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Indiana Administrative Code (Last Updated: December 20, 2016) |
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Title 405. OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES |
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Article 405IAC5. MEDICAID SERVICES |
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Rule 405IAC5-33. Acute Care Hospital Admission |
Section 405IAC5-33-1. Adult medical surgical criteria
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Day of admission appropriateness shall be as follows:
(1) Severity of illness criteria:
(A) sudden onset of unconsciousness or disorientation (coma or unresponsiveness);
(B) pulse rate:
(i) less than fifty (50) per minute; or
(ii) greater than one hundred forty (140) per minute;
(C) blood pressure:
(i) systolic less than ninety (90) or greater than two hundred (200) millimeters mercury; or
(ii) diastolic less than sixty (60) or greater than one hundred twenty (120) millimeters mercury;
(D) acute loss of sight or hearing;
(E) acute loss of ability to move body part;
(F) persistent fever equal to or greater than one hundred (100) (p.o) or greater than one hundred one (101) (R) for more than five (5) days;
(G) active bleeding;
(H) severe electrolyte/blood gas abnormality, including any of the following:
(i) Na < 123 mEq/L
Na > 156 mEq/L
(ii) K < 2.5 mEq/L
K > 6.0 mEq/L
(iii) CO2 combining power (unless chronically abnormal) < 20 mEq/L
CO2 combining power (unless chronically abnormal) > 36 mEq/L
(iv) Blood pH < 7.30
Blood pH > 7.45;
(I) acute or progressive sensory, motor, circulatory, or respiratory embarrassment sufficient to incapacitate the patient (inability to move, feed, or breathe); must also meet intensity of service criterion simultaneously in order to certify; do not use for back pain;
(J) EKG evidence of acute ischemia; must be suspicion of a new MI; or
(K) wound dehiscence of evisceration.
(2) Intensity of service:
(A) intravenous medications and/or fluid replacement (does not include tube feedings);
(B) surgery or procedure scheduled within twenty-four (24) hours requiring:
(i) general or regional anesthesia; or
(ii) use of equipment, facilities, or procedure available only in a hospital;
(C) vital sign monitoring every two (2) hours or more often (may include telemetry or bedside cardiac monitor);
(D) chemotherapeutic agents that require continuous observation for life-threatening toxic reaction;
(E) treatment in an intensive care unit;
(F) intramuscular antibiotics at least every eight (8) hours; and
(G) intermittent or continuous respirator use at least every eight (8) hours.
(3) Criteria of appropriateness of day of care shall include the following:
(A) Medical services:
(i) procedure in operating room that day;
(ii) scheduled for procedure in operating room the next day, requiring preoperative consultation or evaluation;
(iii) cardiac catheterization that day;
(iv) angiography that day;
(v) biopsy of internal organ that day;
(vi) thoracentesis or paracentesis that day;
(vii) invasive CNS diagnostic procedure, for example, lumbar puncture, cisternal tap, ventricular tap, or pneumoencephalography, that day;
(viii) any test requiring strict dietary control for the duration of the diet;
(ix) new or experimental treatment requiring frequent dose adjustments under direct medical supervision;
(x) close medical monitoring by a doctor at least three (3) times daily (observations must be documented in record); or
(xi) postoperative day for any procedure covered in item (i) or (iii) through (vii).
(B) Nursing/life support services:
(i) respiratory care─intermittent or continuous respirator use and/or inhalation therapy (with chest PT, IPPB) at least three (3) times daily;
(ii) parenteral therapy─intermittent or continuous intravenous fluid with any supplementation (electrolytes, protein, or medications);
(iii) continuous vital sign monitoring, at least every thirty (30) minutes, for at least four (4) hours;
(iv) IM and/or SC injections at least twice daily;
(v) intake and output measurement;
(vi) major surgical wound and drainage care (chest tubes, T-tubes, hemovacs, Penrose drains); or
(vii) close medical monitoring by nurse at least three (3) times daily, under doctor's orders.
(C) Patient condition:
(i) within twenty-four (24) hours before day of review inability to void or move bowels (past twenty-four (24) hours) not attributable to neurologic disorder;
(ii) within forty-eight (48) hours before day of review:
(AA) transfusion due to blood loss;
(BB) ventricular fibrillation or ECG evidence of acute ischemia, as stated in progress note or in ECG report;
(CC) fever at least one hundred one (101) degrees rectally (at least one hundred (100) degrees orally), if patient was admitted for reasons other than fever;
(DD) coma─unresponsiveness for at least one (1) hour;
(EE) acute confusional state, not due to alcohol withdrawal;
(FF) acute hematologic disorders, significant neutropenia, anemia, thrombocytopenia, leukocytosis, erythrocytosis, or thrombocytosis yielding signs or symptoms; or
(GG) progressive acute neurologic difficulties; and
(iii) within fourteen (14) days before day of review, occurrence of a documented, new acute myocardial infarction or cerebrovascular accident (stroke).
(Office of the Secretary of Family and Social Services; 405 IAC 5-33-1; filed Jul 25, 1997, 4:00 p.m.: 20 IR 3362; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; readopted filed Sep 19, 2007, 12:16 p.m.: 20071010-IR-405070311RFA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFA)