Wiki Inpatient vs Observation status

Mindy Davis

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I've been ask to provide diagnosis examples that could be under each In-patient and Observation and what documentation is required to determine which category the pt would fall under.
 
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I may be misunderstanding your question, but the categories of inpatient or observation are determined by physician order, not by diagnosis or by documentation. I think just about any diagnosis could fall under either category. Generally speaking, a physician will admit a patient to inpatient status if they anticipate that the course of treatment will require that the patient be in the hospital at least two days, or will admit to observation if they expect it to be less than 48 hours, but this can vary. It would depend more on the patient's condition and planned treatment than on the diagnosis. This is a clinical decision and generally outside the scope of coding except for coders who have the additional clinical training.
 
Utilization Management

Hospitals usually follow certain guidelines that the Utilization Management Department is very familiar with. The hospital I worked for used a combination of McKesson's Interqual Criteria and the Medicare Inpatient Only list to determine if a patient should be inpatient or observation. As thomas7331 said, it ultimately depends on the physician's order. Payers follow certain guidelines as well.
 
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