By Matthew Konya, Esq, EMT-B
Calls involving patients experiencing a behavioral health crisis are common in EMS, but EMS providers encounter patients at different stages and conditions during such a crisis. For example, a patient having a behavioral health emergency may call 911 directly, or a hospital may call an EMS agency to transport a patient from their hospital to a behavioral health facility specially equipped to treat the patient’s medical condition. In some cases, a third-party caller or the police may contact an EMS agency requesting that a person be transported for a behavioral health evaluation at a psychiatric hospital, or even for a medical evaluation that often must occur before receiving mental health care at a specialty hospital. Patients may seek treatment voluntarily or may be subject to an involuntary behavioral health commitment – such as a 302 commitment, 5150 hold, or Baker Act custody.
It is important to recognize that patients requiring behavioral health treatment (either voluntarily or under an involuntary behavioral health commitment) do not automatically require ambulance transport. Documentation is important in all patient encounters and is even more important in behavioral health patient encounters.
Why documentation is important
Medicare is the insurance payer most often billed for ambulance services nationwide, and Medicare will only pay for ambulance transport if the transport meets very strict coverage criteria—that is, medical necessity and reasonableness. Although Medicaid and third-party insurers also have rules regarding payment requirements, this article focuses on the impact of documentation on determining medical necessity and reasonableness under Medicare rules.
First, regarding ambulance transport “medically necessary” under Medicare guidelines, the patient’s medical condition is such that other methods of transportation are contraindicated. If a patient could be transported safely by means other than an ambulance, the transport does not qualify for Medicare reimbursement.
Second, Medicare considers transportation “reasonable” when a patient is transported for services or procedures not available at the point of origin. A patient would not satisfy the reasonableness requirement if they could obtain the necessary services at the point of origin. The classic example of what is not reasonable behavior is transporting a nursing home patient to hospital to receive services that could be provided by nursing home staff – such as simple removal.
Therefore, EMS documentation must be supported both medical necessity and reasonableness of conduct. Medical necessity answers the question, “why did the patient need to be transported in an ambulance?” Rationality answers the question, “why did the patient need to be moved from point A to point B in the first place?” There can be conduct that meets the medical necessity but fails to meet the reasonableness requirement, and vice versa. Alternatively, behavior may fail to meet both requirements. The transportation can only be eligible for Medicare reimbursement when both criteria are met (assuming all other coverage criteria are also met, such as signature, and vehicle requirements).
Documented quick tips for behavioral health trips
Although medical and reasonableness requirements apply to all ambulance transports, documenting these can be very difficult for behavioral health transports. Part of the reason for this difficulty is that, unlike many other medical conditions, the signs of a behavioral health emergency are often not visible or easily quantifiable. In addition, patients may not be accessing information due to the nature of the complaint and the stigma associated with such behavioral health complaints.
1. Document medical necessity
Depending on when EMS comes into contact with the patient, documentation of medical necessity can be difficult. It is probably easy to document the medical need of a patient in the midst of a behavioral crisis, actively seeking to hurt themselves or others. In contrast, it may be more difficult to document a medical need for a patient in a hospital awaiting transport to another facility who has been medically evaluated and has been calm and cooperative with hospital staff since arriving at the hospital a few days earlier. However, in both cases, the patient may need monitoring in the back of an ambulance.
Regardless of the situation, the PCR should document a thorough assessment of the patient, including the patient’s need for observation and potential harm to themselves and others. The PCR should include detailed information about the events leading up to the EMS provider’s interaction with the patient – such as medications, evaluations and interventions received, behaviors exhibited, and hospital provider impressions of the patient. When documenting interfacility transport, there should be documentation of how the patient arrived at the hospital, why the patient arrived at the hospital in the first place, and what the patient’s physical and mental condition was during the hospital stay.
The document must include information about the patient’s behavior and behavior during transport. Finally, there must be documentation if the patient required any restraints beyond the standard cradle straps during transport – physical or chemical – including the reasons why EMS providers used such restraints. Providers should specifically state any protocols followed during transport.
2. Documenting authenticity
In emergencies, reasonableness is usually easier to establish. It is impossible to bring the patient to the hospital, so the patient must go to the hospital. However, it may be more difficult to establish rationality for inter-facility transport, particularly of patients in behavioral health crisis.
Typically, when dealing with inter-facility transport of a behavioral health patient, the reason for the transport is that the hospital where the patient is currently located cannot provide inpatient behavioral health treatment and therefore requires transport to a facility where the patient can be treated. In these cases, the PCR must specifically document the services or procedures available at the destination facility that were not available at the destination facility. Simply noting a “higher level of care” or “services not available” is because the reason for the behavior is not good enough. For example, providers should document as specifically as possible, such as: “a patient transported to a mental health facility to receive cognitive behavioral therapy that is not available at an ABC hospital.” It should be clear that the patient needs ongoing care that could not be provided at the originating facility.
Documenting behavioral health behavior: Baseline
Poor documentation can have many unintended consequences. The patient may be financially responsible for behavior that should be covered by insurance, because the provider failed to document medical necessity or reasonableness in sufficient detail. Poor documentation may also result in an overpayment claim or penalty for an agency that has billed behavior based on documentation deemed inadequate by reviewers and auditors.
Although poor documentation affects all types of EMS behavior, it can be particularly pronounced when dealing with patients in behavioral health crisis. EMS providers should take great care to thoroughly document interactions with patients experiencing a behavioral health crisis. With that in mind, remember, it is not the EMS provider’s job to document every transport in a way that ensures it is reimbursable to insurance.
The goal is to provide billers and coders with enough detailed documentation to make the right billing and coding decision. When medical necessity and reasonableness are clearly met, this should be reflected in the documentation. Where the documentation is complete and thorough but fails to meet Medicare’s medical requirements or reasonableness, then the billers and coders must decide how (and to whom) to bill the behavior. Not all ambulance transports will be covered by Medicare (or any insurance for that matter). It is essential that the documentation is complete so that correct billing decisions can be made.
Outsourcing ambulance billing: Pros and cons
As with most issues that any ambulance operation must address, there is no “one size fits all” answer as many variables come into play.