05/03/12 Condition Code 44 Teleconference Handout - WPS Medicare

Condition Code 44 Teleconference
May 22, 2012
Inpatient Admission Changed to Outpatient
Physician orders beneficiary to be admitted as inpatient
Upon review, hospital UR committee determines inpatient LOC does not meet
hospital’s admission criteria
UR Committee Determination
Prior to making determination, UR committee must:
o Consult with practitioner(s) responsible for patient’s care
o Afford practitioner(s) opportunity to present their views to committee
Who Makes Determination
Determination that admission is not medically necessary may be made by:
o One member of UR committee if practitioner(s) responsible for patient care:
• Concur with determination; or
• Fail to present their views when afforded the opportunity
o Two members in all other cases
Who May Not Make Determination
Any individual with direct financial interest in hospital
Any individual who was professionally involved in patient’s care whose case is being
reviewed
Any case manager/utilization review staff manager with no license from state to
admit patients to a hospital
o However, hospitals expected and encouraged to employ case management staff
A non-physician may never make final determination
Required Procedures Once Determination Made
After UR committee determines inpatient LOC does not meet hospital’s admission
criteria:
o Written notice from UR committee no later than two days after determination
made
o Notice to patient, hospital, practitioner(s) responsible for patient’s care
Created 03/30/2012 1
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Use of Condition Code 44
May use condition code 44 if all conditions are met:
o Status change prior to discharge/release
• Beneficiary must be notified prior to discharge
o No inpatient claim submitted
o Practitioner(s) responsible for patient’s care and UR committee concur with
decision
o Concurrence documented in medical record
How to Bill Condition Code 44
Submit outpatient claim
o TOB 13x or 85x
Condition code 44
Do not split bill
o All services provided during stay reported on one claim
Observation Services
Physician’s order for observation services required in order to bill for observation
services
o Not appropriate to bill for observation services from the inpatient hospital admit
date
• May bill Part B services provided
o Observation services may be billed once a physician’s order is received
How to Bill When Condition Code 44 May Not be Used
Submit inpatient Part B claim
o TOB 12x
No condition code 44
Services eligible for coverage paid under Part B
o CMS Internet-Only Manual (IOM), Publication 100-02, Medicare Benefit Policy
Manual, Chapter 6, Section 10
References
Condition Code 44
o CMS Internet-Only Manual (IOM), Publication 100-04, Medicare Claims
Processing Manual, Chapter 1, Section 50.3
o Medicare Learning Network (MLN) Special Edition article SE0622
UR committee composition and review process
o 42 Code of Federal Regulations (CFR) Section 482.30
Observation services and physician’s order
o CMS IOM, Publication 100-04, Chapter 4, Section 290.2.2
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