memo Upon Receipt Patient Care Documentation

							                                           STATE OF WEST VIRGINIA
                       DEPARTMENT OF HEALTH AND HUMAN RESOURCES
  Bob Wise                              BUREAU FOR MEDICAL SERVICES                       Paul L. Nusbaum
Governor                               350 Capitol Street, Room 251                       Secretary
                                         Charleston, West Virginia 25301-3707
                                   Telephone: (304) 558-1700     FAX: (304) 558-1542



                                        MEMORANDUM


       DATE:       April 6, 2004

       TO:         Air and Ground Ambulance Providers

       FROM:       Jim Shedd, Director
                   Division of Policy Coordination

       RE:         Patient Care Documentation

       Recent reviews of ambulance transportation claims have caused a great deal of concern
       regarding the quality of documentation recorded on the patient care report. Of reports
       reviewed, a majority failed to adequately document the patient’s condition, treatment,
       and/or need for transport by ambulance. This is an issue that has been prevalent in EMS
       for the past several years despite many agencies’ recognition of the problem and signing
       an agreement with the Bureau For Medical Services to institute a plan of correction. Some
       of the issues identified are listed below:

               •   Very few patient care reports are completed in their entirety. EMS personnel are
                   failing to record such items as times, mileages, vehicle unit numbers, State
                   Office of EMS’ identification numbers, EMS personnel certification numbers

               •   EMS personnel are not adequately describing the patient’s current condition
                   which necessitates transport by ambulance

               •   Documentation for inter-facility transports (hospital to hospital) do not
                   substantiate need for transport, i.e. what specialized medical care was not
                   available at sending hospital

               •   Handwriting is so illegible on many reports that it makes reading the report
                   impossible

               •   Billing personnel do not seem to be familiar with the Medicaid Transportation
                   Provider Manual, especially in areas regarding covered services

               •   If a claim is denied, DO NOT resubmit claim unless otherwise directed by BMS
These are the major issues that have and will cause denials or disallowances on claims.
The patient care report, without any supporting documentation, must be able to support the
necessity of transport by ambulance. In such a litigious society, it is also important to note
that poor documentation is not only a reimbursement issue, but could also have legal
consequences.

If you have questions or if I can be of further assistance, please feel free to call me.

JS/tln

CC: Mark King
William Ramsey, MD
Chris Hall