Indian serious male doctor in clinic uses cell mobile apps and laptop computer.

Your health system should define your own standard for infrequency. 

EDITOR’S NOTE: For valuable context to this article, the author suggests the Dr. Juliet Ugarte Hopkins article “Deconstructing the Concept of Condition Code 44,” which includes a complete history and best model approach to the Condition Code 44 process.  

In September 2011, the Centers for Medicare & Medicaid Services (CMS) provided some light reading and clarification to the Condition Code 44 process in the Medicare Claims Process Manual, Chapter 1, General Billing Requirements. Specifically, CMS emphasized that Condition Code 44 should only be utilized during “infrequent occasions, (such) as a late-night weekend admission when no case manager is on duty to offer guidance when internal review subsequently determines that an inpatient admission does not meet hospital criteria and that the patient would have been registered as an outpatient under ordinary circumstances.”   

We are informed that although in no way should non-physicians make the final determination of admission, a case manager, as referenced by CMS (which is really the utilization review specialist), should “facilitate the application of hospital admission protocols and criteria, to facilitate communication between practitioners and the UR (utilization review) committee or Quality Improvement Organization (QIO), and to assist the UR committee in the decision-making process.” They went on to drill the point home, that use of Condition Code 44 is “not intended to serve as a substitute for adequate staffing of utilization management personnel or for continued education of physicians … (and) as education and staffing efforts continue to progress, the need for hospitals to correct inappropriate admissions and to report Condition Code 44 should become increasingly rare.”

CMS states its intentions of the triple aim of the right place, right time, and right care; however, it is understandable that sometimes hospitals do not have the staffing or needed up-front information to create the optimal environment for 100 percent level-of-care accuracy. Thus the allowance of Condition Code 44 to correct patient status prior to a discharge being effectuated. 

How can health systems optimize a process, now understanding that Condition Code 44 should be a rare occurrence?

Frequency of this code is often a metric for care management departments, and it typically appears on UR committee agendas. Many hospitals will report it as a monthly trend line that goes up and down for display and reporting. The UR committee members typically review this information, and depending on meeting engagement or attendance, they may struggle with the concept of relevance. They may not know if the number should go up or down; they may not even know what a Condition Code 44 is, or why it is being reported. So, if we know the answer is that these codes should be rare, then your health system should define your own standard for infrequency.

For the average hospital (around 250-300 beds), pull a baseline, and hopefully your number is less than 10 in a month – ideally, more like one a week. Then look at your processes.  Rather than report the trend, discuss in the UR committee a plan of action and intention for improvement from a utilization management strategy. Your goal is to determine: how can the hospital achieve the correct level of care upon admission? What was missed that led to a Condition Code 44? Was it because of staffing, lack of documentation, physician education, lack of patient information, or a difficult diagnosis to articulate the plan of care? Then, find the pattern and implement change. Data is meaningless if it does not create conversation, action, and movement to adjust results. 

If you have a high number of Condition Code 44s, then you probably have a back-end utilization review process. This means the head is in the bed, and then the UR specialist reworks the chart to figure out what the attending did and query him or her via texts and phone calls to say, “you did it wrong and we need to change the status.” Then, if the doctor says “fine,” you apply the Condition Code 44 process. 

An alternative approach to improve this scenario may be the following:

  • Move as much of the back work to the front as possible. A UR specialist goes in the ED and manages all points of entry as a gatekeeper to assist the admitting docs with the support needed. When peer-to-peer correspondence is beneficial, pull in your trusty friend, the physician advisor. Hopefully, UR understands their role in the organization, because it is key to not just move the staff, but empower the critical thinking and physician partnership required for success.
  • Collect baseline data on Condition Code 44s and audit the charts. Assume that this number can decrease. You will want to look for patterns: time of day, diagnosis, physician, payer, etc.
  • Utilize these same chart audits as case reviews to be presented by your physician advisor as lunch-and-learns to the hospitalist group or med staff.
  • Put this information together to report on appropriate Condition Code 44s as preventions of self-denials…success. And break down your opportunities for improvement.
  • Then work with a small multidisciplinary team, such as your physician advisor, care coordination/care management, clinical documentation improvement (CDI), utilization review, and your physician champion to help impact a prevention strategy. 
  • Report the impact of your prevention strategy through a decrease in your Condition Code 44 process back to your UR committee. UR committee notes and information should funnel up to the medical executive council to highlight successes and continued opportunities.
  • Rinse and repeat!

Thankfully, Condition Code 44s exist to allow hospitals to adjust patient status and inform the patient prior to discharge. CMS clearly articulates that Condition Code 44s should be a rare occurrence to correct patient status. They should be evaluated, with each event being internally audited to determine opportunities for prevention. The data collected can then encompass a comprehensive plan to ensure a mission for patients to receive the appropriate level of care that is medically necessary at time of admission.

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