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. 2. Day of admission appropriateness shall be as follows:

1. (1) Severity of illness criteria:

   1. (A) sudden onset of unconsciousness (coma or unresponsiveness) or disorientation;
   2. (B) acute or progressive sensory, motor, circulatory, or respiratory embarrassment sufficient to incapacitate the patient (inability to move, feed, breathe, or urinate);
   3. (C) acute loss of sight or hearing;
   4. (D) acute loss of ability to move body part;
   5. (E) persistent fever (>one hundred (100) degrees orally or >one hundred one (101) degrees rectally) for more than ten (10) days;
   6. (F) active bleeding;
   7. (G) wound dehiscence or evisceration;

   8. (H) severe electrolyte/acid-base abnormality, including any of the following:

      1. (i) Na < 123 mEq/L

         1. Na > 156 mEq/L

      2. (ii) K < 2.5 mEq/L

         1. K > 6.0 mEq/L

      3. (iii) CO2 combining power (unless chronically abnormal) <20 mEq/L

         1. CO2 combining power (unless chronically abnormal) >36 mEq/L

      4. (iv) Arterial pH < 7.30

         1. Arterial pH > 7.45;
   9. (I) hematocrit < thirty percent (30%);

   10. (J) pulse rate outside following ranges (optimally a sleeping pulse for < twelve (12) years old):

       2–6 years old	70–200/minute
       7–11 years old	60–180/minute
       >12 years old	50–140/minute

   11. (K) blood pressure outside following ranges:

       	Systolic	Diastolic
       2–6 years old	75–125 mm Hg	40–90 mm Hg
       7–11 years old	80–130 mm Hg	45–90 mm Hg
       < 12 years old	90–200 mm Hg	60–120 mm Hg

   12. (L) need for lumbar puncture, where this procedure is not done routinely on an outpatient basis;

   13. (M) any conditions not responding to outpatient, including emergency room:

       1. (i) seizures;
       2. (ii) cardiac arrhythmia;
       3. (iii) bronchial asthma or croup;
       4. (iv) dehydration;
       5. (v) encopresis (for clean-out); or
       6. (vi) other physiologic problem (specify);

   14. (N) special pediatric problems:

       1. (i) child abuse;
       2. (ii) noncompliance with necessary therapeutic regimen; or
       3. (iii) need for special observation or close monitoring of behavior, including calorie intake in cases of failure to thrive.

2. (2) Intensity of service:

   1. (A) 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;
   2. (B) treatment in an intensive care unit;
   3. (C) vital sign monitoring every two (2) hours or more often (may include telemetry or bedside cardiac monitor);
   4. (D) intravenous medications and/or fluid replacement (does not include tube feedings);
   5. (E) chemotherapeutic agents that require continuous observation for life-threatening toxic reaction;
   6. (F) intramuscular antibiotics at least every eight (8) hours; and
   7. (G) intermittent or continuous respirator use at least eight (8) hours.

3. (3) Criteria of appropriateness of day of care shall be as follows:

   1. (A) For medical services, the following documented criteria will be used for continued stay reviews; at least one (1) of the criteria must be met for the continued stay to be recertified:

      1. (i) Procedure in operating room that day.
      2. (ii) Procedure scheduled in operating room the next day, requiring preoperative consultation or evaluation.
      3. (iii) If day being reviewed is the day of admission, any procedure among subdivisions [sic., items] (iv) through (ix) scheduled for the day after admission unless that procedure is usually done at that facility on a same-day basis.
      4. (iv) Cardiac catheterization that day.
      5. (v) Angiography that day.
      6. (vi) Biopsy of internal organ that day.
      7. (vii) Thoracentesis or paracentesis that day.
      8. (viii) Invasive CNS diagnostic procedure, for example, lumbar puncture, cisternal tap, ventricular tap, or pneumoencephalography, that day.
      9. (ix) Gastrointestinal endoscopy that day.
      10. (x) Any test requiring strict dietary control for the duration of the diet.
      11. (xi) New or experimental treatment requiring frequent dose adjustments under direct medical supervision.
      12. (xii) Close medical monitoring by a doctor at least three (3) times daily (observations must be documented in record).
   2. Postoperative day for any procedure covered in item (i) or (iv) through (ix).

   3. (B) Nursing/life support services shall be as follows:

      1. (i) Respiratory care–intermittent or continuous respirator use and/or inhalation therapy (with chest PT, IPPB), at least three (3) times daily, Bronkosol with oxygen, oxyhoods, or oxygen tents.
      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/or output measurement.
      6. (vi) Major surgical wound and drainage care, for example, chest tubes, T-tubes, hemovacs, or Penrose drains.
      7. (vii) Traction for fractures, dislocations, or congenital deformities.
      8. (viii) Close medical monitoring by nurse at least three (3) times daily, under doctor's orders.

   4. (C) Patient condition:

      1. (i) within twenty-four (24) hours on or before day of review, inability to void or move bowels, not attributable to neurologic disorder–usually a post-op;

      2. (ii) within forty-eight (48) hours on or 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 reason other than fever;
         4. (DD) coma–unresponsiveness for at least one (1) hour;
         5. (EE) acute confusional state, including withdrawal from drugs and alcohol;
         6. (FF) acute hematologic disorders–significant neutropenia, anemia, thrombocytopenia, leukocytosis, erythrocytosis, or thrombocytosis–yielding signs of 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 5-33-2; filed Jul 25, 1997, 4:00 p.m.: 20 IR 3364; 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)