus changes daily, so they may not feel the need to summarize conditions that are no longer a focus of their efforts. If there is a disagreement between CDI and coding, it is best to clarify with the provider, assuming the totality of health record supports the condition as reportable.

If the provider only mentions the condition(s) in the H&P, consider querying for the status of the condition to see if it should be reported. For example, if the H&P states “early clinical sepsis” and the physician never documents the condition again, be sure there are clinical indicators that support sepsis as a reportable diagnosis. If there are clinical indicators to support it as a reportable condition than a query may be:

Please clarify the status of the condition “early clinical sepsis” as documented in the H&P in this patient who presented with (give specific signs and symptoms) and was treated  with (give specifics) or had the following diagnostics (give specifics), etc.

• Was the “early clinical sepsis:”
• Confirmed and ongoing
• Confirmed and resolved
• Ruled out
• Without clinical significance
• Unable to determine
• Other:                                                                                                                              

Also note, the multiple choice format would only work well if your organization maintains the query as a permanent part of the health record so it would need to be validated by the provider. If the provider responds, by confirming the diagnosis (either ongoing or resolved), it would be reportable. If the provider responds with any other choice, it would not be reportable.

Keep in mind that you can use clinical indicators obtained from EMT documentation to query the provider if there appears to be an undocumented, reportable condition relevant to the current episode of care, if the current provider documentation doesn’t support code assignment.

Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, Associate Director for Education at ACDIS and CDI Education Director at HCPro in Danvers, Massachusetts, answered this question. Contact her at cericson@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview. This article was originally published on the ACDIS Blog.