405 Ind. Admin. Code 5-33-1

Current through September 4, 2024

Section 405 IAC 5-33-1 - Adult medical surgical criteria

Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2

Affected: IC 12-13-7-3; IC 12-15

Sec. 1.

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).

405 IAC 5-33-1

Office ofthe Secretary of Family and Social Services; 405 IAC 5-33-1; filed Jul 25, 1997, 4:00p.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

Readopted filed 11/13/2019, 11:54 a.m.: 20191211-IR-405190487RFA

Readopted filed 5/30/2023, 11:54 a.m.: 20230628-IR-405230292RFA