Case Management

CMW Tip of the Week: Consider other level-of-care options

Case Management Weekly, July 22, 2009

This week’s tip comes from Deborah Hale, CCS, author of Observation Status: A Guide to Compliant Level of Care Determinations, Second Edition, published by HCPro, Inc.

Inpatient admission and outpatient observation status are not the only options available to hospitals. The following examples describe scenarios in which the patient should be an outpatient without an observation status designation.

  • Minor surgery or other treatment—When patients with known diagnoses enter a hospital for a specific minor surgical procedure or other treatment that is expected to keep them there fewer than 24 hours, they are considered outpatients for coverage purposes. This is true regardless of the hour they arrived at the hospital, whether they used a bed, and whether they remained past midnight (Medicare Benefit Policy Manual, Chapter 1).
  • Treatment room—Treatment room services consist of outpatient services furnished on hospital premises and requiring the use of a bed and periodic monitoring for a relatively brief episode to perform certain nonsurgical procedures (but not in a specialized suite that is otherwise billable). Recovery from the effects of such procedures is similarly an appropriate use of the treatment room. The primary difference between treatment and observation rooms is that use of the former is expected for minor procedures and it replaces the charge for operating and recovery rooms. Examples include port flush, dressing changes, and other services not separately payable. Conversely, the observation room is an unexpected service beyond the normal recovery period due to an unresolved question concerning the patient’s condition.


Have a tip or tool you’d like to share? Or maybe a question for our experts? E-mail it to editor Julie McGinley at jmcginley@hcpro.com.Your comments or suggestions could appear in a future issue of Case Management Weekly!

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