June 9, 2025
Documentation is one of the most essential—and often overlooked—aspects of EMS operations. What happens on scene is only part of the picture; what gets recorded afterward plays a major role in how services are reimbursed, how agencies stay compliant, and how providers protect themselves in case of an audit.
At Lowcountry Billing Services, we review thousands of patient care reports (PCRs) each year. And while no two calls are exactly alike, the documentation issues we see are often surprisingly consistent. The good news? These common mistakes are fixable—and with the right habits in place, EMS providers can significantly reduce denials, improve revenue, and minimize risk.
Here are the most frequent documentation mistakes EMS agencies make—and how to fix them.
One of the most frequent issues we see is a lack of detail in the narrative. Providers may accurately report vitals, interventions, and transport times—but fail to clearly explain what happened and why care was necessary.
Why it matters:
The narrative is your opportunity to justify medical necessity. Without it, payers may deny the claim, especially for non-emergency transports.
How to fix it:
Encourage providers to include the “what, why, and how” in every narrative:
Clear, concise, and complete narratives help tell the full story—and support successful reimbursement.
Vital signs are a cornerstone of patient assessment, but we frequently see reports that are missing vitals entirely or contain inconsistent readings that aren't explained.
Why it matters:
Incomplete vitals can call into question the level of care provided and may result in claim denials or compliance concerns during audits.
How to fix it:
Establish clear expectations for vital sign documentation, including:
Consistency and context go a long way in validating care.
While templates can help streamline documentation, over-reliance on them can make reports look generic or repetitive. Worse, copy-pasting from previous calls can lead to inaccurate or irrelevant information in the PCR.
Why it matters:
Payers—and auditors—are quick to question reports that lack specificity. Reused language may also leave out critical details unique to the call.
How to fix it:
Encourage providers to personalize each report. Even if a call seems routine, no two patients are identical. The narrative should reflect the actual situation—not a generalized summary.
Another common issue is documentation that doesn’t clearly support why advanced life support (ALS) services were necessary instead of basic life support (BLS).
Why it matters:
Payers need clear justification to reimburse at the higher ALS rate. Without proper documentation, agencies risk downcoding or denial.
How to fix it:
Train providers to document:
When in doubt, explain the "why" behind the care level.
Calls that don’t result in a transport can feel less urgent to document—but they’re just as important.
Why it matters:
Incomplete documentation on refusals or non-transports can expose your agency to liability and disrupt billing workflows.
How to fix it:
Include:
Even if the patient walks away, the paper trail should be complete.
At Lowcountry Billing Services, we partner with EMS agencies not just to process claims, but to help improve documentation and compliance. Our team offers feedback, training support, and tools to help your providers write stronger reports—because we know accurate documentation leads to better outcomes for everyone.
If your agency is struggling with denials or simply wants to tighten up your process, we’re here to help. Reach out to our team by phone at (803) 957-7111 or by email at info@lowcountrybilling.com to start the conversation.
Backed by decades of experience, we bring clarity, consistency, and trusted support to EMS billing — so your team can stay focused on the mission ahead.
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