Updated on: August 17, 2018

Condition 44: Confusion is Prevalent

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Original story posted on: August 15, 2018

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Condition 44 is one of three perplexing issues reviewed by the author.

 Last week was a boring regulatory week, other than the continuing talk about the proposed changes to evaluation and management (E&M) coding. That continues to dominate discussions, with ongoing negativity by the physician community.

Without new regulatory controversy, it’s hard to find topics to discuss. But last Saturday I was honored to be in Atlanta speaking at a case management conference, when several topics of discussion led me to produce a series of articles titled “Back to Basics.” So here are four topics for your review:

No. 1:

The condition code 44 process of changing an inpatient to an outpatient always requires involvement of a physician member of the utilization review (UR) committee, even if an attending physician is changing his or her own order. That UR committee physician must be on the hospital medical staff and have voting privileges. A physician working for an external physician advisory company can suggest that an inpatient admission was not proper, and that the patient’s status should be changed to outpatient, but their advice is only a suggestion. You still must consult a UR committee physician.

No. 2:

The condition code 44 process is required for every change from inpatient to outpatient if the patient has been formally admitted as an inpatient. There is a lot of ambiguity here, but an order for inpatient admission does not constitute formal admission; it is the process of formally admitting the patient that makes them an inpatient. So that does leave some wiggle room. If a physician enters an inpatient admission order but the patient is not yet formally admitted, the inpatient order can simply be cancelled without the condition code 44 process.

So the questions to ask are this: did anyone act on that admission order to formally admit the patient? Did registration come visit the patient? Was the Important Message from Medicare (IMM) given? Did the patient leave the ED? If the answers are no, no, no, and no, I think it’s safe to say the patient probably was not formally admitted. It’s tricky, though, because the time the order is placed is used to count days for skilled nursing facility (SNF) qualification, so shouldn’t that also be the start of the formal admission and therefore require a condition code 44? Well, until the Centers for Medicare & Medicaid Services (CMS) actually defines what constitutes a formal admission, I am going to say this is one place we can have our cake and eat it too.

No. 3:

The self-denial process, which CMS allowed as part of the two-midnight rule starting in October 2013, requires review of each case by a physician member of the UR committee if you are going to self-deny an inpatient admission.

It is appropriate to have any utilization review staff screen all potential cases and determine that the requirements to bill the inpatient admission are present, but once the decision is made to actually self-deny, you must follow the full process as outlined in 42 CFR 482.30(d). And as with condition code 44, which also follows 42 CFR 482.30, this physician must be a voting member of the medical staff. Once again, an external company or non-staff physician can help screen cases, but their opinions are only suggestions with no formal weight.

No. 4:

Delivering the follow-up copy of the IMM is difficult. Predicting when a patient is going to be discharged can often be a challenge.

To reduce this burden, some hospitals have a process through which every Medicare and Medicare Advantage patient is given a copy of their initial IMM on Mondays, Wednesdays, and Fridays. If you are with one of those hospitals, stop. It is not permitted.

The follow-up copy can only be given if discharge is anticipated. If you have to deliver it on the day of discharge, that is permitted, but you need to offer the patient four hours to decide if they want to appeal. But don’t chain them to the bed for those four hours; they can choose to leave earlier. And remember, if the patient is discharged within two calendar days of receiving the initial copy, you are not required to provide a follow-up copy.

There are a lot more basics to review. If we have another quiet week on the regulation front, I’ll share some more.

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Ronald Hirsch, MD, FACP, CHCQM

Ronald Hirsch, MD, FACP, CHCQM is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays.

The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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