Q&A: Condition Code 44 Processes

October 25, 2016
Medicare Web

Q: What are the requirements for compliantly using condition code 44 to change a patient’s status?

A: In order to apply condition code 44, the process first begins with a determination by a physician representative of the utilization review committee. This determination must be compliant with the Conditions of Participation. This may be facilitated by a utilization review (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

There must be an order to change the status to outpatient, which will generally include an order for observation if the physician plans to continue to treat the patient at the hospital.

A written notice must be provided to the patient prior to his or her discharge from the hospital.

For more information, refer to the Condition Codes 44 and W2 Training Handbook.

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