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Diagnosis Database
Menu Path:
MAINT/System Files/Diagnosis

The Diagnosis database allows user-defined codes that allow quick selection of ICD codes and associated descriptions when entering a trip ticket.  This database can be added to per user preference, and is initially supplied with valid ICD codes to the highest level of specificity. Certain word-string searches are implemented to allow office personnel to use the EMT narrative on run sheets to be used to search for a correct diagnosis and ICD code.

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Screen 1

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Screen 2

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Screen 3

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Screen 4

From the Main Menu (screen 1), highlight System Files and press the <ENTER> key, and the main diagnosis screen is displayed (screen 2).   To edit or display a diagnosis in the main diagnosis screen, highlight a diagnosis and press E(dit) or D(isplay); if the A(dd)

The DIAGNOSIS database file is a memory bank of diagnoses complete with ICD-9-CM codes. The ICD codes and descriptions come from official code books to reduce the possibilities of claims rejections. Most insurance companies request these codes and Most Medicare carriers require them on electronic claims. The diagnosis database can be added to, and this is done from time to time to add codes that users feel are needed. The difference between claims rejections and acceptance many times will depend upon you proving the need for an ambulance rather than other transportation. Medicare’s rules are simple. Ambulance necessity falls into two categories: Œ Transport by means other than ambulance may be detrimental to the patient’s health,  and the patient could not SIT. As already mentioned, the diagnosis database contains ICD codes and descriptions from a coding manual. However, these were derived for physicians, not ambulances. Normally, you will use the ICD code and description that most nearly matches the condition (not necessarily why the ambulance was called). Then, invariably, (almost invariably) change the extracted wording to match the condition as recorded on the run sheet--see a sample run sheet in another section. Diagnosis wording is expanded upon later in this section.

Code Column -- The codes under this column are those that users prefer to identify with diagnoses, codes that are easy to remember. These are not used for claims filing, but only for choosing diagnoses (ICD and Descriptions). For example, you may choose to code all problems involving the arm with ARM1, ARM2, etc. Then, from the invoice screen when trying to select a diagnosis, entering ARM will not find an exact match, and the diagnosis file will be displayed alphabetically beginning at the nearest match to your keyboard entry, and in this case the first line in the main diagnosis screen will be for ARM1, the second with ARM2, etc. You can highlight your selection, and return is to the invoice screen with the description and ICD code copied into the invoice screen. If after choosing a diagnosis, and transferring into the invoice screen, modify the description to suit the exact situation, while using the same ICD code – do not get too far off base with disagreement between ICD code and description, as discussed in the Diagnosis Description paragraph that follows.

ICD Column -- These must exactly match those listed in ICD-9-CM code books. Note that there are a variable number of characters from one code to another, and ALL numbers should be used, e.g. 812.01; in the past, Medicare would accept 812 only, but beginning (approximately) mid to late 1996, Medicare is saying that all numbers must be used. Print your diagnosis file in order of ICD code, and compare with a coding manual.

Diagnosis Description Column -- Generally, these descriptions match those in coding manuals, but not word for word. Diagnosis descriptions are transmitted in what is call the narrative field. There should be some correlation between the ICD code and the description, but a single ICD code can fit multiple descriptions, for example w Abdomen Pain, Unspecified; w Acute Abdomen Pain; w Abdomen Pain due to pregnancy complications, etc. etc. You would also choose different codes for example: ABDU, ABCAC, ABDP, respectively for the example descriptions above. Note that all of these code and description combinations would have the exact same ICD code.

We have covered in general terms the usage of the diagnosis file, but lets get more specific about coding philosophy and selection of diagnosis codes.

Philosophy of Selecting Diagnoses
If in a medical situation, certain care was rendered by ambulance personnel in order to prevent further pain and/or injury, then ambulance necessity was satisfied--most such cases are obvious. Other than obvious requirements for an ambulance (non-emergency transports e.g.), ambulance necessity boils down to why an ambulance was required rather than other transportation (car, taxi, wheelchair/van, etc.).   Availability is not an issue--IF this other transportation were available, COULD the patient have traveled in that other vehicle--if the answer to that question is YES, you cannot get paid for the transport.  Most emergency transports are clear cut--the patients condition (unconscious, heart attack, etc.) mandates special medical care and transport conditions, in which cases what was wrong, and what you did satisfies ambulance necessity.   The problem area is non-emergency transports.  What you have to prove is that THE PATIENT COULD NOT SIT IN AN ERECT POSITION for the duration of the transport DUE TO a very specific reason (and you must be SPECIFIC). As  mentioned previously, the Diagnosis database can be added to and modified to some degree to fit your needs, and you choose the nearest match to your situation and modify to suit the specifics of this particular transport--diagnosis descriptions do not have to exactly match those directly from a coding manual, but should be reasonably in agreement, and not conflicting.  You may want to add diagnosis codes and descriptions without ICD codes, and these can be used for narratives and phrases that you use frequently and do not want to type each time--a few examples follow. NON-EMERGENCY Transports -- These are the most difficult to get paid.  HCFA now requires a Certificate of Medical Necessity Form to be ON FILE  for certain patients--ON FILE means in your filing cabinet in case you are either audited or requested to submit..  We have made up a sample Front Side and Back Side but you may want to make up your own.  There is no official form, each provider makes their own.  As simply as can be stated, a patient under direct care of a Physician needs the form--this is vague, but that is what the regulation says.  It goes on to say that generally patients transported TO/FROM residences are usually excluded--again vague. It is a good idea to get this form filled out for all non-emergency transports--it may be needed to refile with a HCFA1500 form if you get rejected electronically.

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Here we have added our own narratives that can be used in the secondary diagnosis field for Hospital to Hospital transports and coded these beginning with T-   Note that the description field is wider than can be displayed, but is scrolled when you are in the EMS program.

Another special diagnosis you may consider is for frequent flyers, and you use the same (or a few) diagnoses, depending upon the particular transport that day.   For example, Martha Mayfield may be a dialysis patient.  Most transports are to the dialysis center, but occasionally Martha is transported to a remote specialty center.  You can make up special codes for Martha as shown below.

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Here MM1 and MM2 are primary and secondary diagnoses for frequent trips to the dialysis center; MMDOC1 and MMDOC2 are other not-so-frequent to the doctor, but periodic transports.

One other point – diagnosis descriptions are transmitted in what is called the narrative field. The way this is done is that the primary diagnosis description and the secondary diagnosis description are strung together like one long sentence, with two spaces between the end of the primary and the beginning of the secondary. Medicare personnel evaluating your claim will see these in this format on their computer screen, along with other information for the claim. Medicare is looking for one thing specifically – AMBULANCE NECESSITY

Obviously there needs to be a correct Medicare number, name, etc. as well as other information, but the difference between approval and rejection will boil down to AMBULANCE NECESSITY

Assuming you are using an ICD code that reflects the possibility of AMBULANCE NECESSITY, then your diagnosis descriptions (narrative field) will make the difference. For example, if you use an ICD code for Fractured Arm, you may get rejected (I have seen such a rejection), but if you add to the diagnosis description splinting required to prevent further injury, you are practically assured of approval.

There is a sequence of things to include in your narrative field as follows:

ΠWhat is Wrong With The Patient

Not what happened – Blunt Trauma to the Forehead – there is an ICD code with this description. This is not what is wrong, but what happened. MVA, there are several ICD codes for MVA, but this is what happened. Instead of Blunt Trauma to the Forehead, your choice of Diagnosis (and ICD code) is

Severe Laceration to the forehead.

 What happened

If it was Blunt trauma to the forehead, Add to the diagnosis as follows Severe Laceration to the forehead as a result of assault with a shovel

Ž What did the paramedics do that would not have been done via automobile transport

Add further as follows Severe Laceration to the forehead as a result of assault with a shovel – controlled bleeding, secured to stretcher due to transient awareness of patient.

Other things to say:

93 yr. old patient – History of CVA – Patient is totally bedridden, cannot sit, stand, walk – Restraints required due to mental condition – result of MVA.  Medicare may tell you not to include such information, but do not listen to that and put your best shot in a particular Medicare person reviewing your claim.

Add to your primary diagnosis (and ICD code) with wording that reinforces AMBULANCE NECESSITY. Do it for all claims, not just Medicare, because, a claim that starts out private pay may end up Medicare (if you did not know that it was Medicare to begin with).

Only Use a Single ICD code--Medicare requires only a single ICD code. If you give them more, you are possibly giving them conflicting data and possible grounds for rejection. Instead, load up your primary and secondary diagnosis descriptions as described above. Ambulance diagnoses differ from physicians in that a physician has the benefit of X-rays, lab tests, etc. such that a diagnosis code can exactly describe the situation. Ambulance technicians do not enjoy that luxury, and further do not diagnose, but instead choose a diagnosis and expand upon it with narrative, as previously described.

ALABAMA MEDICAID APPROVED ICD-9 CODES
(codes other than these will be automatically rejected)

Listed below are codes initially published by Blue Cross / Blue Shield (Alabama Medicare carrier) -- immediately following this, Alabama Medicaid published the same list with a statement that codes not on this list will result in claims rejections. In the DIAGNOSIS data bank (at left), these codes are identified by descriptions not being all-capitalized.  Alabama Medicaid Bulletin 77 (January 1999) issued the following list of codes no longer valid: 482.4, 519.0, 564.8, 763.8, V02.5, V13.6, V16.5, V18.6, V44.5, 965.6, V23.8.  Note that all of these codes do not have the highest level of specificity (5th digits).

250.2-250.3 511.0-512.8 658.2 760.75 778.4 813.1-813.9 941.3-941.5 992.0-992.9
251.0 518.0-519.0 661.3 761.5 779.0,2,4,5 818.1 942.3-942.5 993.3
282.62 578.0-578.9 666.0-666.3 762.1,2,5 780.01-780.3 819.0-823.9 943.3-943.5 994.0,1,7,8
290.3 585 707.0 763.5 785.50-785.59 827.0-828.1 944.3-944.5 995.0
290.40-290.43 634.1,3,5,6 741.0-742.9 765.0,1 786.00-786.1 836.0-837.1 945.3-945.5 997.3
291.0-293.1 635.1,3,5,6 745.0-748.0 767.0,4,8,9 786.50-786.59 843.0-844.9 946.3-946.5 999.4
295.0-299.9 636.1,3,5,6 748.3,8 768.4-770.8 789.00-789.09 850.0-900.9 947.0-947.9 V44.0-V44.1
345.10-345.51 637.1,3,5,6 750.3 771.7-772.4 790.1-790.3 901.1-904.9 948.3-948.9 V55.0-V55.1
410.0-411.89 638.1,3,5,6 751.1,2 773.0-773.5 799.0-808.9 925.1-927.1 952.00-952.09
413.1-415.1 639.1,3,5,6,8 756.6 774.4 809.1 927.8 958.0,1,2,4
416.0-437.9 640.0-641.9 759.4,7 775.1,2,3,5,6 810.1 928.0-929.0 960.0-979.9
480.0-487.8 642.5-642.6 760.2 776.2,4,5 811.1 933.0-934.9 990
506.1 644.0-645.0 760.70-760.73 777.1-777.9 812.1-812.5 935.1 991.6

 

Special Services / Procedures Affecting 1995 HCPCS Codes (Florida Medicare)

Listed below are what has become known as SPECIAL SERVICES. Beginning in 1995, special services will be a factor in correct choices of HCPCS billing codes.

administration of IVs (Intravenous therapy, D5W, ringers lactate, dextrose and water, or drugs)

  initiation of oxygen

  application of anti-shock trousers (MAST)

  metabolic integrity by treatment for prevention of alkalosis or acidosis

  cardio-pulmonary resuscitation (CPR)

  neurologic assessments for changes in level of consciousness

  cardiotherapeutic drug treatment

  relieve pneumothorax/hemothorax conditions

  cardioversion

  splinting fractures

  control of bleeding

  tracheostomy

  defibrillate the heart

  treatment for CVA, substance abuse, or poisoning agents

  delivery of babies

  treatment for shock

  EKG monitoring

  use of a backboard in spinal immobilization

  establish and maintain the patient’s airway

  utilized the suction machine

Special services were defined as changing HCPCS codes for billing purpose. For example, there will be two base rates for ALS and BLS emergency, and the difference is whether or not a special service (above) was performed. Similar wording in the table above for the secondary diagnosis will reinforce ambulance necessity, and thus, the table above is included in this section dealing with diagnoses. This same wording is displayed as a help screen during posting charges when the question is displayed:

Special Services Y/N?

 

DIAGNOSIS FILE USAGE -- The DIAGNOSIS file is accessed three ways:

Œduring invoice data entry when the blank primary or secondary diagnosis (code) fields in the invoice screen are reached, and the ENTER key is pressed with eight or less characters; if less than eight (including blank), the entry is considered a code, if an exact match is found in the DIAGNOSIS file (ABD *BV for example), the ICD code (902.9) and diagnosis description (Abdomen .........) are copied to the invoice screen. Otherwise, the main diagnosis screen is displayed beginning at the nearest matching code entered, whereupon several search and select options are available to you.

CTRL-Page Down can be entered at a diagnosis code field, regardless of field content, and the main diagnosis screen is displayed.

Ž from the menu selections MAINT/System Files/Diagnosis, as shown, and this is used for adding/editing/displaying diagnoses

Diagnosis File Keyboard Functions and Field Descriptions

Function Key F10 -- When in the invoice screen, a string of characters entered of length less than 8 into the diagnosis field will result in searching the diagnosis file for a diagnosis code match or nearest match. If an exact match is found, the ICD code and description are retrieved into the invoice screen; otherwise, the nearest matching diagnosis codes and descriptions are displayed for selection. If the list of displayed nearest matches does not contain a suitable diagnosis, using F10 will allow you to enter a character string after a which a window of diagnoses will be displayed with diagnosis descriptions that have that sequence of characters. For example, note in the main diagnosis screen above that AND is displayed next to F10-->. This will result in a screen(s) of descriptions with that string, and will include all with the word HAND, the word GLAND, and there may be others. This is a powerful feature is searching for diagnoses using key words in the description fields. If a number is entered instead of a character string, the search will be for the nearest matching ICD CODE.

CTRL-U to Delete Record -- The highlighted record will be deleted.

Code -- The diagnosis code is a one to eight character field that can be either letters or numbers. An attempt has been made to install a DIAGNOSIS file with (short) code selections that are easy cross-references for (long) diagnostic descriptions, as described immediately above. Diagnostic codes can be changed by users to suit individual preferences; if another code system works better, change these codes. However, use caution in changing ICD codes and diagnostic descriptions that are not compatible with official ICD code books.

ICD -- As described above, this is the ICD.9.CM code required by Medicare and most insurance companies. Do not change these codes unless there is a directive from Medicare. The same ICD code and description can be used with more than one diagnosis code; for example HED CUT and FAC CUT could both have the same ICD code and description since the face (FAC) falls into the head (HED) category.

Diagnosis Description -- These descriptions match those listed in code books. To be consistent, as well as using wording that is less likely to be misunderstood by paper claims processors, take care in drastically editing this Diagnosis Description field. EMT's and Paramedics legally cannot diagnose, and thus it may be best to preface some diagnosis descriptions with "possible"; e.g. possible fracture; possible stroke. Sometimes the patient complains of, e.g. abdominal pain or chest pain, and these do not require the "possible" preface word.

Arrow Keys(),HOME, END, PGDN, PGUP -- These key entries reposition the cursor and/or pointer position in the file, and well as change the display accordingly. As previously described, the arrow keys can be used to highlight a diagnosis.

HOME - jumps to the beginning of the DIAGNOSIS file and displays the first 10 diagnoses

END - jumps to the end of the file and displays the last 10 diagnoses

PGDN - jumps 10 down in the file and displays next 10

PGUP - jumps 10 up in the file and displays and displays previous 10

ENTER KEY -- The <ENTER> key is used: t to select the highlighted diagnosis when the screen was displayed when branching from the invoice screen. t to terminate a keyboard string entry as a result of A-Add, E-Edit, F-Find, and F-->Filter function selections

A-Add, D-Display, E-Edit -- From the main screen, results in the appropriate detail screen display.

F-Find -- Similar to F10->Find that searches for a string-match in the description field, F-Find searches the code field. A prompt will be displayed allowing entry of a string of code characters to be entered, after which the window will display codes beginning with the nearest (or exact) match.

ESC-Quit -- Pressing the ESCape key branches back to the previous screen with data entry, changes, etc. aborted and no action taken such that all files, data fields, etc. remaining in the same condition as before entering the screen.

CTRL-END to Save -- The CTRL-END key entry will save and exit a screen data entry at any field position, in some cases. If a screen contains necessary unfilled fields, the entry is aborted (with a message display) and the next (from the top) required field is highlighted. Successively pressing the <ENTER> key past the last data field will also save data on the screen.