Status Determination Skill

Screens inpatient/observation status decisions after the hospital has coded the patient but before claim submission—catching likely denials based on ICD-10 validation, documentation gaps, medical necessity alignment, and Two-Midnight Rule compliance.

Target Users: Hospital case managers, utilization review nurses, admitting physicians

Architecture

This skill uses a 2-step workflow with a clinical review checkpoint:

Step 1: Intake & Assessment
  ↓ (parse data, apply rubric, generate preliminary verdict)
  ↓ writes: waypoints/assessment.json

[User Checkpoint: Review & Confirm]

Step 2: Decision & Letter
  ↓ (capture reviewer input, generate report)
  ↓ writes: waypoints/decision.json
  ↓ writes: outputs/status-validation-report.md

Quick Start

1. •Provide paths to the admission packet (ADT, labs, vitals, MDM note)
2. •Run Step 1: Intake & Assessment
3. •Review the checkpoint summary
4. •Confirm agreement or provide override reasoning
5. •Receive the Status Validation Report

Execution Flow

Startup: Check for Existing Assessment

Before starting, check if waypoints/assessment.json exists:

IF waypoints/assessment.json exists AND status = "assessment_complete":
  → Ask: "Found existing assessment for [MRN]. Resume from Step 2? (Y/N)"
  → If Y: Skip to Step 2
  → If N: Start fresh from Step 1

ELSE:
  → Start from Step 1

Step 1: Intake & Assessment

Execute: Read and follow references/01-intake-assessment.md

Input: 4 data files (ADT, ORU labs, ORU vitals, MDM note)

Process:

1. •Parse admission data from all sources
2. •Validate ICD-10 codes using MCP tools
3. •Assess Severity of Illness against rubric thresholds
4. •Assess Intensity of Services requirements
5. •Check Two-Midnight Rule compliance (Medicare)
6. •Identify documentation gaps
7. •Generate preliminary verdict (SUPPORTED / AT RISK / LIKELY DENIAL)

Output: waypoints/assessment.json

After Step 1: Display summary and ask: "Ready to proceed to Step 2: Clinical Review & Letter Generation? (Y/N)"

Step 2: Decision & Letter

Execute: Read and follow references/02-decision-letter.md

Input: waypoints/assessment.json

Process:

1. •Display clinical review checkpoint with assessment summary
2. •Ask reviewer: "Do you agree with this assessment? (Agree/Disagree)"
3. •If Disagree: Capture reasoning, flag for escalation
4. •Generate Status Validation Report using assets/letter-template.md

Output:

• •waypoints/decision.json
• •outputs/status-validation-report.md

Verdict Definitions

Reference Files

Tool Dependencies

This skill integrates with:

• •ICD10_Codes - Diagnosis code validation, hierarchy, specificity checks
• •CMS_Coverage - Medicare coverage policy lookup (optional)

Directory Structure

daisy-skill-1/
├── SKILL.md                     ← You are here (orchestrator)
├── rubric.md                    ← Clinical criteria thresholds
├── tools.md                     ← MCP tool integration
├── references/
│   ├── 01-intake-assessment.md  ← Step 1 logic
│   └── 02-decision-letter.md    ← Step 2 logic
├── waypoints/
│   ├── assessment.json          ← Step 1 output (resume state)
│   └── decision.json            ← Step 2 output
├── outputs/
│   └── status-validation-report.md  ← Final report
├── assets/
│   └── letter-template.md       ← Report template
├── sample-data/
│   ├── adt-a01-admission.json
│   ├── oru-r01-labs.json
│   ├── oru-vitals.json
│   └── mdm-t02-ed-note.json
└── examples/
    └── case-001-sepsis-cap.md   ← Reference output

Sample Usage

User: Run status determination on the sample data in sample-data/

Claude:
1. Loads sample-data/adt-a01-admission.json, oru-r01-labs.json,
   oru-vitals.json, mdm-t02-ed-note.json
2. Executes Step 1 (01-intake-assessment.md)
3. Writes waypoints/assessment.json
4. Displays checkpoint summary
5. User confirms agreement
6. Executes Step 2 (02-decision-letter.md)
7. Writes outputs/status-validation-report.md
8. Displays completion with verdict and action items