Identify at least one criterion in each of these categories (severity of illness
ID: 68851 • Letter: I
Question
Identify at least one criterion in each of these categories (severity of illness and intensity of service) and explain why it meets the requirements for admission to the hospital. Then summarize why the preadmission screening process is an important component of the continuum of care.
2 page paper
Introduction: Why do we need criteria to assess preadmission, care management and discharge processes?
Body: Identify the criteria that meet requirements for hospital admission (one from the severity of illness category and one from the intensity of service category).
Conclusion: Summarize why the preadmission process is so important, what negative outcomes can happen if patients are not appropriately screened? What are the implications for the hospital (financial or otherwise), for the patient?
Explanation / Answer
If a hospital is found to have a high frequency of short inpatient hospital stays, Medicare will investigate. If inappropriate admissions are found, the sanctions can be severe. As a result, hospital health information management (HIM) and utilization management (UM) staff closely monitor the medical necessity of inpatient hospital admissions and short inpatient hospital stays. Their efforts can put pressure on emergency department physicians to make sure that each inpatient admission from the ED is medically necessary and will pass fiscal intermediary or Medicare Area Contractor (MAC) scrutiny.
These decisions generally revolve around patients’ IS (Intensity of Service) and SI (Severity of Illness). These are listed in the various medical necessity-screening tools.
The main criteria relate to intensity of service and severity of illness. From both the hospital and payer's perspective, it is the admitting physician's decision whether or not to admit the patient. If a hospital is not being totally or adequately paid for such inpatient admissions, hospitals will strenuously attempt to remedy the situation.
Documentation by the treating physician becomes key in determining the intensity of service and the severity of illness. This includes the emergency department record.
Once the admission or observation review is opened, there is a tree structure of criteria for both "severity of illness (SI) and "intensity of service (IS)". Both SI and IS criteria must be met to support the medical necessity for admission, observation or another service in the system. Many of the criteria are similar for observation and inpatient but the inpatient admission SI and IS criteria indicate higher acuit
Document the full clinical picture of patients' severity of illness in the ED. This includes any social conditions, co-morbidities and debilities that affect your decision to admit.