Q&A: Using condition code 44

Q: What are Medicare's requirements for applying condition code 44 to a claim?

A: If the determination that an admission is not medically necessary is made prior to the patient’s discharge, the hospital may convert that patient to an outpatient using the condition code 44 process. Claims must meet the following requirements to be submitted with condition code 44:

• The determination and change in status is made while the patient is still in the hospital
• The patient is notified of the determination prior to discharge
• The attending physician concurs with the UR committee’s decision
• The physician’s concurrence is documented in the medical record

If all conditions for application of condition code 44 are met, hospitals should submit an outpatient claim (Type of Bill (TOB) 013X).

For more information, see the Patient Status Training Toolkit for Medicare Utilization Review, Second Edition.