Observation vs. Inpatient Admitting Criteria
According to Interqual (Medical Necessity criteria utilized by CMS), Observation should be considered when the patient is hemodynamically stable, does not meet acute care criteria and if any of the following apply:
Commercial payers will only authorize observation up to 23 hours. Under Medicare observation is no longer limited to 23 hours and can be used as an effective alternative until the need for admission is clearly determined. Medicare will allow up to 48 hours of observation. However the physician is encouraged to determine by 23 hours whether the patients needs to be admitted or discharged to a lower level of care. According to Medicare the following are indications for an extended Observation (up to 48 hours) and generally lack medical necessity for inpatient admission unless specific complications or co-morbidities exist:
Additional diagnosis appropriate for an observation stay according to commercial payers utilizing Milliman & Robertson criteria include the following:
The admission into observation or inpatient status is based on the patient’s severity of illness and the intensity of service provided. Conversion of an observation case to inpatient is not based on time. A patient in observation status should not be converted to an inpatient at the end of the 23-hour timeframe unless the patient’s acuity and treatment meet inpatient. Links: |
Observation Status
Severity of Condition (SC)General Compromised airway secondary to allergic reaction Bleeding - BP>100 – no postural changes and >one
HCT <25% - without symptoms Ingestion of toxic substance & stable Acute Ogliuria (<. 5ml/kg/h) without outlet obstruction Severe Pain >1:
Suicidal or Homicidal ideation, >1:
FUO – Temp >101 for >3wks Toxic appearing with skin rash/infection >1:
Cardiac/Respiratory Asthma / Wheezing, Both
Bronchodilator > 3does (>2 if pregnant) ER Treatment 1-3Hr OP treatment >2d
Carboxy-hgb 25-29% w/out mental status change Chest Pain (cardiac) all:
DVT Dyspnea with P02 <60 or O2 Stat< 91% Near Drowning without mental status change Spontaneous Pneumothorax, >15% Smoke inhalation Syncope, unknown etiology Hypertensive emergency – Systolic> 250 / Diastolic > 120 without organ compromise CNS Suspected CNS Infection Grade III concussion Disorientation/ Increased lethargy |
Exacerbation of neuro deficit >1
Seizure / prolonged postictal state >10-15 min in pt with known history of seizures GI Vomiting /Diarrhea/ Inadequate oral intake, >1:
Metabolic BS < 50 requiring > 2 boluses of .50 glucose BS > 400 >1:
K <3 or > 5.5 Na <120 or > 150 OB Pregnancy, not in active labor, >1:
Surgery/Trauma Foreign body unable to extract in ER Post-op Ambulatory Surgery/ procedure, >1
Trauma with normal initial exam & suspected organ injury |
Observation Status
Level of Service
Discharge Criteria
Level of Service >1 (Excludes PO meds unless noted) Assessment q4h >1:
Blood Products / Volume Expander Insulin adjustment > 3/24H / Pump regulation IVF 100ml/h LMWH (Initial dose) Medication(s) >2 does, >1:
Medication(s) >1 does, >1:
Repeat LP w/in 12 h Psychiatric crisis intervention / stabilization with observation q15 min PUBS > 1x/24 h O2> 28% & oximetry / ABG Therapeutic Throacentesis |
D/C Guidelines (Meet both clinical & Level of care) General >1:
Cardiac/ Respiratory, >1:
CNS, >1:
GI / metabolic: >1:
OB, >1:
Fetal HR stable No bleeding on ambulation No contractions
Surgery/Trauma, >1
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Chest Pain (Milliman & Robertson)Goal LOS = Ambulatory to 1 Day Admission is indicated for any one of the following:
MI risk Indicator List High risk is determined by any one of the following indications:
03-13-2005 |
