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:

    • Stabilization and discharge are expected within 24 hours.
    • More than six hours of treatment will be required
    • Clinical diagnosis is unclear and may be determined in less than 24 hours
    • Procedure requiring observation greater than 6 hours
    • Complications of ambulatory surgery / procedure
    • Symptoms unresponsive to at least 4 hours ED treatment

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:

    • Rule Out Myocardial Infarction / Chest Pain
    • Asthma or COPD
    • Simple Pneumonia
    • Congestive Heart Failure
    • Syncope or decreased responsiveness
    • Atrial Arrhythmias
    • Gastroenteritis/Esophagitis
    • Renal Colic/UTI
    • Dialysis
    • Lower back pain
    • Fracture, Sprain, stain of upper are or lower leg

Additional diagnosis appropriate for an observation stay according to commercial payers utilizing Milliman & Robertson criteria include the following:

    • Diabetes
    • Rule Out CVA
    • Hypertension
    • Dehydration

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:

Summary of Interqual Criteria – Observation Status

Milliman & Robertson – Chest Pain Criteria

Observation Status

Severity of Condition (SC)General

Compromised airway secondary to allergic reaction

Bleeding - BP>100 – no postural changes and >one

  • Bleeding disorder
  • Epitasis with packing
  • Bleeding >24 hr.

HCT <25% - without symptoms

Ingestion of toxic substance & stable

Acute Ogliuria (<. 5ml/kg/h) without outlet obstruction

Severe Pain >1:

  • Sickle Cell Crisis
  • Unknown etiology, abdominal pain
  • Potential renal calculi or pyelonephritis
  • Intractable pain

Suicidal or Homicidal ideation, >1:

  • Intoxication
  • Dangerous behavior last 7 days
  • Organic Disease without a support system.

FUO – Temp >101 for >3wks

Toxic appearing with skin rash/infection >1:

  • Temp > 100.4 or < 96
  • WBC > 15,000
  • HR 100-140
  • Resp. 20-28

Cardiac/Respiratory

Asthma / Wheezing, Both

  • PEF 50-70% after >1

Bronchodilator > 3does (>2 if pregnant)

ER Treatment 1-3Hr

OP treatment >2d

  • Resp. rate<24/min

Carboxy-hgb 25-29% w/out mental status change

Chest Pain (cardiac) all:

  • - CK-MB / Troponin I / Troponin T
  • EKG unchanged / normal
  • BP stable (systolic >100)
  • Pain resolved in ER

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

  • Ataxia / incoordination
  • Paresis / muscle weakness

Seizure / prolonged postictal state >10-15 min in pt with known history of seizures

GI

Vomiting /Diarrhea/ Inadequate oral intake, >1:

  • BUN>45, Creatinine > 3
  • HR > 100
  • NA > 150\
  • Urine Specific gravity > 1.030
  • Postural Systolic BP drop >30
  • Disorientation / ­ Lethargy
  • Persistent vomiting & unresponsive to treatment in ER >3hr

Metabolic

BS < 50 requiring > 2 boluses of .50 glucose

BS > 400 >1:

    • Disorientation / ­ lethargy
    • New onset type I DM
    • Postural Systolic BP drop >30

K <3 or > 5.5

Na <120 or > 150

OB

Pregnancy, not in active labor, >1:

  • Abdominal pain / trauma
  • ¯ Fetal movement
  • Gestational Rh incompatibility / Fetal genetic determination
  • Severe headache unresponsive to IM/IV meds
  • Hyperemesis gravadarum & persistent vomiting unresponsive to O/P hydration
  • R/O labor or pre-term labor
  • R/O HELLP / PHI /Pre-eclampsia
  • Rescue Cerclage
  • Ruptured / leaking membranes at term
  • Temp > 102
  • Vaginal Bleeding < 1pad/H w/o fetal compromise

Surgery/Trauma

Foreign body unable to extract in ER

Post-op Ambulatory Surgery/ procedure, >1

  • Arrhythmia(s)
  • Bleeding
  • Recovery delay due to Anesthesia
  • Electrolyte imbalance
  • Uncontrolled pain, headache or Vomiting
  • Psychotic Behavior

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:

  • Bleeding
  • Monitoring, > 1
  • Arrhythmia(s)
  • Lab
  • Neurologic signs
  • Oximetry/ABG
  • PEF
  • Urine output
  • Uterine/Fetal
  • Vital Signs
  • Psychotic Behavior
  • Vomiting / Diarrhea

Blood Products / Volume Expander

Insulin adjustment > 3/24H / Pump regulation

IVF 100ml/h

LMWH (Initial dose)

Medication(s) >2 does, >1:

  • Analgesics
  • Anticoagulants
  • Antiemetics
  • Anti-infectives
  • Antipsychotics
  • Bronchodilators
  • Corticosteroids
  • Diuretics
  • Glucose 50%, multiple boluses
  • Kayexalate PO / enemas & Hyperkalemia
  • Muscle Relaxants
  • Narcotic Antagonists
  • Sedatives / anti-anxiety agents
  • Tocolytics

Medication(s) >1 does, >1:

  • Anticonvulsants
  • Antihypertensives
  • Glycosides
  • Vasodialtors

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:

  • Allergic reaction resolved
  • Bleeding controlled last 6h
  • Hct > 25%
  • No s/s withdrawal
  • Not unsafe to self or others
  • Pain controlled
  • ¯ toxic levels
  • Urine output >.5 ml/kg/h
  • Vital signs stable last 8h

Cardiac/ Respiratory, >1:

  • Absent Carboxy-Hgb
  • Chest pain resolve, MI R/O and no evidence of ischemia
  • DVT R/O or anticoagulants started
  • No syncopal episodes
  • O2 Sats > 91% /PO2 > 60 / return to baseline
  • Wheezing resolved / PEF >70% / returned to baseline

CNS, >1:

  • Neurologically stable
  • Repeat LP negative

GI / metabolic: >1:

  • BUN < 45
  • HR 50-100
  • NA 125-150
  • PO fluids tolerated
  • Vomiting & diarrhea controlled
  • BS 70-250
  • K 3-5.5

OB, >1:

  • Contractions controlled / cervix unchanged
  • Fetal compromise resolved
  • Fever resolving
  • Maternal/Fetal stability post PUBS
  • No Bleeding
  • No evidence of injury, all:

Fetal HR stable

No bleeding on ambulation

No contractions

  • Pain resolved
  • Vomiting controlled & able to maintain hydration

Surgery/Trauma, >1

  • Bleeding controlled 8h

Chest Pain (Milliman & Robertson)

Goal LOS = Ambulatory to 1 Day

Admission is indicated for any one of the following:

  • High Suspicion of MI after screening evaluation (Refer to table below)
  • Suspected cardiac ischemia with factors precluding rapid evaluation protocol including any one of the following"
    • Prior known MI or unstable angina
    • Complication of MI or ischemia (eg, ventricular arrhythmia, syncope)
    • New ECG findings consistent with MI or ischemia
    • Instability (eg, hypotension, hypertension, heart failure, arrhythmia)
    • Inability to complete exercise test (eg, <1 block exercise tolerance, hemiparesis)
  • MI (Refer to MI, acute guideline)
  • High-risk unstable angina (Refer to Angina guideline)
  • Other acute causes requiring hospitalization (pulmonary embolus, new stroke, aortic dissection, mediastinitis)

MI risk Indicator List

High risk is determined by any one of the following indications:

Indication 1

MI on ECG: ST segment elevation or Q wave in 3 or more leads not known to be old

Indication 2

Ischemia or strain on ECG: ST segment depression or T wave inversion in 2 or more leads not known to be old

Indication 3

Must have presence of all

  • Chest pain < 48 hours old
  • History of angina or MI
  • Pain > 1 hour duration
  • Pain worst than usual or similar or earlier MI

Indication 4

Must have presence of all

  • Chest pain < 48 hours old
  • Pain radiating to left arm, shoulder or neck
  • Age >40
  • Pain is not radiating to back, not stabbing in nature, not reproduced by palpation

Indication 5

Chest pain with any one of the following risk factors:

  • Systolic BP <110mm hg
  • Rales above bases on exam
  • Known unstable ischemic heart disease

Back to Billing Updates

03-13-2005