Non-Emergency Coding Clinic

Transcription

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3 Tomorrowland Elementary School United Church Monstropolous Golden SNF General Hospital Neverland Apartment Fantasyland Medical Center Outpatient Center Holy Spirit Hospital & Select LTACH Power Plant Good Samaritan Hospital Radiator Springs Magic SNF Hotel Frontierland Community Hospital 2015, Page, Wolfberg & Wirth, LLC Dialysis Center Assisted Living Arendelle MAP OF MAGIC KINGDOM

4 List of Facilities and Locations Medical Center Trauma Center and 1,000 Bed Hospital 1 Magic Kingdom Way, Fantasyland General Hospital 500 Bed Hospital w/ ER 10 Atlantica View Rd., Neverland Good Samaritan Hospital 200 Bed Hospital w/ ER 14 Randall Dr., Monstropolus Holy Spirit Hospital 150 bed hospital w/ separate specialty center th St. Frontierland, Community Hospital 25 Bed Hospital and ER 6467 Race St., Arendelle, Select LTACH 10 Bed SNF, 20 Bed Hospital inside Holy Spirit Hospital (4 th Floor) th St. Frontierland, Golden SNF 75 Bed SNF, with Hospice Care 2319 Sock Dr., Monstropolous, Magic SNF 100 Bed SNF and Assisted Living Facility 1501 Oswald St., Fantasyland, Assisted Living Personal Care Home, no skilled services offered 42 Wallaby Way, Atlantica, Dialysis Center Dialysis Center (not hospital based) 7878 Creek Run Road Frontierland Outpatient Center Ambulatory surgery & diagnostic services 14 Granite Dr. Radiator Springs Apartment Complex 150 Units 500 Dwarf Street, Fantasyland Power Plant 2320 Atlantica View Rd., Neverland Hotel 99 Olaf St., Arendelle, Elementary School 2004 Incredible Dr., Tomorrowland, United Church 1001 Acorn Way, Fantasyland, 99916

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7 Magic Kingdom Department of Health - Approved ALS Drugs 1. Activated Charcoal 2. Adenosine 3. Albuterol 4. Amiodarone 5. Aspirin 6. Atropine 7. Calcium Chloride 8. Diazepam 9. Dilaudid 10. Diltiazem 11. Diphenhydramine HCL 12. Epinephrine 13. Fentanyl 14. Furosemide 15. Glucagon 16. Intravenous solutions (Dextrose, NaCl, Lactated Ringer s) 17. Lidocaine 18. Lorazepam 19. Magnesium Sulfate 20. Midazolam 21. Morphine 22. Naloxone HCL (Narcan) IV 23. Nitroglycerin 24. Ondansetron 25. Sodium bicarbonate + EMT-B scope of practice includes transport of a patient with an existing IV lock, O2 administration, BGL check, and Narcan administration IM. Signed: Effective Date: 7/1/2015 Walt Disney, MD Medical Director, Magic Kingdom Department of Health

8 Mickey Mouse Ambulance Abbreviation List A&O ALOC AMS AOS ASA BVM CA CAD CC CMS CP CVA CXR DC DM DOA ECT ED EKG EtCO2 ETOH HEENT HOB HTN ICU IV JVD LLE LS MS NC NIDDM NKDA NRB NSS Alert and Oriented Altered Level of Consciousness Altered Mental Status Arrived on scene Aspirin Bag valve mask Cancer Coronary Artery Disease Chief complaint Circulation, motor, sensory Chest pain Cerebrovascular Accident Chest X-ray Discharge Diabetes Mellitus Dead on Arrival Electroconvulsive Therapy Emergency Department Electrocardiogram End tidal carbon dioxide Alcohol Head, Eyes, Ears, Nose, Throat Head of Bed Hypertension Intensive Care Unit Intravenous Jugular venous distension Lower left extremity Lung sounds Multiple Sclerosis Nasal cannula Non-insulin Dependent Diabetes Mellitus No known drug allergies Non-rebreather Saline N/V O2 O/S PEA PERRL PIV P/M/S POV PRN P/W/D Q.D. SNF SOB SpO2 TBI TKO UOA UTO VS WNL Y/O/(m)(f) Nausea/Vomiting Oxygen On scene Pulseless Electrical Activity Pupils Equal, Round, Reactive to Light Peripheral IV Pulse/Motor/Sensory Privately Owned Vehicle As Needed Pink/Warm/Dry Every day Skilled Nursing Facility Shortness of breath Pulse oximetry Traumatic Brain Injury To keep open Upon our arrival Unable to obtain Vital signs Within normal limits Year old (male) or (female) Note: This list of abbreviations is for illustration purposes only to provide a key for the abbreviations used on the PCRs in the Coding Clinics. These are not necessarily universally accepted or approved abbreviations that must be used on actual PCRs used by your ambulance service. This is not an exhaustive list of commonly used abbreviations, but just provides a sampling of abbreviations used in the Coding Clinics.

9 ICD-10 Codes Note: These are just a small number of ICD-10 Codes listed for purposes of the coding clinics. This minimal list is for educational purposes only and does not suggest that these are the only (or best) ICD-10 Codes that should be used for ambulance billing purposes. F29 ICD 10 ICD 10 Code Definition Unspecified psychosis not due to a substance or known physiological condition G89.29 Other chronic pain I26.02 Saddle embolus of pulmonary artery with acute cor pulmonale I46.9 Cardiac arrest, cause unspecified I49.9 Cardiac arrhythmia, unspecified I50.9 Heart failure, unspecified I67.89 Other cerebrovascular disease I Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side J96.00 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia L Pressure ulcer of unspecified part of back, unstageable L Pressure ulcer of unspecified buttock, unspecific stage R06.02 Shortness of breath R07.9 Chest pain, unspecified R09.2 Respiratory arrest R09.89 Other specified symptoms and signs involving the circulatory and respiratory systems R10.8 Other abdominal pain R10.84 Generalized abdominal pain R10.9 Unspecified abdominal pain R11.2 Nausea with vomiting, unspecified

10 ICD 10 ICD 10 Code Definition R11.2 Nausea with vomiting R GCS R GCS 9-12 R40.4 Transient alteration of awareness R41.82 Altered mental status, unspecified R41.89 Other symptoms and signs involving cognitive functions and awareness R51 R52 Headache Pain, unspecified R53.1 Weakness R68.89 Other general symptoms & signs R69 S09.90XA Illness unspecified Unspecified injury of head, initial encounter T14.80 Other injury of unspecified body region V16.9XXA W10.1XXA Unspecified pedal cyclist injured in collision with other nonmotor vehicle in traffic accident, initial encounter Fall (on)(from) sidewalk curb, initial encounter W37.0 Explosion of bicycle tire Y82.8 Other medical devices associated with adverse incidents Z49.0 Preparatory care for renal dialysis Z74.01 Bed confinement status Z74.3 Need for continuous supervision Z76.89 Persons encountering health services in other specified circumstances Z78.1 Physical restraint status Z99.11 Dependence on respirator/ventilator status Z99.81 Dependence on supplemental oxygen Z99.81 Dependence on supplemental oxygen dependence on supplemental oxygen Z99.89 Dependence on other enabling machines and devices

11 ABC 360 Coding Clinic Checklist Non Emergency Run # Medical Necessity Documented? (Y/N) Reasonableness Met? (Y/N) Transport to Covered Destination? (Y/N) Mileage Recorded? (Y/N) PCS Criteria Met? (Y/N) Signature Valid for Claim Submission? (Y/N) Coding Comments 001 NE 002 NE 003 NE 004 NE 005 NE 006 NE 007 NE 008 NE 009 NE 010 NE

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42 Physician Certification Statement for Non-Emergency Ambulance Services SECTION I GENERAL INFORMATION Patient s Name: Mal Eficent Date of Birth: 6/28/1939 Transport Date: 9/30/15 (PCS is valid for round trips on this date and for all repetitive trips in the 60-day range as noted below.) Origin: Medical Center Destination: Magic SNF Is the pt s stay covered under Medicare Part A (PPS/DRG?) YES NO Closest appropriate facility? YES NO If no, why is transport to more distant facility required? If hosp-hosp transfer, describe services needed at 2 nd facility not available at 1 st facility: If hospice pt, is this transport related to pt s terminal illness? YES NO Describe: SECTION II MEDICAL NECESSITY QUESTIONNAIRE Ambulance Transportation is medically necessary only if other means of transport are contraindicated or would be potentially harmful to the patient. To meet this requirement, the patient must be either bed confined or suffer from a condition such that transport by means other than ambulance is contraindicated by the patient s condition The following questions must be answered by the medical professional signing below for this form to be valid: 1) Describe the MEDICAL CONDITION (physical and/or mental) of this patient AT THE TIME OF AMBULANCE TRANSPORT that requires the patient to be transported in an ambulance and why transport by other means is contraindicated by the patient s condition: Bed confined, unresponsive, decreased GCS 2) Is this patient bed confined as defined below? Yes No To be bed confined the patient must satisfy all three of the following conditions: (1) unable to get up from bed without Assistance; AND (2) unable to ambulate; AND (3) unable to sit in a chair or wheelchair 3) Can this patient safely be transported by car or wheelchair van (i.e., seated during transport, without a medical attendant or monitoring?) Yes No 4) In addition to completing questions 1-3 above, please check any of the following conditions that apply*: *Note: supporting documentation for any boxes checked must be maintained in the patient s medical records Contractures Non-healed fractures Patient is confused Patient is comatose Moderate/severe pain on movement Danger to self/other IV meds/fluids required Patient is combative Need or possible need for restraints DVT requires elevation of a lower extremity Medical attendant required Requires oxygen unable to self administer Special handling/isolation/infection control precautions required Unable to tolerate seated position for time needed to transport Hemodynamic monitoring required enroute Cardiac monitoring required enroute Unable to sit in a chair or wheelchair due to decubitus ulcers or other wounds Morbid obesity requires additional personnel/equipment to safely handle patient Orthopedic device (backboard, halo, pins, traction, brace, wedge, etc.) requiring special handling during transport Other (specify) SECTION III SIGNATURE OF PHYSICIAN OR HEALTHCARE PROFESSIONAL I certify that the above information is true and correct based on my evaluation of this patient, and represent that the patient requires transport by ambulance and that other forms of transport are contraindicated. I understand that this information will be used by the Centers for Medicare and Medicaid Services (CMS) to support the determination of medical necessity for ambulance services, and I represent that I have personal knowledge of the patient s condition at the time of transport. If this box is checked, I also certify that the patient is physically or mentally incapable of signing the ambulance service s claim and that the institution with which I am affiliated has furnished care, services or assistance to the patient. My signature below is made on behalf of the patient pursuant to 42 CFR (b)(4). In accordance with 42 CFR , the specific reason(s) that the patient is physically or mentally incapable of signing the claim form is as follows: Minnie Mouse, RN 9/30/15 Signature of Physician* or Healthcare Professional Date Signed (For scheduled repetitive transport, this form is not valid for transports performed more than 60 days after this date). Minnie Mouse Printed Name and Credentials of Physician or Healthcare Professional (MD, DO, RN, etc.) *Form must be signed only by patient s attending physician for scheduled, repetitive transports. For non-repetitive, unscheduled ambulance transports, if unable to obtain the signature of the attending physician, any of the following may sign (please check appropriate box below): Physician Assistant Clinical Nurse Specialist Registered Nurse Nurse Practitioner Discharge Planner This is a sample only and does not constitute legal advice. User bears all responsibility for compliance with all applicable laws and regulations.

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