Revenue Cycle

CAHs and condition code 44

Medicare Update for CAHs, September 21, 2011

The October 2011 update of the hospital outpatient prospective payment system (OPPS) contains a bit of guidance for critical access hospitals that might otherwise go unnoticed.

Within CMS transmittal R2296CP is a clarification to the condition code 44 policy. Condition code 44 is when a patient’s status may be changed from inpatient to outpatient under certain circumstances. For quite some time, condition code 44 has been an issue that has plagued providers with headaches, which has led to a number of similar situations in which CMS is required to release additional guidance.

The instruction states that 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. Of particular interest to critical access hospitals, however, is the clarification that states that condition code 44 policies do in fact apply to CAHs.

CAHs have unique staffing issues, including recruitment of a medical staff that is appropriate to their volume of patients that they treat. Some CAHs are small enough that just meeting the Medicare Conditions of Participation to have two physicians on their utilization review committee is a struggle in itself, says Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc.

“CAHs need to be aware that if they are going to use condition code 44, they must involve at least one of the utilization review committee physicians in addition to the attending physician to make the determination that the patient would be more appropriate as an outpatient instead of an inpatient,” she says.

She continues, “If CAHs are using their case management nurses and the attending physician to make a decision to “roll back” the patient’s status from an inpatient to an outpatient, they are not meeting CC44 requirements and should be billing limited services under Type of Bill 121.”


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