Case Management

CMW Tip of the Week: Using Condition Code 44

Case Management Weekly, April 15, 2009

This week’s tip, an ask the expert,  was submitted by Elaine Hall, LPN, a care management utilization review (UR) nurse at Exempla Lutheran Medical Center in Wheat Ridge, CO, and answered by Deborah Hale, CCS.

Q: We have a question about when to use Code 44. We know we use it when the UR committee decides to change a status from inpatient to observation status, but what if the Medicare patient is admitted as inpatient, then the attending physician rounds and after discussion with the case manager or UR nurse decides the patient does not meet inpatient criteria? The physician then writes an observation status order after discussion with either a case manager or UR nurse. There is no involvement by the UR committee, but it’s a Medicare visit that started as inpatient and was changed to observation. Is code 44 used in this scenario?

A: In order to comply with Transmittal 299 and MedLearn Matters instructions for changing the patient's status, the change must be approved by one physician representing the UR committee since the attending physician has already expressed his or her agreement with the change. The hospital would then include Condition Code 44 on the claim form when it bills for outpatient services as though the inpatient admission had not occurred. The patient must be notified of the change prior to discharge. Remember that Condition Code 44 permits the hospital to bill for medically necessary outpatient services that do not necessarily include observation; the Transmittal refers to changing inpatient to outpatient.

Have a tip or tool you’d like to share? Or maybe a question for our experts? E-mail it to editor Julie McGinley at thoughts could be featured in the next issue of Case Management Weekly!

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