[[Manual/Releases.ReleaseRecord0025][]] Note for "Admission Date"

• *Topic Version for Release 25
• Topic has changed since last release: Compare versions

Rationale

To align with NHQM.

Description

In the Notes for Abstraction change from:

• The intent of this data element is to determine the date that the patient was actually admitted to inpatient care. Because this data element is critical in determining the population for all measures, the abstractor should NOT assume that the claim information for the admission date is correct. If the abstractor determines through chart review that the date is incorrect, for purposes of abstraction, she/he should correct and override the downloaded value.
• A patient of a hospital is considered an inpatient upon issuance of written doctor’s orders to that effect. (Refer to the Medicare Claims Processing Manual, Chapter 3, Section 40.2.2.)
• For patients who are admitted to Observation status and subsequently admitted to acute inpatient care, abstract the date that the determination was made to admit to acute inpatient care and the order was written. Do not abstract the date that the patient was admitted to Observation.
• For patients that are admitted for surgery and/or a procedure, if the admission order states the date the orders were written and they are effective for the surgery/procedure date, then the date of the surgery/procedure would be the admission date. If the medical record reflects that the admission order was written prior to the actual date the patient was admitted and there is no reference to the date of the surgery/procedure, then the date the order was written would be the admission date.
• For HBIPS only, admission dates prior to 2001 are acceptable.

to:

• The intent of this data element is to determine the date that the patient was actually admitted to inpatient care. Because this data element is critical in determining the population for all measures, the abstractor should NOT assume that the claim information for the admission date is correct. If the abstractor determines through chart review that the date from billing is incorrect, for purposes of abstraction, she/he should correct and override the downloaded value.
• For patients who are admitted to Observation status and subsequently admitted to acute inpatient care, abstract the date that the determination was made to admit to acute inpatient care and the order was written. Do not abstract the date that the patient was admitted to Observation. o Example: Medical record documentation reflects that the patient was admitted to observation on 04-05-20xx. On 04-06-20xx the physician writes an order to admit to acute inpatient effective 04-05-20xx. The Admission Date would be abstracted as 04-06-20xx; the date the determination was made to admit to acute inpatient care and the order was written.
• If there are multiple inpatient orders, use the order that most accurately reflects the date that the patient was admitted. The admission date should not be abstracted from the earliest admission order without regard to substantiating documentation. If documentation suggests that the earliest admission order does not reflect the date the patient was admitted to inpatient care, this date should not be used. o Example: Preoperative Orders are dated as 04-06-20xx with an order to admit to Inpatient. Postoperative Orders, dated 05-01-20xx, state to admit to acute inpatient. All other documentation supports that the patient presented to the hospital for surgery on 05-01-20xx. The admission date would be abstracted as 05-01-20xx.
• For HBIPS only, admission dates prior to 2001 are acceptable.
• For PC only, an initial set of physician orders addressing care or treatment of the newborn can be interpreted as newborn admission orders, and the date of these orders can be considered the admission date

Under suggested data sources change from:

PRIORITY ORDER FOR THESE SOURCES

• Physician orders
• Face sheet
• UB-04, Field Location: 12

to:

ONLY ALLOWABLE SOURCES

• 1. Physician orders
• 2. Face sheet

Excluded Data Sources

• UB-04, Field Location: 06