AdmissionObservationDischarge Criteria and Documentation Issues

1
Admission/Observation/Discharge Criteria and
Documentation Issues

• Tina R. Strawn, RN
• Nurse Auditor for Hospital Patient Financial
  Services
• Ext. 71170

2
DOCUMENTATION ISSUES

• Documentation must be legible and should
  substantiate the level care that is being
  provided to the patient.
• If the patient is in DSU or observation status
  and is changed to observation or admission
  status, the documentation should support the need
  for the higher level of care.
• If a planned surgery/ procedure is cancelled
  without being performed, the physicians
  documentation in the chart should explain the
  reason for the cancellation.

3
DOCUMENTATION ISSUES

• All documentation in the chart should support the
  order. For example if a patient has an admission
  order the Plan of Care, History Physical, etc.
  should support the admission status.
• If the plan is to admit to a certain team or
  unit, the order should not appear to be an
  admission order.

4

• Admission Criteria
• UTMB uses the Texas Medical Foundation Criteria
  to determine if the patient meets the guidelines
  for admission.
• In order to meet the guidelines the patient must
  meet the Indications for Hospitalization and
  the Treatment Criteria.
• When the physician calls the BIC for a bed, they
  are asked questions related to the diagnosis,
  symptoms, labs, x-rays, and the plan for
  treatments. This is to determine whether the
  patient meets these guidelines for admission

5

• Observation Criteria
• This status is appropriate when the physician is
• Unsure about the patients need for inpatient
  admission and needs additional time to evaluate
  the patient or the physician feels that the
  patient will respond quickly to treatment per
  TMF.
• When the BIC personnel screens the patients with
  the TMF criteria and the patient does not meet
  for admission, the physician will be notified and
  the patient will be placed in observation status.
• NO PATIENT WILL BE DENIED A BED

6
Medicare/Medicaid Issues

• Both Medicaid and Medicare have lists of
  procedures that must be done in
  outpatient/inpatient status in order for
  hospitals to be reimbursed. If the patient is in
  a status other than what is mandated the
  documentation must support the physicians
  decision.

7
SUMMARY

• All payors have physicians and nurses that review
  charts for medical necessity.
• Documentation is the only way for the
  physicians/nurses reviewing the chart to
  determine if an admission is appropriate.
• UTMB physicians can place patients in admission
  status at any point during the hospitalization
  but if the documentation does not support the
  admission status, UTMB will not be reimbursed for
  the care provided.
• Medicare does not allow planned observation. The
  patient must be evaluated after a procedure and
  documentation must support the observation/admissi
  on stay.

8
ADDITIONAL INFORMATION

• If your intent is to place a patient in
  observation status, the order in the chart should
  be clear Place patient is observation status.
• If your intent is to place the patient in
  admission status, the order in the chart should
  be clear Place patient in admission status.
• Admission orders are effective at the date/time
  the order is written. The order can not be
  back-dated or retroactive.

9
Discharge Criteria

• The documentation should substantiate the plan
  for discharge.
• The vital signs/labs/x-rays should be within the
  normal limits or a post discharge plan should be
  documented in the discharge summary to assist or
  evaluate the patient with any abnormal
  symptoms/labs/vital signs/x-rays/treatments. This
  could include home health, clinic visits, future
  surgeries, etc.
• The discharge disposition should be documented in
  the discharge summary (home, home with home
  health,SNF, Rehab unit, Psychiatric unit,etc.)

10
Inpatient Discharge CPT Codes99238-99239

• Used to report the total duration of time spent
  by a physician for final discharge of a patient
• This includes, as appropriate
• Final examination of the patient
• Discussion of the hospital stay
• Instructions for continuing care to all
  caregivers
• Preparation of discharge records, prescriptions,
  and referral forms

11
CPT Codes 99238-99239

• These are timed codes
• 99238 30 minutes or less
• 99239 more than 30 minutes
• They are to be used to report all services
  provided to a patient on the date of discharge if
  other than the date of the initial admit

12
CPT Codes 99238-99239

• Do not use these codes in the following
  scenarios
• To report concurrent services provided by
  physician(s)
• other than the attending physician (use
  subsequent care
• codes 99231-99233 on the day of discharge)
• Observation Care Discharge (use 99217)
• For Observation/Inpatient admission and discharge
  on
• the same date (use codes 99234-99236)
• Nursing Facility Care Discharge (use codes 99315,
  99316)
• For newborns admitted and discharged on the same
  date (99345)