Wiki Observation care

[kaydlady]

Is there guidance on documenting that the patient was admitted to observation? Also we have an issue where psych patients are held in the ED for several days waitng fpr a bed at the local Behavioral Health facility. We are not sure how to bill. The providers were billing daily consult codes, we know that's WRONG!!! and now they are using subsequent Ob's codes without there being an initial admit to Ob's. I'm sure this is wrong too. what should we bill? they have not been admitted to Ob's nor the hospital.

 

[Pam Warren]

For every hospitalization, whether or not it's inpatient or outpatient, there should be an order from the attending physician. Use that to determine patien'ts admission status. The facility's registration staff should be placing the patient in whichever status they're being admitted as soon as the order is written, but sometimes that doesn't happen. That's why we go by the written (or computerized order) as our definitive documentation.

We used to have an issue with patients being held in the ED pending a bed, but if the order said that they were admitted to OSV, it didn't matter where they were physically located, we'd code as if they were in observation.