/policies/,/policies/clinical/,/policies/clinical/uw-health-clinical/,/policies/clinical/uw-health-clinical/gen-care/,/policies/clinical/uw-health-clinical/gen-care/admission-discharge-transfer/,

/policies/clinical/uw-health-clinical/gen-care/admission-discharge-transfer/2137.policy

201711331

page

100

UWHC,UWMF,

Policies,Clinical,UW Health Clinical,General Care and Procedures,Admission, Discharge, Transfer

Patient Status During Hospitalization (2.1.37)

Patient Status During Hospitalization (2.1.37) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Admission, Discharge, Transfer

2.1.37


UW HEALTH CLINICAL POLICY 1
Policy Title: Patient Status During Hospitalization
Policy Number: 2.1.37
Category: UW Health
Type: Inpatient
Effective Date: November 21, 2017

I. PURPOSE

This document provides guidelines and procedures for determining the appropriate patient status (i.e.,
inpatient, observation, or outpatient short stay) for hospitalized patients to meet the following performance
objective:

Obtain the appropriate admission status in a timely manner and maintain throughout each
hospitalization to allow for the provision of appropriate payer-related benefits for the patient and
to support accurate claim submission and reimbursement.

The patient status and claim submission guidelines for both government and commercial payers change
over time. Coordinated Care, Billing, and other designated teams are responsible for maintaining current
knowledge and updated department policies related to these issues.

II. DEFINITIONS

A. AMA: Against medical advice, in reference to a patient discharge.
B. BI: Billing indicator.
C. CMS: The Centers for Medicare & Medicaid Services, part of the U.S. Department of Health and Human
Services, administers the Medicare program and works in partnership with state governments to administer
Medicaid programs.
D. Code 44 (also known as Condition Code 44 or CC44): A Medicare payment policy issued in 2004,
applicable when there has been a qualifying change from inpatient to outpatient status prior to discharge.
When all criteria for a Code 44 have been met, Billing enters Code 44 on the claim. Other payers may or will
require Code 44.
E. ED: Emergency department.
F. Initiation of care: The starting point for the 2-Midnight timeframe when the patient starts receiving services
at UW Health or an outside ED or hospital. Triaging activities before the patient is roomed are excluded.
G. IP: Inpatient status.
H. Health Link: UW Health’s electronic medical record.
I. Medicare 2-Midnight Policy: In general, if length of stay (LOS) is expected to be 2 or more midnights, the
appropriate patient status for a Medicare patient is IP. Conversely, if LOS is expected to be 0 or 1 midnight,
appropriate patient status for Medicare patient is outpatient (i.e., OBS or OSS). Exceptions to the 2-
Midnight Policy include: IP-only procedures; death; unexpected transfer; unplanned mechanical ventilation;
departure AMA; rare unforeseen recovery; and election of hospice care.
J. MOON: Medicare Outpatient Observation Notice.
K. OBS: Observation status (outpatient with observation services; requires physician order).
L. OM: Outcomes Manager.
M. OSS: Outpatient short stay status (outpatient for expected recovery after a procedure).
N. RN CM: Registered Nurse Case Manager.
O. SW: Social Worker.
P. UR Committee: Utilization Review Committee.
Q. UR PA: Utilization Review Physician Advisor.
R. UR RN: Utilization Review Registered Nurse.

III. POLICY ELEMENTS

A. Coordinated Care UR RNs and RN CMs and designated staff in other departments are responsible
for maintaining current knowledge about payer-specific status guidelines.
i. Payers have various guidelines for determining patient status for accurate claim submission. CMS
implemented the 2-Midnight Policy (effective October 1, 2013) for traditional Medicare
hospitalizations. Some Medicare Advantage, managed Medicaid, and/or commercial payers may
have implemented or will implement this policy. Payers that have not adopted the 2-Midnight Policy
use various guidelines to determine patient status, including McKesson InterQual
®
, MCG



UW HEALTH CLINICAL POLICY 2
Policy Title: Patient Status During Hospitalization
Policy Number: 2.1.37

(previously Milliman Care Guidelines), and proprietary screening tools. Both government and
commercial payers periodically revise their patient status guidelines.
B. UR RNs and RN CMs perform patient status reviews for each hospitalization and are responsible for:
i. Using the most current version of UW Health’s patient status review and Code 44 process tools.
ii. Making patient status recommendations to providers based on payer- or payer category-specific
guidelines.
iii. Performing status reviews at various designated points throughout each hospitalization.
iv. Performing status reviews within designated timeframes.
v. Clearly documenting his/her recommendation and rationale for patient status in designated
locations for each status review performed.
vi. Consulting with providers if his/her recommendation is different from the current status.
vii. Consulting with an OM when: assistance in determining appropriate patient status is needed;
provider disagrees with patient status recommendation; and OBS or OSS length of stay exceeds
one midnight. OMs consult with the UR Program Manager and/or URPAs as needed.
C. When a hospitalization does not meet payer guidelines for IP, OBS, or OSS, the case is referred to a UR PA
for further review. Refer to department specific policies for how to manage patient status after a UR PA
concurs that there is no acute medical need for a hospitalization (commonly referred to as a social
admission).

IV. PROCEDURE

A. Initial Status Reviews
i. Pre-planned hospitalizations: For designated hospitalizations, the initial status review is
performed prior to the patient’s arrival to a UW Health hospital. Designated pre-admission
staff, RN CMs, and/or UR RNs performs status reviews based on Health Link information
and/or conversation(s) with outpatient providers and other staff. Upon arrival to a UW Health
hospital unit, an RN CM or UR RN performs a status review within 16 hours.
ii. Transfers and unscheduled direct hospitalizations:
a. Access Center staff perform the following:
1. Review available information from documents and conversations with
providers and other staff at the referring facility.
2. Identify and document the initiation of care date and time for inter-hospital
transfers.
3. Assist the UW Health provider, as needed, in determining the appropriate
initial status.
b. Initial status orders are determined and placed by the attending physician or delegate.
c. Upon arrival to a UW Health hospital unit, RN CMs perform a subsequent status
review within 16 hours.
d. UR RNs, RN CMs, SWs, and/or Admissions staff determines when a MOON or other
notice of outpatient services is needed based on payer-specific requirements.
1. Staff members who deliver MOONs or other required status-related notices
follow their respective department polices for providing patients with copies
of notices, as needed, and ensuring that required documentation is
completed.
iii. Unscheduled hospitalizations:
a. Initial status orders are determined and placed by the attending physician or delegate.
b. Upon arrival to a UW Health hospital unit, an RN CM or UR RN performs a status
review within 16 hours.
1. Review available information from documents and conversations with
providers and other staff at the referring facility.
2. Identify and document the initiation of care date and time for inter-hospital
transfers.
3. Assist the UW Health provider, as needed, in determining the appropriate
initial status.
B. Concurrent Status Reviews
i. After the first hospitalized midnight, an RN CM or UR RN reviews the patient status,
incorporating the management plan at that point to determine if the patient will be discharged
or if a second midnight is needed for continued hospital care. If the status appears to be



UW HEALTH CLINICAL POLICY 3
Policy Title: Patient Status During Hospitalization
Policy Number: 2.1.37

appropriate for OBS or OSS for two or more midnights, the RN CM consults with the OM. The
OM determines if consultation with a UR PA is needed.
ii. When the RN CM or UR RN identifies a hospitalization with a patient status of OBS or OSS
that appears to be appropriate for an IP status, he/she consults with the provider.
a. If the provider agrees with IP status, the RN CM ensures that an IP order has been
entered in Health Link. As needed, the RN CM obtains a verbal order for the
appropriate status.
b. If the provider does not agree with IP status, the RN CM consults with the OM as
needed. The OM determines if consultation with the UR PA is needed.
iii. When the RN CM identifies a hospitalization with a patient status of IP that appears to be
appropriate for OBS or OSS, he/she:
a. Determines if Code 44 process is required. If so, the UR RN or RN CM ensures that
the Code 44 process is completed.
b. If Code 44 process is not required, the RN CM consults with a designated provider. If
the provider decides that the patient status should remain IP, the RN CM consults
with the OM. The OM determines if consultation with the UR PA is needed.
iv. After the second midnight, subsequent status reviews are performed as needed.
v. Hospitalizations with lengths of stays of 15 or more days are reviewed weekly at the multi-
disciplinary Long Stay meeting.
vi. The UR Committee reviews any hospitalization upon request or from case finding activities.
C. Retrospective Status Reviews
i. After discharge, short-stay hospitalizations with an IP patient class and a primary payer of
traditional Medicare or Medicaid, and other identified payers, are reviewed by a UR RN to
determine the appropriate patient status for accurate claim submission.
a. If an IP status is appropriate, the designated BI is entered and the case is
automatically routed for coding and claim submission.
b. If the appropriate patient status appears to be OBS or OSS, the case is
referred for UR PA review.
1. If the UR PA concurs with OBS or OSS status, the designated BI is entered
and the case is routed for coding and claim submission. The UR RN notifies
the Billing team if split-bill is needed.
2. If the UR PA does not concur with OBS or OSS status, the status remains
IP, the designated BI is added, and the case is routed for coding and claim
submission.
D. Provider Team Responsibilities
i. The attending physician is responsible for the following:
a. Ensuring that the appropriate status order is entered in a timely manner and
changed, as needed, prior to discharge.
b. Ensuring that status orders are signed by a qualifying provider prior to
discharge.
c. Collaborating with UR RNs, RN CMs, OMs, and/or UR PAs, as needed, to
ensure the appropriate patient status throughout each hospitalization.
d. Responding to RN CMs, UR RNs, OMs, and/or UR PAs in a timely manner
upon receiving recommendations for a change in status.
e. Adhering to UW Health Administrative Policy #6.15, Medical record
Documentation’s, guidelines.
E. Coding and Billing Requirements
i. Coding staff review the status order and/or relevant BI comments to ensure that the
appropriate IP vs. outpatient coding is performed.
ii. Billing staff review BI comments to ensure that the appropriate IP vs. outpatient claim is
submitted based on payer-specific guidelines.
a. Collaborate with Coordinated Care staff, as needed, to verify the appropriate
billing status.
b. As needed based on payer specific guidelines, perform a split-bill process
when a status has been changed from IP to outpatient prior to or after
discharge.
c. As needed based on payer specific guidelines when a status has changed
from IP to OBS or OSS prior to discharge, enter Code 44 on the claim.




UW HEALTH CLINICAL POLICY 4
Policy Title: Patient Status During Hospitalization
Policy Number: 2.1.37

I. COORDINATION

Author: Director of Coordinated Care, Medical Director for UR and Case Management
Senior Management Sponsor: VP of Revenue Cycle
Reviewers: UR PAs, Director of Access Services, Manager of Access Services, Director of Coding and CDI,
and Manager of Government Billing and Reimbursement, and Medicare/Medicaid UR Program Manager.
Approval committees: Utilization Review Committee, UW Health Clinical Policy Committee, Medical Board
UW Health Clinical Policy Committee Approval: October 16, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

II. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

III. REFERENCES

UW Health Administrative Policy # 6.15, UW Medical Record Documentation
Utilization Review Committee Charter
UW Health Code 44 process

IV. REVIEW DETAILS

Version: Revision
Last Full Review: November 21, 2017
Next Revision Due: November 2020
Formerly Known as: UWHC Policy #1.03, Patient Status and Observation Patient Management