Inpatient Facility Coding & Compliance Alert

Question: What is condition code 44 and how what are the guidelines to apply it for patients?

Kansas Subscriber

Answer: Condition Code 44 is used to switch an inpatient admission to outpatient under certain circumstances. The only trick for Medicare is that the patient must still be in the hospital. If you get the patient admitted as an inpatient and then decide during the course of stay that the patient rather needs to be classified as outpatient observation, then Condition Code 44 is the vehicle by which you are going to get that done. However, this provision is not to be frequently resorted to.

The Federal Register on Condition Code 44 says: “As we stated for the Condition Code 44 policy (MCPM, Chapter 1, Section 50.3.1), changes in patient status from inpatient to outpatient should be few because hospitals should have case management and other staff available at all times to assist the physician in making the appropriate initial admission decision. Use of Condition Code 44 or Part B inpatient billing pursuant to hospital self-audit is not intended to serve as a substitute for adequate staffing of utilization management personnel or for continued education of physicians and hospital staff about each hospital’s existing policies and admission protocols. As education and staffing efforts continue to progress, inappropriate admission decisions, and the need for hospitals to correct inappropriate admissions or report Condition Code 44, should become increasingly rare.” (78 FR 50914).