Daily Q&A: Condition Code 44

Q: Does the concurrence of the attending physician, that is required for condition code 44, need to be recorded by the attending physician, or can another practitioner write the concurrence on behalf of the attending? For example, could a case manager document that they spoke to the attending and he or she agrees with the change in status?

A: The requirement for concurrence by the attending physician comes from the Condition of Participation (CoP) for utilization review (42 CFR 482.30(d)). Neither the CoP nor the interpretive guidelines specify how this concurrence should be documented. There is also an MLN Matters article  that discusses the requirements for condition code 44, and it is also silent on how to document the concurrence. It states that the concurrence must be "fully documented" in the medical record, and mentions orders and notes indicating why the change was made and the participants in the decision.

With this in mind, I would expect that the case management or UR nurse's notes with the information on how the decision was made and the UR physician involved would document the determination process. As for the concurrence, I have always considered the change in order by the attending, the documentation of the concurrence of the attending. The physician is documenting a new observation or outpatient order for the services, reflecting that they agree the services should be changed to outpatient or outpatient with observation. Ideally, they would also mention the change in their progress notes, but I'm not sure that is necessary, especially if the case manager or UR nurse's notes contain all the information required for the determination and application of condition code 44.

This Q&A was answered by Kimberly Anderwood Hoy Baker, JD, regulatory specialist for HCPro.  

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