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Observation Unit Overview
Transcript of Observation Unit Overview
Observation Medicine and Hospitalist Patients
Observation Medicine Basics
Workflow of unit
Order Sets and Documentation
HMS CDU ordersets are in development
H&P by NP/PA as per previous
HMS CDU Progress Note will be completed by APP
this INCLUDES discharge summary
Billing is already handled in imbills
Structure of Service
Selection of Patients
Most critical part of unit function
You should be anticipating a 70% chance of DISCHARGE WITHIN 24 HOURS
All patients should have either a TREATMENT or DIAGNOSTIC endpoint
Inclusion/Exclusion are on orderset
CDU manual is available on itunes
Call me at anytime (843) 276 8358
apps in development
Who are the obs patients?
from the ED
Patients admitted for 24-28 hours
Patients admitted for >5 days
Definition of Terms
Observation Status - as opposed to "Inpatient Status"
Observation Services/Care - services that are provided to determine if the patient needs further treatment as an inpatient
Observation Unit - protocol driven location (virtual or geographic) where observation services occur
ED Clinical Decision Unit
HMS Clinical Decision Unit
Observation Services are a good thing
Multiple published studies
Improved patient Satisfaction
Frees inpatient beds for improved payer mix
More services available
Less unecessary work
*all patients being discharged from the HMS CDU to home require a discharge exam by physician ideally performed at 9am rounds.
** new admissions are seen as close to real-time by admit pager holder as possible
HMS CDU Provider Responsibilities
HMS Renal Nocturnist (7pm – 7am)
7pm – Receives signout of patients from HMS CDU MLP
7pm – 7am Available for urgent HMS CDU issues and late disposition
7am – Provides signout to HMS CDU MLP and receiving team physicians in the event of transfer or new admissions
HMS Admitter (12pm – 12am)
Staffs new admissions to HMS CDU
HMS CDU MLP (7am-7pm)
7am – 8am Pre-rounds in CDU
8am – 9am Rounds in unit with HMS Consult Physician
9am – 12pm Management of Protocols and Patients in the CDU
12pm – 2pm Assist HMS Consult on new admissions for HMS CDU or elsewhere
2pm – 4pm Disposition Management of CDU patients
4pm – Phone Rounds w/ Consultant
4pm – 7pm Assist HMS Consult on new admissions for HMS CDU or elsewhere
7pm – signout to Overnight Renal NP
HMS Consult (7am-7pm)
8am – 9am Rounds with MLP
10am – 12pm Staffs new admissions to HMS CDU
7am – 7pm Available for MLP backup on established and new CDU patients
What: 6 month pilot
Where: old PACU
How: 8 bed
When: March 14th?
Who: Consult Service + dedicated NP
How to admit patients to the obs unit
Admitter (50409) makes decision as close to real-time as possible
Bed Request field
Obs Unit NP does admission H&P
Billing and Billing
1. Professional (Current Procedural Terminology) code
2. Hospital (Ambulatory Payment Classification) code
Basically, There's 2 bills
“. . . used to report the evaluation and management services provided to patients designated / admitted as “observation status” in a hospital.
It is not necessary that the patient be located in an observation area designated by the hospital.
If such an area exists in a hospital (as a separate unit in the hospital, in the ED, etc), these are the codes to be utilized. . .”
CPT: Observation Services
TWO DAY SCENARIO:
ONE DAY SCENARIO:
99218, 19, 20
Obs discharge code - 99217
One day “combo” codes (initial E/M + d/c)
99234, 35, 36
CPT: Two scenarios – 1 vs 2 days
Family history is required
or down-coding will occur (unique to observation and inpatient E/M codes, not emergency). Midlevel may do.
When does the clock start for physicians billing observation (scenario 1)?
Interpretation: The clock starts at placement in the obs unit
“Same day” code LOS issues: 8 hour minimum
99234-6 paid if LOS>8hr. If < 8 hr, then use 99218-20 without a discharge code.
CPT Observation billing issues:
Things to consider for patients admitted to obs unit
1) Can care be delivered in 24 hours or less
2) Do we have a protocol that meets their need
3) Can the patient return to their previous living arrangements once the protocol is complete
Patients who are not good candidates
1) Patients who should be admitted (ie. surgery wants to see the patient in the morning and STILL plans on taking them to the operating room
2) Drug seeking patients
3) Anyone with an acute disturbance in gait (ie grandma can no longer walk)
1) NP does H&P and it's staffed by HMS attending (no change)
2) Morning NP starts CDU Observation Summary note (temporary name) and updates it until discharge
3) At discharge, this note is sent to the rounding attending
*no additional dictation of discharge
*If the patient is admitted from observation, designate this as happening in the Observation Summary
*Transfer the patient like if the patient was transferring from the ICU through bed control.
*Must EITHER have established clinic OR be known not to be able to have a clinic (ie no new placement)
*Must consult Nephrology
*Must have consult to IR placed
*May come as direct admission, but definitely consider ED evaluation