Q&A: Condition code 44 process

Q: What are the requirements for using condition code 44?

A: In order to apply condition code 44, the process first begins with a determination by a physician representative of the utilization review (UR) committee. This determination must be compliant with the Conditions of Participation (CoP) for UR. This may be facilitated by a UR nurse or case manager. This determination should be documented either in the UR committee’s records or in the medical record of the patient.

CMS has four requirements for a compliant condition code 44 process:

• The attending physician must agree with the UR committee’s determination
• The attending physician’s concurrence is documented in the medical record
• The patient must still be a patient in the hospital
• The hospital cannot have already billed for the stay

For more information, see Medicare Compliance Essentials Training Compendium.

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