Ambulatory Surgery

Unknown
in CDI Talk Archive
Hey all. I was recently at a Medicare Bootcamp and a discussion was had if you have an ambulatory surgery patient that doesn't meet medical necessity for admission and the surgeon wants to keep the patient overnight, do you place the pt in observation and bill that way or do you place the patient as an "outpatient in a bed" and code that way and expect no payment? I am still relatively new at this and would appreciate your help. Thanks
Elaine Sakala RN/CDI

Comments

  • sharon.cooper@owensborohealth.orgsharon.cooper@owensborohealth.org
    edited May 2016
    We place that type of patient in 'outpatient in a bed' status for as long as necessary for recovery; or until such time that they meet Observation status or Inpatient status.

    Sharon Cooper, RN-BC, CCS, CCDS, CDIP, CHTS-CP
    AHIMA-Approved ICD-10-CM/PCS Trainer/Ambassador
    Manager Clinical Documentation/Appeals

    sharon.cooper@owensborohealth.org
    (270) 417-4612 Office
    (270) 316-9088 Cell
    (270) 417-4609 Fax

    Owensboro Health Regional Hospital
    P.O. Box 20007
    Owensboro, KY 42304-0007

  • Unknown
    edited May 2016
    Hey thanks everyone for your input!

    Elaine Sakala RN
    Clinical Documentation Specialist/UR
    Delta County Memorial Hospital
    esakala@deltahospital.org
    970-874-2287

  • delana.knupp@wiseregional.comdelana.knupp@wiseregional.com
    edited May 2016
    How do they chart? Do the nurses do all the admission and floor charting, or do they just continue recovery charting?

    Delana

    Delana Knupp, RN, CRRN
    Integrated CDI/Case Mgmt Director
    Wise Regional Health Systems
    O: 940-626-1242
    F: 940-626-3935
    delana.knupp@wiseregional.com




  • Unknown
    edited May 2016
    They chart per observation protocol

    Elaine Sakala RN
    Clinical Documentation Specialist/UR
    Delta County Memorial Hospital
    esakala@deltahospital.org
    970-874-2287

  • sharon.cooper@owensborohealth.orgsharon.cooper@owensborohealth.org
    edited May 2016
    Patients in the heart cath recovery area stay the night in that area if needed & yes, they just continue recovery charting. Outpatient surgery patients return to the outpatient surgery area for recovery until department closes - if patient still needing routine recovery, they are transferred to a nursing unit for continued recovery; or change to Observation and/or inpatient if medical necessity criteria met.

    We have on occasion had patients in outpatient status for a day or two because they did not meet criteria for Obs or Inpt and the physician refused to discharge, or could be due to a social issue.

    For outpatients, the nurses have an outpatient assessment that are completed on all patients preoperatively.

    Our nursing admission assessment is divided into two parts. If the patient is admitted in Observation status, the first half of the assessment is completed; if patient admitted as inpatient, the entire assessment must be completed.

    Sharon Cooper, RN-BC, CCS, CCDS, CDIP, CHTS-CP
    AHIMA-Approved ICD-10-CM/PCS Trainer/Ambassador
    Manager Clinical Documentation/Appeals

    sharon.cooper@owensborohealth.org
    (270) 417-4612 Office
    (270) 316-9088 Cell
    (270) 417-4609 Fax

    Owensboro Health Regional Hospital
    P.O. Box 20007
    Owensboro, KY 42304-0007

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