Action Alerts

Condition Code 44, to be Implemented October 12, 2004
Condition Code 44 - Inpatient Admission Changed to Outpatient
September 2004

Condition code 44 (effective April 1, 2004) is to be used on outpatient claims only when the physician has ordered inpatient services but upon internal utilization review performed before the claim is originally submitted, the hospital has determined that the service did not meet inpatient criteria.

The hospital may submit condition code 44 in FL 24-30 on an outpatient claim (TOB 13x, 85x) for medically necessary Part B services provided to a Medicare beneficiary, provided all of the following conditions are met:

1. The change in patient status from inpatient to outpatient is made prior to discharge or release, while the beneficiary is still a patient of the hospital;
2. The hospital has not submitted a claim to Medicare for the inpatient admission;
3. A physician concurs with the utilization review committee’s decision; and,
4. The physician’s concurrence with the utilization review committee’s decision is documented in the patient’s medical record.

See Transmittal 299, published September 10, 2004.