Observation to Inpatient
When a patient is changed from observation to inpatient what is your current CDI practice?
1. Is a query placed concurrently looking for specific medical diagnosis as to why the change was made. If CDI does query concurrently, is a Physician answer in the prog notes sufficient or does this documentation need to be in the DC Summary?
2. Is the pdx determined by using clinical knowledge when the documentation is clear?
3. Do the coders take care of this on the backend?
Thank you!