May

21

Q&A: Condition code 44

By Case Management Weekly

By Kimberly Hoy, JD, regulatory specialist for HCPro.

Q:  A case management (CM) or utilization review (UR) nurse and the attending physician agree that the patient’s status should have been observation and the attending physician is ready to discharge that patient, but there is insufficient time to process it through the UR committee to obtain another approval if we are trying to comply with code 44 guidelines by writing the order prior to discharge. How should we handle this?

A: Condition code 44 requires a UR committee determination that a patient’s status should be changed from inpatient to outpatient, even if the attending physician is in concurrence. A representative of the committee may make this determination. However, the CM and UR nursing staff are not considered members of the UR committee for purposes of the Conditions of Participation (CoPs) so they may not be considered representatives of the UR committee. That leaves you in a very difficult position in the scenario you describe in which CM/UR nursing staff determines very close to the time of discharge that the patient’s status should have been observation.

Even though the attending physician agrees, condition code 44 and the CoPs require that two physicians make this determination. One may be the attending physician, but at least one must be a representative of the UR committee. In this situation, you may not be able to meet requirements for condition code 44 to bill the case as an outpatient, but all is not lost. CMS states in MLN Matters Article SE0622 that the appropriate billing method when you don’t meet condition code 44 criteria but the UR committee finds lack of medical necessity upon review of the case using CoPs guidelines is submission of the claim on a 12X type of bill. This type of bill allows payment for certain limited services (e.g., diagnostics, implants, dressings) under Part B when the stay was not medically necessary under Part A. Refer to the Benefit Policy Manual, Chapter 6, Section 10 for more information, including the complete list of services paid under the 12X billing methodology. This will require good communication with your billing department to distinguish these cases from condition code 44 cases, but affords hospitals the opportunity to receive some payment instead of writing the entire stay off as not medically necessary.
 
Going forward, the hospital may wish to consider asking physicians such as hospitalists, who are more readily available in these time sensitive situations, to serve on the UR committee. Alternatively, some hospitals find that a paid physician advisor, who serves on the UR committee and is on-call for consultation, is helpful when time is an issue. Physician advisors can be internal physicians on your medical staff with an interest in the UR committee. Alternatively, some companies provide contracted physician advisor services.