Remember Ralphie, the boy from the movie Christmas Story? Ralphie had many adventures working his way to Christmas Day including the day he used bad words in front of his mother. Her response to the bad words was to make him sit with a bar of soap in his mouth.

Times have thankfully changed, but our industry does seem to have a problem with the use of “bad words.” There are some words that do not help describe the patient’s problem – the patient is documented as being “weak” or suffering from “weakness.”

I work and travel a great deal. At the end of a week of traveling and changing time zones, I will feel “weak.” I won’t need an ambulance; I’ll need a glass of wine and time with Netflix! Other “bad words” we see to describe the patient’s need for ambulance are “abnormal gait.” If I drank too much of that wine, my gait might become abnormal. We see these words frequently documented in trip reports. This isn't just a field provider problem. Those words then translate into the ICD codes billers use to prepare the claim.

The trouble is, those words really don’t describe why the patient needs an ambulance and can’t be transported any other way. Let’s take the patient with weakness. Is the weakness the result of a CVA causing the patient to need special positioning during transport? Is the patient unable to support themselves in a wheelchair for the length of time of the transport? Is the patient a fall risk or safety risk? These are the issues that need to be documented.

In addition to being non-descriptive of the patient’s condition, Novitas (the Medicare contractor for Pennsylvania, Texas, New Jersey, Colorado, New Mexico and Louisiana) specifically addressed the use of the word “weakness” in the Local Coverage Determination (LCD L35162) published October 1, 2015. According to Novitas, the use of weakness without supporting documentation does not provide back-up to pay the claim.

Novitas said: “Statements such as the following, absent supporting information in relevant bullets above, are insufficient to justify Medicare payment for ambulance services: Patient complained of shortness of breath - History of stroke - Past history of knee replacement – Hypertension - Chest pain - Generalized weakness/pain - Is bed-confined.”  When claims get coded with the description “weakness,” it has the potential for being a red flag. Billers need to assure there is documentation that demonstrates medical necessity for ambulance prior to billing.

Billers get frustrated when “weakness” is the word documented in the trip as to why the patient needs ambulance. They sometimes feel they have no other choice than to work with what they have – and weakness is all they have.

A bar of soap is not going to solve the problem of “bad words” in documentation and billing, but education will. Assure that crews understand the significance of describing why the patient needs to be in an ambulance and cannot be transported any other way. Teach crews to carefully review the dropdown boxes in their ePCR to find the best description of the patient’s condition. Finally, teach billers the importance of coding claims in the most descriptive terms to represent the patient’s condition and need for ambulance.

Let us know if we can help!

About the author:  Maggie Adams is the president of EMS Financial Services, with 25 years’ experience in the ambulance industry as a business owner and reimbursement and compliance consultant. Known for a practical approach and winning presentation style, Maggie has worked with medical transportation providers and billing companies of all kinds to provide auditing services, assess their billing for best practices and support their billing and documentation training efforts. “Like” EMS Financial on Facebook, follow us on LinkedIn or for more info, contact Maggie directly at or visit