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. (1) Severity of illness criteria:

   1. (A) sudden onset of unconsciousness or disorientation (coma or unresponsiveness);

   2. (B) pulse rate:

      1. (i) less than fifty (50) per minute; or
      2. (ii) greater than one hundred forty (140) per minute;

   3. (C) blood pressure:

      1. (i) systolic less than ninety (90) or greater than two hundred (200) millimeters mercury; or
      2. (ii) diastolic less than sixty (60) or greater than one hundred twenty (120) millimeters mercury;
   4. (D) acute loss of sight or hearing;
   5. (E) acute loss of ability to move body part;
   6. (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;
   7. (G) active bleeding;

   8. (H) severe electrolyte/blood gas abnormality, including any of the following:

      1. (i) Na < 123 mEq/L
      2. Na > 156 mEq/L
      3. (ii) K < 2.5 mEq/L
      4. K > 6.0 mEq/L
      5. (iii) CO2 combining power (unless chronically abnormal) < 20 mEq/L
      6. CO2 combining power (unless chronically abnormal) >36 mEq/L
      7. (iv) Blood pH < 7.30
      8. Blood pH > 7.45;
   9. (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;
   10. (J) EKG evidence of acute ischemia; must be suspicion of a new MI; or
   11. (K) wound dehiscence of evisceration.

2. (2) Intensity of service:

   1. (A) intravenous medications and/or fluid replacement (does not include tube feedings);

   2. (B) surgery or procedure scheduled within twenty-four (24) hours requiring:

      1. (i) general or regional anesthesia; or
      2. (ii) use of equipment, facilities, or procedure available only in a hospital;
   3. (C) vital sign monitoring every two (2) hours or more often (may include telemetry or bedside cardiac monitor);
   4. (D) chemotherapeutic agents that require continuous observation for life-threatening toxic reaction;
   5. (E) treatment in an intensive care unit;
   6. (F) intramuscular antibiotics at least every eight (8) hours; and
   7. (G) intermittent or continuous respirator use at least every eight (8) hours.

3. (3) Criteria of appropriateness of day of care shall include the following:

   1. (A) Medical services:

      1. (i) procedure in operating room that day;
      2. (ii) scheduled for procedure in operating room the next day, requiring preoperative consultation or evaluation;
      3. (iii) cardiac catheterization that day;
      4. (iv) angiography that day;
      5. (v) biopsy of internal organ that day;
      6. (vi) thoracentesis or paracentesis that day;
      7. (vii) invasive CNS diagnostic procedure, for example, lumbar puncture, cisternal tap, ventricular tap, or pneumoencephalography, that day;
      8. (viii) any test requiring strict dietary control for the duration of the diet;
      9. (ix) new or experimental treatment requiring frequent dose adjustments under direct medical supervision;
      10. (x) close medical monitoring by a doctor at least three (3) times daily (observations must be documented in record); or
      11. (xi) postoperative day for any procedure covered in item (i) or (iii) through (vii).

   2. (B) Nursing/life support services:

      1. (i) respiratory care–intermittent or continuous respirator use and/or inhalation therapy (with chest PT, IPPB) at least three (3) times daily;
      2. (ii) parenteral therapy–intermittent or continuous intravenous fluid with any supplementation (electrolytes, protein, or medications);
      3. (iii) continuous vital sign monitoring, at least every thirty (30) minutes, for at least four (4) hours;
      4. (iv) IM and/or SC injections at least twice daily;
      5. (v) intake and output measurement;
      6. (vi) major surgical wound and drainage care (chest tubes, T-tubes, hemovacs, Penrose drains); or
      7. (vii) close medical monitoring by nurse at least three (3) times daily, under doctor's orders.

   3. (C) Patient condition:

      1. (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;

      2. (ii) within forty-eight (48) hours before day of review:

         1. (AA) transfusion due to blood loss;
         2. (BB) ventricular fibrillation or ECG evidence of acute ischemia, as stated in progress note or in ECG report;
         3. (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;
         4. (DD) coma–unresponsiveness for at least one (1) hour;
         5. (EE) acute confusional state, not due to alcohol withdrawal;
         6. (FF) acute hematologic disorders, significant neutropenia, anemia, thrombocytopenia, leukocytosis, erythrocytosis, or thrombocytosis yielding signs or symptoms; or
         7. (GG) progressive acute neurologic difficulties; and
      3. (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; readopted filed Nov 13, 2019, 11:54 a.m.: 20191211-IR-405190487RFA; readopted filed May 30, 2023, 11:54 a.m.: 20230628-IR-405230292RFA)