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Follow strict guidelines for condition code 44

HIM Connection, May 17, 2005

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Last September, CMS issued transmittal 299 which describes how a hospital may change a patient's status from inpatient to outpatient with condition code 44, effective April 1, 2004.

On outpatient claims only, facilities may use condition code 44 (inpatient admission changed to outpatient), when the physician ordered inpatient service, but internal utilization review (UR) before claim submission determined that the services did not meet inpatient criteria.

The transmittal also describes the appropriate use of condition code 44 in form locator 24-30 or its electronic equivalent, on outpatient claims (type of bill 13X, 85X).

Transmittal 299 is clear about when facilities can change a patient's status from inpatient to outpatient. The scenario must meet all of these four criteria:

1. The facility changes the patient status from inpatient to outpatient prior to discharge or release while the beneficiary is still a patient in 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
4. The physician's concurrence with the UR committee's decision is documented in the patient's medical record

Therefore, it's imperative you assign condition code 44 before the patient is discharged from the hospital.

"If you know what you're doing and you use this code correctly, it's a cushion," says Arlene Baril, MS, RHIA, vice president of HIM and software services for UASI in Cincinnati. "But if the patient's already gone, it's too bad for you, the provider."

This excerpt is adapted from Briefings on APCs.

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