Condition Code 44 and its Compliant ExecutionDr. Maria Johar, MBA 92 year old independent lady who lives alone in a rural area is brought in by her granddaughter, who is a nurse, for persistent tachycardia and disorientation with difficulty following commands. She has persistent alteration in mental status, a heart rate of 160- 190 which has remained elevated in the ED. ECG in the ED is interpreted as possible WPW syndrome. Cardiology is consulted; they determine IV meds and aggressive care is required for the new symptoms. Pt arrived at the first hospital on 1/31/2022 at 9:30 pm. Pt has an inpatient order placed at 2/1/ 2022 at 1:30 am. IMM signed by granddaughter. Pt was being treated but due to persistent atrial fib in the setting of WPW and documented change in mental status the cardiologist suggests a transfer for the patient to another hospital with ICU and interventional cardiology capabilities. The patient is picked up by the ambulance on 2/2 at 10 am. Insurance: Traditional Medicare Pt arrives at the tertiary hospital on 2/2/2022 at noon with persistent atrial fib, iv meds and intermittent confusion and lethargy. Hospitalist admits as inpatient, IMM is signed again, and a very concerned granddaughter is aware her grandmother is an inpatient and will probably need ongoing care. Cardiology recommends an intervention. Patient is awaiting transfer to the cath lab. On 2/3, a new hospitalist (who has recently undergone UM training and is a new student of the 2 midnight rule) reviews the record and reads that patient is feeling better and has converted back to sinus rhythm and become more lucid and after speaking with the cardiologist again has decided she is not interested in an intervention and decides she wants to go home. The hospital is full and the RN granddaughter agrees to honor her grandmother’s wishes and will be able to stay with her at her home. The doctor decides to discharge the patient per her wishes later that evening once he has communicated with cardiology. Then he realizes she was in his hospital for only one midnight and changes the order to Observation. He wants to put his new knowledge into practice and be compliant with Medicare rules. This change in status causes the overworked Utilization Nurse to stress out and call on the friendly physician advisor immediately. The physician advisor reviews the case and disagrees regarding the change to observation status. The physician advisor wants to call the attending regarding status change, but the physician is unavailable, he is working the covid unit and missed the call. The attending places a discharge order at 4:30 pm on 2/3/2022. The anxious granddaughter wants to drive the patient home by car as soon as the discharge papers are done due to the long drive home and needs to pick up supplies. The Utilization Nurse and case manager are now firmly planted in the physician advisor’s office, do they give the MOON or not? Do they inform the granddaughter and patient that now the patient has no appeal rights etc.? Physician advisor Dr. Calmly Confident explains to the Utilization Nurse that the patient is still inpatient appropriate due to Medicare rules. Condition Code 44 is not applicable. The case manager is concerned she needs to get the right paperwork done or it will be counted against her by her manager as a “failed cc44.” The attending physician has gone for the day, the new on call hospitalist says “I do not know the patient, my colleague has already done a discharge summary and signed off, I am no longer involved in the care of this discharged pt.” While all this is going on the patient leaves the building with her family. Questions: UR = Is this an observation case? Biller = how are we billing this claim? Billing auditor = the last order is observation so are we billing observation? CDI = is this an inpatient or observation and who is going to follow up on the query placed for malnutrition, BMI 16.5 but not clarified? Coder = is this to be sent to the inpatient or outpatient coder? Answers: Dr Calmly Confident explains to the staff, while the order is valid both for the intervention planned and the observation, both are immaterial. Patient will remain an inpatient. Just like we cannot bill for the valid interventional procedure that was never performed, we will not bill for the observation services. We provided valid inpatient care due to
Physician advisor makes an appointment to go over the case at the next departmental meeting as well as having a conversation with the attending next day. UM committee would also be notified for further discussion as they do go over monthly condition code 44 and failed condition code 44 (part b billing) on a regular basis. Please audit your cc44 cases, ensure the process is compliant, they should be rare and unusual as well as part of your UM committee agenda. |