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October 2012
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What is Condition Code 44?

In some instances, a physician or state licensed practitioner may order an individual to be admitted to an inpatient bed, but upon subsequent review, a hospital's utilization review committee determines the patient does not meet inpatient admission criteria. A scenario in which the hospital changes a patient's status from inpatient to outpatient before a Medicare beneficiary's claim has been submitted is defined as Condition Code 44.

Inpatient status is based upon medical necessity for inpatient care, whereas outpatient status is assigned to patients who are registered on hospital records as an outpatient receiving services (rather than supplies alone) directly from the hospital. Outpatient encompasses patients who receive observation services and patients who receive care but do not meet medical necessity for inpatient status.

For a Condition Code 44 to occur, all of the following conditions need to be met:

  • The change in patient status from inpatient to outpatient is made prior to discharge or release, while the beneficiary is still a patient of the hospital;
  • the hospital has not submitted a claim to Medicare for the inpatient admission;
  • a physician concurs with the utilization review committee's decision; and
  • the physician's concurrence is documented in the patient's medical record.

Frequently Asked Questions

Question:

May a hospital change a patient's status using Condition Code 44 when a physician changes the patient's status without utilization review (UR) committee involvement?

Answer:

No. The policy for changing a patient's status using Condition Code 44 requires that the determination to change a patient's status be made by the UR committee with physician concurrence. An attending physician may not change status from inpatient to outpatient (including observation) without the involvement of UM committee, which is facilitated by the clinical resource manager (CRM).

Question:

What if the physician feels, after further review of the case, that the patient does not meet inpatient level of care and would like to change status to outpatient?

Answer:

The physician should contact the unit's clinical resource manager for assistance.

Medical staff members who have additional questions should speak with a clinical resource manager or call Kathleen Sammons, manager of Clinical Resource Management, at 847.618.4562.

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Last Updated 2012/10/18