2/20/2012. 2. DOCUMENTATION ISSUES . Documentation must be legible and should substantiate the level care that is being provided to the patient. If the patient is in DSU or observation status and is changed to observation or admission status, the documentation should support the need for the higher level of care. If a planned surgery/ procedure is cancelled without being performed, the physician's documentation in the chart should explain the reason for the cancellation..
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1. 2/21/2012 1 Admission/Observation/Discharge Criteria and Documentation Issues Tina R. Strawn, RN
Nurse Auditor for Hospital Patient Financial Services
2. 2/21/2012 2 DOCUMENTATION ISSUES
3. 2/21/2012 3 DOCUMENTATION ISSUES
4. 2/21/2012 4
5. 2/21/2012 5
6. 2/21/2012 6 Medicare/Medicaid Issues
7. 2/21/2012 7 All payors have physicians and nurses that review charts for medical necessity.
Documentation is the only way for the physicians/nurses reviewing the chart to determine if an admission is appropriate.
UTMB physicians can place patients in admission status at any point during the hospitalization but if the documentation does not support the admission status, UTMB will not be reimbursed for the care provided.
Medicare does not allow planned observation. The patient must be evaluated after a procedure and documentation must support the observation/admission stay.
8. 2/21/2012 8 ADDITIONAL INFORMATION If your intent is to place a patient in observation status, the order in the chart should be clear: “Place patient is observation status.”
If your intent is to place the patient in admission status, the order in the chart should be clear: “Place patient in admission status.”
Admission orders are effective at the date/time the order is written. The order can not be back-dated or retroactive.
9. 2/21/2012 9 Discharge Criteria The documentation should substantiate the plan for discharge.
The vital signs/labs/x-rays should be within the normal limits or a post discharge plan should be documented in the discharge summary to assist or evaluate the patient with any abnormal symptoms/labs/vital signs/x-rays/treatments. This could include home health, clinic visits, future surgeries, etc.
The discharge disposition should be documented in the discharge summary (home, home with home health,SNF, Rehab unit, Psychiatric unit,etc.)
10. 2/21/2012 10 Inpatient Discharge CPT Codes 99238-99239 Used to report the total duration of time spent by a physician for final discharge of a patient
This includes, as appropriate:
Final examination of the patient
Discussion of the hospital stay
Instructions for continuing care to all caregivers
Preparation of discharge records, prescriptions, and referral forms
11. 2/21/2012 11 CPT Codes 99238-99239
12. 2/21/2012 12 CPT Codes 99238-99239