Health Information Management

Q/A: Ambiguous orders

APCs Insider, March 25, 2011

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Q: Our physician writes an order to “admit to 2 West” and intends this to be an observation status stay. What happens if Is a patient has a conflicting order to admit to a nursing unit and it is not distinguished as admit to Observation or Inpatient status?

A. Ambiguous language can have ramifications. The Medicare Benefit Policy Manual, Chapter 6, §20.6, defines observation as:

A well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.

CMS views a written order to “admit” a patient as an order for inpatient admission. Observation is an outpatient service used to determine whether inpatient admission is warranted. Several RACS have recommended using the phrases “place in” or “refer to” when writing an order for observation services.

Editor’s note: Andrea Clark, RHIA, CCS, CPCH, president of Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.



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