Observation/Inpatient Unlock The Mystery

What does it all mean? In the early 90s guidelines for insurance and Medicare payments to hospitals began to go through some drastic changes. Stricter regulations were introduced that defined diagnosis driven billing. Patients hospitalized with certain diagnosis's had to be discharged within 24 hours. The hospital then receives the payment indicated for that diagnosis. Thus, the word “observation” took on a new light and the question was being asked in hospitals around the country, “Is this patient Observation or Inpatient?”.

Patients being admitted to the hospital must now have an “admission status” of “Inpatient” or “Observation”. They have to be registered in the computer as an (O) Observation or (I) Inpatient and must have a doctor’s order for that status. They also must have a doctor’s order for any changes in the status. Patients admitted with diagnosis's that can be treated and released within 24 hours are admitted as observation. Patients admitted with diagnosis’s that require a longer treatment plan are admitted as inpatient. Some patients are admitted as observation but due to complications or changes in their medical condition cannot be discharged after 24 hours and must be changed to inpatient. There must be a doctor’s orders for “Upgrade to Inpatient”. The hospital is paid a set sum for the observation portion of the admission and then paid for the inpatient portion of the admission providing that all guidelines are followed correctly.

Patients Admitted From the ED The patient is registered in the computer in a unit called DEH (HEH in Hasbro), a “cyberspace” holding unit where the patient’s information and orders will stay until they are transferred to their in-house bed. The Emergency Department doctor will let the registrar know whether the patient will be registered as inpatient or observation. When the admission orders are entered, the physician may agree or not with the admit status ordered by the Emergency Department doctor. The admission orders are entered by the physician that will be caring for the patient once they are transferred to the unit. The doctor will enter “Admit as Inpatient” or “Assign as Observation”. ED Doctor In-house Doctor

The Patient Arrives Once the patient arrives on the inpatient unit the Unit Secretary begins to process the patient’s orders. The secretary compares how the patient is registered in the computer to the doctor’s order. Is the registration an I or O? Is the doctor’s order, Admit as Inpatient or Assign as Observation? If they are both the same the U.S will not need to do anything. If they are not the same he/she will need to take the next step. Unit Secretary Unit Secretary

Sending a Notification The Unit Secretary sends a notification to the Business Office to change the status via the computer by going to (1) ADT and picking one of the two notifications. (42) Inpt to Obs Notification (44) Obs to Inpt Notification The status must be changed to match the doctor’s order. Example: Registration (I) Dr’s Order (O) US sends Inpt to Obs Notification. Unit Secretary Business Office

The Status Is Changed After receiving the notification the Business Office will change the status to Obs or Inpt as indicated on the notification. The notification prints 2 copies-one to the Business Office and one on the unit. File the one you receive on your printer in the chart immediately after the demographic sheet. It may take a little while before you see the status change in the computer. The US is only sending a notification, the Business Office makes the actual change.

Upgrade to Inpatient An observation patient that cannot go home within 24 hours must be upgraded to inpatient. The doctor will place an order for “Upgrade to Inpatient”. When the US receives the order, he/she must send an Observation to Inpatient Notification. The Business Office will change the patient to Inpatient.

As you have learned, patients admitted as observation can be upgraded to inpatient. This actually creates 2 accounts when the billing is completed. The observation portion and the inpatient portion. However, patients admitted as inpatient can only be changed to observation dating and timing back to admission. So in other words, the observation portion of the account must be first. A patient’s status can only be changed once in 24 hours. Example: patient is admitted as inpatient patient arrives on the unit and the MD enters “Assign as Observation”. the Unit Secretary sends notification “Inpatient to Observation” and the Business changes the patient to (O) Observation.  later that day doctor enters “Admit as Inpatient”.  the US sends the “Observation to Inpatient” Notification.  the Business Office will not be able to change the status until after midnight. But the US must still send the notification so the Business Office will know to change the status after midnight.

Please register Mr. Pain as Observation. 1 2 Please register Mr. Pain as Observation. We’ll have you in your room soon Mr. Pain. I will send an Obs to Inpt notification because he is registered as Observation. 4 3 I entered an “Admit as Inpatient” order for Mr. Pain. INPATIENT OR OBSERVATION? Hmm…it seems as if all changes were made correctly. The hospital will receive full payment for this case. I received the Obs to Inpt notification and I will change Mr. Pain to Inpatient. 6 5

Please register Mr. Pain as Observation. 1 2 Please register Mr. Pain as Observation. We’ll have you in your room soon Mr. Pain. OK, I don’t need to do anything with the status. 4 3 I entered an “Admit as Inpatient” order for Mr. Pain. INPATIENT OR OBSERVATION? Hmm…it seems as if all changes were not addressed correctly. The hospital could loose a lot of money on this account! 5

Observation Start Date/Time Insurance providers look for several pieces of information when approving or denying observation accounts for payment. These are the 2 pieces they look for when reviewing the admission portion: The first indication of care being rendered once the patient has arrived on the unit. This would be the time the first set of vital signs taken and date/time documented by RN/CNA. The “Observation Start Date/Time” entered by the Unit Secretary when the transfer function was performed. These 2 times must coincide or total or partial payment can be denied.

How will RN/CNA/US make sure these times match? Notify RN/CNA that the patient is observation. Before transferring the patient into your census you must know the time of the first set of vital signs as documented on the Flow Sheet. If you do not get that information from the RN/C.N.A. then you must obtain it before you can transfer the patient. Transfer patient into your census. On the transfer screen, enter the date/time of the first vital signs, as documented on the Flow Sheet, in the “Transfer Date/Time and the “Start Obs Date/Time” field. Ask the US if the patient is observation. Notify US of the time documented on the Flow Sheet for the first set of vital signs.

Observation End Care Date/Time Insurance providers look for several pieces of information when approving or denying observation accounts for payment. These are the 2 pieces they look for when they are reviewing the discharge portion: The last indication of care being rendered once the patient is ordered to be discharged. This would be the date/time the nurse reviews the discharge instructions with the patient. The date/time the Unit Secretary entered in the “End Care Date/Time” field when performing the discharge function. These 2 times must coincide or total or partial payment can be denied.

How will RN/US make sure these times match? Before performing the discharge function, locate the CoC/Patient Instruction sheet(s). Enter the exact date/time written by the RN on the bottom of page 2 of the CoC/Patient Instructions into the “Obs End Care Date/Time” fields when performing the discharge function. If date/time is not documented, inform the RN that the date/time must be documented on the CoC/Patient Instruction sheet so that you can enter the exact same time RN Enters or writes the time discharge instructions are reviewed with the patient/family on the bottom of page 2 of the CoC/Patient Instruction Sheet. If CoC/Patient Instructions are being printed immediately before giving the instructions, the date/time can be entered on the electronic CoC form. If the CoC/Patient Instructions have been completed electronically but instructions are not going to be reviewed yet, print the CoC/Patient Instructions and write the time that instructions are reviewed.