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Observation Status Medicare Rules ©2003 Duke University Hospital
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Observation Status
Medicare Rules
Observation Status
Medicare Rules
©2003 Duke University Hospital©2003 Duke University Hospital
Who does this apply to?Who does this apply to?
These rules apply to all patients, regardless of payer.
These rules apply to all patients, regardless of payer.
MedicareMedicare
Medicare established Observation Status in 1984 and developed
specific guidelines for placing a patient in this status. These guidelines are strict and any
variance is considered fraudulent and could cost the hospital
millions of dollars.
Medicare established Observation Status in 1984 and developed
specific guidelines for placing a patient in this status. These guidelines are strict and any
variance is considered fraudulent and could cost the hospital
millions of dollars.
MedicareMedicare
CEU Protocols for all Assigning Conditions have been established to meet Observation criteria. Protocols can be viewed @ clineval.dukehospital.org
Additionally, Medicare has provided guidelines for three Observation diagnoses
These diagnoses are: Chest Pain Asthma CHFStringent guidelines for care are required!
CEU Protocols for all Assigning Conditions have been established to meet Observation criteria. Protocols can be viewed @ clineval.dukehospital.org
Additionally, Medicare has provided guidelines for three Observation diagnoses
These diagnoses are: Chest Pain Asthma CHFStringent guidelines for care are required!
Requirements for Chest Pain Observation
Requirements for Chest Pain Observation
Two sets of cardiac enzymes, as well as two sequential EKGs, are required.
The DUKE ED chest pain protocol ensures these requirements are easily met.
Inclusion and Exclusion criteria should be used to determine the need for observation care.
Two sets of cardiac enzymes, as well as two sequential EKGs, are required.
The DUKE ED chest pain protocol ensures these requirements are easily met.
Inclusion and Exclusion criteria should be used to determine the need for observation care.
Requirements for Asthma ObservationRequirements for Asthma Observation
A peak expiratory flow rate or pulse oximetry reading must be taken once during the ED visit and at least once during the CEU visit.
Inclusion and Exclusion criteria should be used to determine the need for observation care.
A peak expiratory flow rate or pulse oximetry reading must be taken once during the ED visit and at least once during the CEU visit.
Inclusion and Exclusion criteria should be used to determine the need for observation care.
Requirements for CHF ObservationRequirements for CHF Observation
A Chest X-Ray, EKG, and pulse oximetry must take place during the visit.
Inclusion and Exclusion criteria should be used to determine the need for
observation care.
A Chest X-Ray, EKG, and pulse oximetry must take place during the visit.
Inclusion and Exclusion criteria should be used to determine the need for
observation care.
What is Observation Status?What is Observation Status?
Services which are reasonable and necessary to evaluate an outpatient’s condition to determine the disposition.
Observation status allows physicians to have additional time needed to evaluate and determine whether to admit or discharge.
Services which are reasonable and necessary to evaluate an outpatient’s condition to determine the disposition.
Observation status allows physicians to have additional time needed to evaluate and determine whether to admit or discharge.
Observation Status cannot be used for:
Observation Status cannot be used for:
A substitute for medically necessary admissions
Routine surgical procedures, routine post operative or pre-operative phases of care
Routine diagnostic tests and therapeutic interventions unless an untoward, unexpected, situation occurs
A substitute for medically necessary admissions
Routine surgical procedures, routine post operative or pre-operative phases of care
Routine diagnostic tests and therapeutic interventions unless an untoward, unexpected, situation occurs
Surgical ProceduresSurgical Procedures
Surgical procedures can only be outpatient or inpatient. From the ED, both types can exist. A complicated trauma patient with
internal injuries would be admitted as inpatient.
A patient with a simple fracture could be an outpatient.
Surgical procedures can only be outpatient or inpatient. From the ED, both types can exist. A complicated trauma patient with
internal injuries would be admitted as inpatient.
A patient with a simple fracture could be an outpatient.
Outpatient Therapeutic ServicesOutpatient Therapeutic Services
Observation may not be used for the administration of blood, drugs, or other treatments unless the patient experiences an unanticipated reaction and the physician requires more time to evaluate the patient and make a disposition
Observation may not be used for the administration of blood, drugs, or other treatments unless the patient experiences an unanticipated reaction and the physician requires more time to evaluate the patient and make a disposition
Direct AdmissionsDirect Admissions
Observation may not be used for direct admissions
Observation may not be used for direct admissions
Inpatient StatusInpatient Status
Once an order for Inpatient Admission has been written, it
CANNOT be changed to Observation.
Once an order for Inpatient Admission has been written, it
CANNOT be changed to Observation.
If the patient needs admissionIf the patient needs admission
Observation status may not be used as a substitute for a medically necessary admission, even if a short stay is anticipated.
A patient may be admitted after the observation period is completed
Observation status may not be used as a substitute for a medically necessary admission, even if a short stay is anticipated.
A patient may be admitted after the observation period is completed
When can observation be used?When can observation be used?
Patients typically fall into two groups when coming into the CEU from the Emergency Department: Patients who present with symptoms in which
additional time is required to make a diagnosis and/or disposition (chest pain/abdominal pain)
Patients who require more than the usual time to respond to interventions (asthma/CHF).
Example: A patient presents with abdominal pain, an initial set of tests are run, and no diagnosis can be made. The patient is placed in observation status for further monitoring until a disposition can be determined.
Patients typically fall into two groups when coming into the CEU from the Emergency Department: Patients who present with symptoms in which
additional time is required to make a diagnosis and/or disposition (chest pain/abdominal pain)
Patients who require more than the usual time to respond to interventions (asthma/CHF).
Example: A patient presents with abdominal pain, an initial set of tests are run, and no diagnosis can be made. The patient is placed in observation status for further monitoring until a disposition can be determined.
How long can a patient be in observation?
How long can a patient be in observation?
Medicare generally views observation status as LESS than 24 hours.
The patient should only be kept until a Disposition is made and no longer.
24 hours is simply a guide and patients should not remain in observation for a full 24 hours unless that period of time is necessary
Medicare generally views observation status as LESS than 24 hours.
The patient should only be kept until a Disposition is made and no longer.
24 hours is simply a guide and patients should not remain in observation for a full 24 hours unless that period of time is necessary
How do I write the order?How do I write the order?
The Observation order should read: Place or Assign to Observation Status Date, sign and time the order
DO NOT use the word “ADMIT” with an OBSERVATION ORDER, or the phrase “23 HRS”!!
The Observation order should read: Place or Assign to Observation Status Date, sign and time the order
DO NOT use the word “ADMIT” with an OBSERVATION ORDER, or the phrase “23 HRS”!!
Documentation Documentation
Documentation must clearly support the medical necessity and rationality of observation services.
Supporting ancillary reports such as labs and diagnostic test, frequent nursing and physician notes, must also be present.
Documentation must clearly support the medical necessity and rationality of observation services.
Supporting ancillary reports such as labs and diagnostic test, frequent nursing and physician notes, must also be present.
Documentation Documentation
All Nursing and Medical Staff will follow the approved documentation requirements for Observation patients
Must reflect the reason for continued observation
All Nursing and Medical Staff will follow the approved documentation requirements for Observation patients
Must reflect the reason for continued observation
Observation at DukeObservation at Duke
Most Observation patients should qualify to be assigned into the Clinical Evaluation Unit.
If a service requests Observation Status for a Duke north bed, please contact the CEU Patient Resource Manager @ 970-1427 or Bed Control for assistance.
Most Observation patients should qualify to be assigned into the Clinical Evaluation Unit.
If a service requests Observation Status for a Duke north bed, please contact the CEU Patient Resource Manager @ 970-1427 or Bed Control for assistance.
Information on ObservationInformation on Observation
The PRMs or the PRM office can be contacted for questions about Observation status. 668-2483
Information sheets are available from the PRMs and also on the inpatient units
The PRMs or the PRM office can be contacted for questions about Observation status. 668-2483
Information sheets are available from the PRMs and also on the inpatient units
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