Condition Code 44

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Condition Code 44

• Empire Medicare Services Provider Outreach
  Education

EMPIRE MEDICARE SERVICES A Division of Empire
HealthChoice Assurance, Inc., a CMS-Contracted
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http//www.cms.hhs.gov
PET1109 (11/06)
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Condition Code 44 - Defined

• For use when inpatient admission changed to
  outpatient
• For use on outpatient claims only when physician
  ordered inpatient services
• Upon internal utilization review, hospital
  determined services did not meet its inpatient
  criteria
• Performed before inpatient claim was initially
  submitted

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UR Committee

• All hospitals are required to have a utilization
  review (UR) plan
• A UR committee consists of two or more
  practitioners at least two must be doctors of
  medicine or osteopathy
• Other members may be any other type of
  practitioners

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UR Committee

• The determination that an admission is not
  medically necessary can be made
• By either one member of UR committee if physician
  concurs or fails to present a view, or
• Two members of the UR committee in all other
  cases

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UR Committee

• UR committee must consult with practitioner
• Allow views to be presented before making
  determination
• If UR committee determines that admission is not
  medically necessary
• Give written notification no later than two days
  after determination
• To hospital, patient, and the practitioner

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Condition Code 44 - Policy

• Hospital Utilization Review Committee (URC)
  determines inpatient admission does not meet
  hospital inpatient criteria
• Hospital may change beneficiarys status from
  inpatient to outpatient
• Submit an outpatient claim for medically
  necessary outpatient services

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Condition Code 44

• Following conditions must be met
• Patient status from inpatient to outpatient is
  made prior to discharge
• Beneficiary is still a patient of hospital
• Inpatient claim has not been submitted
• Physician concurs with URC decision
• Physician concurrence with URC committees
  decision
• Documented in medical record

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Condition Code 44

• If all conditions are met
• Submit an outpatient claim
• All medically necessary outpatient services
• Bill type 13x
• Condition code 44
• Note Entire episode of care should be treated as
  though inpatient admission never occurred

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References

• PUB 100-4, Chapter 1, section 50.3
• MLN Matters SE0622- Clarification of Medicare
  Payment Policy when inpatient admissions is
  determined not to be medically necessary,
  including the use of condition code 44 Inpatient
  admission changed to outpatient

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National Provider Identifier (NPI)

• Providers required by law to apply for NPI
• Include your legacy identifiers when applying
• Must have by 05/23/2007
• CMS page for NPI news and educational products
  (articles, fact sheets and NPI viewlet)
• http//www.cms.hhs.gov/NationalProvidentStand/
• Online NPI application tool
• https//nppes.cms.hhs.gov
• To request paper application
• Call 1-800-465-3203

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Provider Inquiries
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