Observation vs. Inpatient

donna.kentdonna.kent
in CDI Talk Archive
I suspect others are dealing with this. Hope so. The RAC is hitting us hard on 1 day stays. They are basically denying the elective PCIs that the doctor has decided to make inpatient after the procedure. And yet may times the doctor writes, "No complications". These patients frequently are discharged after less than 23 hours. The available documentation does not reveal any reason why these should have been billed as in patient other than the physician's order. Wouldn't it make more sense for the physician to write for observation if they really feel they need to have the patient more carefully monitired than would be standard for a non-complex PCI? Please help. Donna

Comments

  • mdomineseymdominesey
    edited May 2016
    I sit in on the daily UR meetings with the case managers and their physician advisor (who also happens to be one of my advisors) and this is a common scenario. The UR people look at the Interqual guidelines to determine if a procedure meets inpatient criteria, but many physicians have no idea what meets or does not meet, hence the UR process. You describe something that will occur without an UR process, physicians will often inpatient admit instead of observation admit, then be very light on intensity of service and when they write "no complications" the severity of illness is also not of an inpatient level of care. Your RAC reviews are likely two-three years back; do you have a comprehensive UR program with weekend coverage now? Sadly, you will likely lose many of these 1 day no complication post procedure stays.

    Kindest Regards,

    Mark



    Mark N. Dominesey, RN, BSN, MBA, CCDS
    Sr. Clinical Documentation Improvement Specialist
    Sibley Memorial Hospital


  • robert.hodges2robert.hodges2
    edited May 2016
    I haven't done UR in a while, but if I recall you can't do observation post ambulatory surgery but you can do something called "extended recovery". In any event the provider has to document the reason for the extended recovery, be it anesthesia or monitoring for suspected complications. You may want to get with your UR guru and see what the rules are now.

    Robert

    Robert S. Hodges, BSN, MSN, RN, CCDS
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
     
    P: 989-497-2500 x13101
    F: 989-321-4912
    E: Robert.Hodges2@va.gov
     
    "We are dealing with Veterans, not procedures; With their problems, not ours." --General Omar Bradley

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Yes, do you have a UR process at your facility? We would make these patients OBS here. Our UR nurses review the record and see if they meet. The patients are in OBS unless the UR nurse determines that the patient meets IP criteria.

    Katy Good, RN, BSN, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Office: 928.214.3864
    Cell: 928.814.9404

  • donna.kentdonna.kent
    edited May 2016
    Thanks Mark. I suspect what you described is exactly what's happening.
    I will have to figure out how to make sure we can contribute to the
    process here. I don't know yet what the daily UR process is here.

    Donna Kent, RN, BSN, CCDS
    Manager, Clinical Documentation Integrity Program
    Clinical Quality and Accreditation
    Torrance Memorial Medical Center
    ph.:310 784-6884 fax:310 784-6899
    donna.kent@tmmc.com
  • laura.bohls@prairielakes.comlaura.bohls@prairielakes.com
    edited May 2016
    Patients can be Observation post-op for "unexpected complications" If the MD is not documenting any complications or reason for inpatient they should stay Outpatient. Very rarely would a post cath qualify for observation. They will either meet Inpatient or need to stay as outpatient.

    Laura Bohls, RN
    Prairie Lakes Hospital

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016

    Attached is a PowerPoint I have used to educate physicians re: OBS Svcs. Not updated since 2008, but many points pertinent. Will attempt to post, but is a large file.
  • mary.mcgrady@accuityhealthcare.commary.mcgrady@accuityhealthcare.com
    edited May 2016
    Hello,
    Would you mind sending it to me as well. We have started doing reviews in the ED and are working on work flow, obs and inpatient.
    thanks

    Mary McGrady, MSN
    Manager Clinical Documentation Program
    Department of HIM
    NYU Langone Medical Center
    560 1st Avenue, TH-194
    New York, NY 10016
    212-263-8557
    Mobile: 646-588-9208


  • vleadbetter@cmcvtx.orgvleadbetter@cmcvtx.org
    edited May 2016
    Will you please provide me with a copy of the PowerPoint also?

    Thanks,
    Vickie Leadbetter
    Clinical Documentation Improvement Coordinator
    Citizens Medical Center
    2701 Hospital Drive
    Victoria, TX 77901

    vleadbetter@cmcvtx.org

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Vickie: Please see the message a few response ago for this attachment.

    Thanks, Paul





    Paul Evans, RHIA, CCS, CCS-P

    Supervisor, Clinical Documentation Integrity, Quality Department
    California Pacific Medical Center
    2351 Clay #243
    San Francisco, CA 94115
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
    evanspx@sutterhealth.org
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