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

JustCoding News: Inpatient, February 25, 2015

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Q: Can CDI programs use the 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: You need to consider several things. First, can you code from EMT documentation, such as trip sheets? No. Although these documents are often included in the health record, these documents are not “owned” by the hospital. They are usually classified as external correspondence. If the claim is selected for complex review, the EMT trip sheet cannot be released. As such, it can’t be used to support code assignment.

There is one caveat to this statement. In ICD-10-CM, when implemented, the code for Glasgow coma scale requires a character that indicates when the assessment was made, which can include those made by an EMT. See Coding Clinic, First Quarter 2014, for more specifics.

Second, you could run into a problem with how the provider is reiterating the EMT findings in the health record. The provider is expected to provide a history of present illness as part of the history and physical. However, he or she should not report conditions not related to the current episode of care. The provider’s documentation needs to clearly show the conditions that exist at the time of admission, rather than just listing an overall history.

Sometimes a 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, coders may not think it is reportable. Many coders begin the coding process with the discharge summary because it is the final word of the attending provider. However, Coding Clinic, First Quarter 2014, states, “documentation is not limited to the face sheet, discharge summary, progress note, physical&P, 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. The provider’s focus changes daily, so he or she may not see the need to summarize conditions that are no longer a focus of his or her efforts. If CDI specialists and coding professionals disagree, you should 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 provider, in his or her history and physical, documents “early clinical sepsis” and never document sepsis again, be sure clinical indicators support it as a reportable diagnosis. If clinical indicators do support sepsis as a reportable condition than your query may be as follows:

Please clarify the status of the condition “early clinical sepsis” as documented in the H&P in this patient who presented with (give specific s/sx) 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



Also note, the multiple choice format would only work well if your organization maintains the query as 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-aApproved ICD-10-CM/PCS trainer, Associate Director for Education at ACDIS and CDI Education Director at HCPro, a division of BLR, in Danvers, Massachusetts, answered this question.

This answer was provided based on limited information submitted to JustCoding. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

Need expert coding advice? Submit your question to Senior Managing Editor Michelle Leppert, CPC, at mleppert@hcpro.com, and we’ll do our best to get an answer for you.




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