Condition code 44 – The continuing saga
On August 28, CMS issued Medicare Claims Processing Manual (MCPM) transmittal 1803, which is the October 2009 update to the Outpatient Prospective Payment System (OPPS). CMS included minor revisions to those sections of Chapter 1 of the MCPM that relate to condition code 44.
As you will recall, condition code 44 is used when a patient’s initial inpatient status is successfully changed to outpatient for purposes of billing and payment. This generally occurs when case management and other utilization review personnel were not available (weekends and holidays) at the time that the admission decision was made, and it is later determined that the patient does not meet Medicare’s inpatient guidelines. Condition code 44 is reported on the subsequent outpatient (013X) type of bill that is submitted to recover for the services provided in the inpatient setting.
Those inpatient services are covered and reimbursed on the same terms and conditions as if they actually had been provided in the outpatient setting, so long as all of the following criteria are met:
- The decision to change status must be made by the hospital’s “utilization review committee” (UR committee). One “member” of the UR committee can make the decision, with the attending physician’s agreement; in all other cases, the decision must be made by at least two “members.” The change in status must be made prior to discharge or release of the patient and before the hospital has submitted a claim for the inpatient admission;
- A physician must concur with the decision;
- The physician’s concurrence must be documented in the patient’s medical record; and
- The UR committee must provide written notice to the hospital, the patient and the patient’s physician within two days (but not later than the patient’s discharge or release from the hospital) of the change and its impact on the patient, including financial liability for applicable deductible and coinsurance amounts.
In the transmittal issued on August 28, CMS stated that although one physician member of the UR committee is empowered to make the decision to change status, the physician member who makes the decision must be different from the concurring physician, who is the physician responsible for the care of the patient. Based upon this most recent statement, it is not clear what the effect would be if the physician responsible for the care of the patient did not concur with the change in status.
The regulations that set out the hospital’s conditions of participation (CoP), which call for the establishment of a UR committee, along with the scope of its responsibility and authority (including change of status), indicate that, in all other circumstances, the change in status decision must be made by two members of the UR committee. Presumably, this is the procedure that a hospital should follow if it were unable to obtain the agreement of the patient’s physician to change the status of care from inpatient to outpatient.
Hospitals are encouraged to have at least two signatures on the documentation for the change in status: (1) when the attending physician concurs, signatures of both the attending physician and the physician member of the UR committee who made the change in status decision; or (2) when the attending physician does not concur, signatures of the two physician members of the UR committee who made the decision to change status.
Hospitals are also encouraged to confirm with their FI/MAC that the process as outlined above, particularly when the patient’s physician does not concur, meets the requirements of a condition code 44 change in status.
Editor’s note: This article was written by Judith Kares, an, instructor for HCPro’s Medicare Boot Camp – Hospital Version. It was originally published on the MedicareMentor blog. Read the original post here.
About the Author: Ben Amirault is the editor for the case management market at HCPro. Ben writes and edits the monthly newsletter as well as the weekly e-newsletter. Ben also organizes case management audio conferences and manages the Case Management Mentor blog. To contact him with questions, comments, or to contribute to the blog email bamirault@hcpro.com.
Sandra McCune BSN, RN | Sep 8, 2009 | Reply
Regarding what to do if the attending does not agree – I got this clarification from our FI: “CC 44 is defined by coverage and payment rules concerning billing. The CoP defines what must occur to remain in compliance with Medicare participation. If the physician does not agree and 2 members of the UR committee make the decision then CC 44 PAYMENT rules are not met and only Part B services (12X BT) can be billed to Medicare. The CoP defines WHO can make the decision re: medical necessity per Medicare; it does not define HOW that situation is paid (CC 44 and the manual does).”
Jenny Stelzner | Sep 9, 2009 | Reply
We recently had discussions about this, and would like to clarify whether or not others see it the same way…assuming all of the other conditions are met, a hospital can only bill for “outpatient services” from the point of admission until the point of the order to change the admission status. Then, if another order is obtained to change to observation status, then at THAT point (and not earlier), the hospital can charge observation hours. Is this truly the case?
Sandra McCune BSN, RN | Sep 9, 2009 | Reply
I think it’s best to ask your FI/MAC these questions.
I did, & their response was “At the time the order was written. Observation, just as inpatient can not be back-dated to the admission/patient arrival time. Since observation time depends on hours for billing, there must be an order and “time” begins with that order. This has been clarified through CMS. The clarification came via email to our medical directors, not through a CR.” (This is me now) So it’s very important to get the order as early in the stay as possible, since you won’t get the APC payment if you don’t have at least 8 hours of billable observation.
Ronald Hirsch, MD | Sep 9, 2009 | Reply
Two questions:
-What about if the case manager asks the attending to change the status to OPO and the doc says “ok, my partner on call picked the wrong status”. Does the UR Committee still need to review the change if all the other components are followed?
-And if the attending does not agree (as Sandra discusses above), then does the hospital still notify the patient that the status is no longer inpatient and that Medicare will be billed for Part B services?
Sandra McCune BSN, RN | Sep 11, 2009 | Reply
I’ve asked my FI about this in the past & they said the physician & UM Committee must agree. (Of course, only one physician member of the committee needs to agree)
I don’t have an official answer to the 2nd question, but my take on it is that if you are not billing with CC 44, you are not required to notify the patient. (The status is still technically inpatient) My billing department tells me the patient has little or no financial responsibility after Part B payment.
Carol Franklin RN Case Manager | Sep 12, 2009 | Reply
Is there a standard form to give to the patient/family regarding the change in status? If there is, where can it be found?
Sandra McCune BSN, RN | Sep 14, 2009 | Reply
CMS does not specify what type of written notification the patient receives, or it’s content. Most hospitals have developed a letter or brochure that explains that the patient is in an outpatient status & that their financial responsibility may be affected.
Jenny Stelzner | Dec 2, 2009 | Reply
Does CMS specify whether or not the requirements for CC44 apply to CAH hospitals? CMS 50.3 refers to the conditions for participation for PPS hospitals, but does not specifically note the conditions for participation for CAH hospitals. Does the CAH have to document the UR physician concurrance?