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The issue of patient status has long been a topic of confusion. As physicians finally developed a sense of understanding of the Centers for Medicare & Medicaid (CMS) two-midnight rule, status challenges regarding managed and commercial plans ramped up. 

One point that seemed reasonably straightforward was the issue of status for post-procedural patients. Looking beyond the quagmire of inpatient-only procedures and pre-authorization details, the consideration of outpatient versus outpatient with observation services can appear rather simple. Did the procedure take place without complication and was the recovery also unremarkable? Outpatient. Were there any complications with the procedure or delay in progress through the normal recovery pathway? Now you’re providing additional observation services, which should be billed in addition to the procedure fee.

While this may seem like a simple decision, surgeons and proceduralists can still enter into a loop of uncertainty when they try to come to a decision. “The case was really long” or “this patient has a history of poor pain control” are common refrains when discussing if the care provided was expected and routine or unanticipated and a deviation from the norm. 

A helpful way of looking at it can be this – did the physician anticipate and plan for the manner in which the patient would respond during recovery? If a patient controlled analgesia (PCA) pain pump is ordered immediately post-op to run until the following morning, then you’re expecting there to be significant issues with pain, requiring said pump for that period of time. The appropriate status is likely to remain outpatient. But if the initial orders for pain control included a PRN IV analgesic for the first four hours post-op, followed by conversion to orals, and six hours later the patient is in extreme pain, leading the physician to add an order extending the length of time the IV modality can be given, now you’ve entered into observation territory.

Another hindrance in the crusade of achieving correct patient status may even lie within your medical staff’s rules and regulations. While history and physicals (H&Ps) are generally required for every patient entering the hospital, such is not the case for discharge summaries. Harkening back to the days when there were patient classifications like “23-hour OBS” and “short stays,” there was also an antiquated idea that patients who were hospitalized for short periods of time did not require a document detailing the hospital stay. Seeing that this contributed to the already gargantuan problem of continuity of care, many hospitals changed this rule in recent years, making discharge summaries necessary for all patients in inpatient status or with an “observation” designation.

Unfortunately, this can serve as an inadvertent incentive for surgeons and proceduralists to think twice about adding an observation order. All physicians want to do right by their patients, and most also want to help keep their hospitals afloat. But when already feeling overburdened with work and faced with a decision to add a classification that will require yet another piece of documentation to be completed, it can be tempting to take the simpler path. 

Look into your medical staff rules about discharge summaries and see what is required. Especially if you have suddenly noted a decrease in post-procedural patients with observation services, you may find the reason right there on the books.


Juliet B. Ugarte Hopkins, MD, CHCQM

Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV, is a physician advisor for case management, utilization, and clinical documentation at ProHealth Care, Inc. in Wisconsin. Dr. Ugarte Hopkins practiced as a pediatric hospitalist for a decade. She was also medical director of pediatric hospital medicine and vice chair of pediatrics in Northern Illinois before transitioning into her current role. She is the first physician board member for the Wisconsin chapter of the American Case Management Association (ACMA), a member of the RACmonitor editorial board, and a member of the board of directors for the American College of Physician Advisors (ACPA). Dr. Ugarte Hopkins also makes frequent appearances on Monitor Mondays and contributes to ICD10monitor.

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