Question

I need to answer following based on the information provided in the case -

Patient Name

MRN

Date of Service

Meets definition of observation? Y/N

Compliant order for observation? Y/N

Physician Evaluation? Y/N

Identify additional hospital services (Clinic, Critical Care, Direct Referral for Observation, Emergency Dept)

HCPCS code assignment for observation and additional hospital services. This does not include the HCPCS codes for labs and medications which would be captured and reported via chargemaster (This column is for informational purposes only)

Comments

Case 4

Patient Overview

[Patient came in for anemia due to chemotherapy. Patient has a history of breast cancer with metastasis to the axillary lymph nodes. Patient admitted to observation for transfusion.

This is an example of incorrect use of observation status. If a patient receives diagnostic or therapeutic services for which active observation is a part of the procedure then that observation is considered part of the diagnostic or therapeutic services. It does not meet the definition of observation care status.]

Admission Details

Patient Name: Brenda Obs Thrush

Encounter Type: Observation

Admission Time: 0900

Orders

Order	Order Details	Order Date/Time
Observation Order	Observation during transfusion of red blood cells	[Date of arrival] / 0900
Red Blood Cells	2 units packed cells	[Date of arrival] / 0900
Hemoglobin	Once	[Date of arrival] / 0900
Hematocrit	Once	[Date of arrival] / 0900

History and Physical Note

[Completed at 1400 day before encounter.]

Reason for visit:

Severe anemia secondary to breast cancer

History of Present Illness:

The patient has a history of breast cancer. She had a mastectomy approximately two months ago and it was determined that it has metastasized. She was seen yesterday in the office and came in with a complaint of a cough. She was examined and a CBC was done and determined that her hemoglobin was 7.8 at that time. She was admitted to observation for transfusion.

Planned Procedure:

Give two units of packed red blood cells.

Answer 1

Case 4

Patient Name	MRN	Date of Service	Meets definition of observation? Y/N	Compliant order for observation? Y/N	Physician Evaluation? Y/N	Identify additional hospital services (Clinic, Critical Care, Direct Referral for Observation, Emergency Dept)	HCPCS code assignment for observation and hospital services. This does not include the HCPCS codes for labs and medications which would be captured and reported via chargemaster (This column is for informational purposes only)	Comments
Brenda Obs Thrush	1012307	9/5/2018, 0900	Yes Observation during transfusion of red blood cells	Yes She underwent mastectomy 2 months ago, presently she came with the complaint of a cough. In the CBC revealed that her hemoglobin was 7.8	Yes Presently she came with a complaint of a cough. She was examined and a CBC was done and determined that her hemoglobin was 7.8 on 9/5/2018 at 0900. She was admitted to observation for transfusion.	Planned Procedure: *Give two units of packed red blood cell *Observation during transfusion of red blood cells *Check for the hemoglobin and hematocrit once	The HCPCS code for blood transfusion is 36430 should only report one time, per transfusion, regardless of how many units are administered.	In the order details : *Observation during transfusion of red blood cells *Transfusion of RBC 2 units *Check for Hemoglobin and hematocrit level once