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Medicare Compliance & Reimbursement

HOSPITALS:

Once An Inpatient, Not Always An Inpatient

Published on Wed Oct 27, 2004

Know your patient's status with new condition code.

Here's the deal: The physician admits a 71-year-old woman to an inpatient bed. But later the hospital utilization committee reviews the case and decides that the patient's care hasn't met the facility's requirements for inpatient admission. Should you bill the services as inpatient?

No, according to a recent CMS transmittal - bill the services as outpatient. The agency has come up with a new condition code to describe this sticky situation: 44 (Inpatient admission changed to outpatient). You'll report this code on outpatient claims with bill types 13x or 85x.

The catch: Make sure your services meet the following conditions if you decide to report condition code 44:

  • You make the change to outpatient status before discharge or release - while the patient is still receiving hospital services;

  • You haven't already submitted a claim for inpatient admission;

  • A doctor agrees with the utilization review committee's decision; and

  • You've documented the physician's agreement in the patient's medical record.

    Once the situation meets these criteria, you should treat the episode of care as if it were outpatient the entire time, CMS says. Make sure you use qualifier BG on claims with condition code 44.

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