Inpatient Admissions without an Inpatient Physician Order

[#1]

Connolly has posted on their website within the past week a CMS approved issue which deals with physician orders.

Description: Admissions to teh inpatient setting require a physician's order to qualify and be paid as an inpatient stay.

Please make sure your case management departments are checking for the presence of an inpatient order on the medical record and that it meets medical necessity for that status.  

[#2]

If our Case Management team finds an inpat w/o order what do we need to do?

Example, we had a patient who was scheduled on the pre-op forms(PATS)  as an inpat. for a TURP, (inpat only prodedure) scheduled and done on 8/17.  Case management reviewed case 8/18 and found that the phys. did not write an

inpat. order, the phys just started with plan of care orders(this was done on 8/17 @ 14:10).  There is nothing in the h&p indicating inpt.  Can our case management on 8/18 ask the phys. to clarify his order and document

chart of the clarification and still use the admit date of 8/17 and time of 14:10 or do we take the admit date and time of

the clarification order?

[#3]

Hello khawn

The inpatient order needs to be clarified as soon as possible. In the example given above you cannot back date  the order. The order would be effective the date and time of the clarification order. The nursing staff can help with this process when the take admissions orders off and don't see a status ordered, they can prompt the physician. Of course you would need to education them on how to do this.

Debbie