Q&A: Urgent versus elective admission types

Q: We are looking more closely at the National Uniform Billing Committee (NUBC) definitions of admission type, specifically urgent versus elective. We have received several inquiries from the care teams to update cases from elective to urgent; however, when we look at the timeline and documentation, urgent is not supported, so we are working with them to provide additional details. We realize that the responsibility of determining admission type varies at each hospital, but for those that have CDI validating/reviewing the admission type, have you developed internal guidelines that expand on the current NUBC definitions for urgent versus elective?

A: There are times when a patient is scheduled for an elective surgery but the surgeon’s documentation reveals, due to a complicating circumstance or condition, that it is an urgent procedure. When that occurs the quality department can work with the provider to have the admission type changed.

It may be helpful to have a list of agreed-upon definitions for each type of admission. These could be some variation of the below:

• Emergent: An admission where the absence of immediate medical attention could result in a severe life-threatening or possibly disabling condition. Generally, emergent patients are admitted through the emergency department or are direct admissions to critical care, surgery, labor, and delivery, or from another hospital.
• Urgent: An admission for a medical condition that could become an emergency if not diagnosed or treated in a timely manner but where the patient’s condition is stable enough to slow a short delay. Generally, an urgent admission should occur within 14 days and because of the urgency, the admission is arranged for the first available and suitable accommodation.
• Elective: An admission which is scheduled in advance and for which a delay in the delivery of medical treatments or diagnosis would not substantially affect the health or safety of the patient.
• Trauma: An admission that results from trauma activation and the patient being admitted for further evaluation and treatment.
• Newborn: An admission resulting from delivery either inside or outside the admitting hospital.

CDI reviews can also look at the patient presentation and reach out to the patient registration team to change the admission type if warranted. Having a second-level review CDI team look at pre-bill quality reviews may also reveal any ongoing issues with admission type capture. In some instances, the admission type alone will exclude the patient from a patient safety indicator (PSI). 

It’s also helpful to note that, most of the time, transfers will fall under urgent as the reason the patient is sent to a higher level of care because they are not deemed stable at the prior location. Even if a patient looks like a scheduled admission, it’s worth confirming because it is possible the patient was scheduled for a later date and then had to change to a direct admission at an earlier date due to some unforeseen issue. Sometimes, those scenarios can support urgent or emergent admission types as well.

No matter how involved your CDI team becomes, there is an opportunity to educate those who are responsible for the admission type field as they may not understand how much of an impact the wrong selection can have on the organization.

Editor’s note: This question was answered by members of the ACDIS CDI Leadership Council.