Case Management

CMW sneak peek: Your condition code 44 questions answered

Case Management Weekly, January 20, 2010

In a recent HCPro audio conference titled “Condition Code 44 and the Utilization Review Committee: Ensure Process and Documentation Compliance,” Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance for HCPro, and Sandra McCune, BSN, RN, utilization management specialist at Lakeland Regional Health System in St. Joseph, MI, answered listeners’ questions about proper use of condition code 44.

Q. Can we use condition code 44 if a physician realizes his or her mistake and changes a patient’s status from inpatient to outpatient prior to discharge without review from the utilization committee?

A. The condition code 44 regulations state that the utilization committee and the attending physician must concur when changing patient status from inpatient to outpatient. So if the physician wants to make that change, he or she must notify the utilization review (UR) committee and get their concurrence to use condition code 44.

Q. If a UR case manager is on the UR committee, can he or she fulfill the requirement that the attending physician must agree with a member of the UR committee?

A. No. CMS does not consider case managers or other ancillary members of the committee eligible to make medical necessity decisions. A physician member of the UR committee must make that determination.

Check out the February 2010 issue of Case Management Monthly to learn more. You also can discover the benefits of becoming a Case Management Monthly subscriber.

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