Condition code 44 – The continuing saga
On Friday, 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 Friday, 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.
About the Author: Judith Kares is an instructor for HCPro's Medicare Boot Camp - Hospital Version. Judith has also been involved in the following:
Penny Ruiz | Sep 1, 2009 | Reply
I’m not sure why there is such confusion surrounding the use of this condition code or it’s requirements. It’s very simple and spelled out quite plainly. If the hospital determines the patient does not meet their admission criteria, they cannot simply change the patient status. It must be discussed by the UR committee. If the UR committee which must include at least two physicians agrees, then the admitting physician must be given the opportunity to explain/provide evidence that supports the admission. If the admitting physician agrees with the committee, the hospital may then proceedd with the status change after they inform the patient, who may also disagree. If the admitting physician does not agree but does not provide information to support the admission, the hospital needs at least two physicians from the UR committee to decide to make the change anyway, but again must inform the patient and should also include the QIO for backup later on. The only change that is made to what has already occurred is a change in the bill type from 11X to 13X. Nowhere is it written that a hospital may remove charges or change the account retrospectively. The bill type change only allows the payment of part B services that would otherwise not be payable along with the prevetitive services that are payable on the 12X bill type. It was not possible to receive the additional part B payment before condition code 44. It was created because hospitals frequently lost all reimbursement because of weekend admissions and physicians with preferences rather than medical necessity supporting their decisions.
Nancy Nicholson | Sep 9, 2009 | Reply
The case managers are an arm of the UM committee at my hospital. We inform the physician that the patient does not meet acute care. If the physician agrees with the CM, thus agreeing with the UM committee, the MD will write an order to the effect, “After review, this patient is most appropriate for obsv. stay. Please change to obsv. stay”.
Most of these cases are related to after hours admits by the ED physician.
Velva Charles | Oct 16, 2009 | Reply
Is this process, in compliants with the CMS? If so what is the next next, how/where is the documentation for the UR Committee, how do you notify the hospital, patient, and physician of the change that could be financil?
Could you contact me?
Thank you,
Catherine Hicks | Nov 24, 2009 | Reply
This should be simple and intuitive, but with Medicare, nothing ever is. Our Case Managers are also an arm of the UM Steering Committee. If they discuss the admission with the attending physician and the MD agrees and writes and order to change the patient to Observation Status, why does the process need to continue through the UM committee review and documentation of agreement, etc? Why can’t it stop when the attending physician agrees with the CM? Is there a CMS citation or FAQ that deals with this specific scenario?
Catherine Hicks | Dec 9, 2009 | Reply
Penny – thanks for your comments. The problem is that in this time of shorter admissions, the UM/CM may find the case on Monday and speak with the attending physician who, after discussion, agrees with a change from IP to OBS. The doctor writes the order at that time and the UM/CM talks to the patient about the change in status. If everyone agrees, what is the purpose of the second physician?
Donna Matiste | Dec 16, 2009 | Reply
Code 44 requires that a physician of the U.R. committee talk to the physician. Physician to physician. Medical criteria, Interqual and Milliman require secondary physician review. According to Mckesson’s guidelines, it is mandatory. According to Code of Federal Regulations, and Conditions of Participation, a casemanager is a non physician and so cannot change a patient inpatient status to outpatient. Casemanagers can facilitate communication between the Doctor and the U.R. doctor but you cannot write an order to change the status right there and then.
Debbi Russell | Apr 4, 2010 | Reply
I have also read that the change from inpatient to an out patient status does not allow the entire stay to be billed as out patient. The out patient portion starts with the physician writing an out patient order along with the concurring physician’s supporting documentation. You cannot retro the out patient stay back to the time the inpatient order was written.
Please comment. Thank you.
Jen | Nov 4, 2010 | Reply
I am also curious about this regulation. I’ve been reading about this and I cannot figure out if this means that when the physician/UR committee decides that the inpatient should be an outpatient, and the phys writes the order, does this mean that the entire inpatient stay needs to become an outpatient (obs) stay or does it mean that the inpt should be rolled to an obs acct at the time the order is written?
Jan Grady | Nov 10, 2010 | Reply
Hello:
If the attending MD agrees with the CM to change a patient’s status from Inpatient to Observation, can the CM
take a verbal order or telephone order from the MD and write the change from Inpatient to Observation? Or does the MD have to write and sign the order for the change from Inpatient to Observation?
Thanks,
Jan Grady, RN, BSN, CCM
Admission Coordinator