Health Information Management

Q/A: Who must approve change in patient status for condition code 44?

APCs Insider, December 30, 2011

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Q: Our question pertains to condition code 44. At our hospital, a patient’s physician must concur with the utilization review (UR) committee’s decision to change the patient’s status.

We’ve heard otherwise that a physician who is not treating a patient may also concur with the decision to change the patient’s status. We’ve also heard that a hospital’s medical director can serve in this role. Is there any truth to any of this?

A: CMS’ policy allows hospitals to change a patient’s status from inpatient to outpatient when certain criteria are met and documented in the medical record. When all criteria are met and documentation is present, coders may report condition code 44 on a claim to indicate that the patient’s status has been changed.

The original information in the Medicare Claims Processing Manual §482.30(d)(1) states that the following four requirements must be met:

  1. 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;
  2. The hospital has not submitted a claim to Medicare for the inpatient admission;
  3. A physician concurs with the UR committee’s decision; and
  4. The physician’s concurrence with the UR committee’s decision is documented in the patient’s medical record.

In the October 2011 update to OPPS, Transmittal 2296, CMS published the following clarification:

The practitioner who is responsible for the care of the patient must concur with any decision by the hospital’s Utilization Review committee to change a patient’s status from inpatient to outpatient.

The Medicare Claims Processing Manual has been updated to reflect this clarification. It now states the following:

3. The practitioner responsible for the care of the patient and the UR committee concur with the decision; and
4. The concurrence of the practitioner responsible for the care of the patient and the UR committee is documented in the patient’s medical record.

Although the UR committee as a whole typically decides whether a change in patient status is warranted, one physician member of the UR committee may decide for the committee, provided that physician is someone other than the concurring practitioner who is responsible for the care of the patient.

One very important provision of the policy that has not changed is that the medical record must include documentation of the UR committee’s decision and the concurrence of the practitioner responsible for the care of the patient. You should review encounters that meet the requirements for condition code 44 to ensure that all required elements are included the medical record.

The complete policy and reporting requirements for condition code 44 are in the Medicare Claims Processing Manual, Chapter 1–General Billing Requirements, §50.3.2, Policy and Billing Instructions for Condition Code 44.

Editor’s note: Andrea Clark, RHIA, CCS, CPCH, president of Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.



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