Suscríbete a eNews Contacta con nosotras / IVR

Status Change: Inpatient to Outpatient

In some instances, patients are admitted as hospital inpatients, but upon review it is determined that the patient does not meet inpatient criteria. If the determination occurs prior to discharge, and other criteria are met, the status may be changed to outpatient. If the criteria are not met, the status must remain inpatient.

Condition Code 44

When a physician orders an inpatient admission, but the hospital's utilization review committee determines that the level of care does not meet admission criteria, the hospital may change the status to outpatient only when certain criteria are met.

Providers should use this code on outpatient claims only.

The change from inpatient to outpatient is met when all of the following conditions are met:

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

Utilization Review Committee Requirements

Two or more practitioners must carry out the utilization review (UR) function. At least two members must be doctors of medicine or osteopathy.

The determination that an admission or continued stay is not medically necessary must either be made by:

  • One member of the UR committee, if the practitioner(s) responsible for the care of the patient either concurs with the determination or fails to present their views when afforded the opportunity, or
  • Two members of the UR committee in all other cases

The UR committee must consult with the practitioner(s) responsible for the care of the patient and allow them to present their views before making the determination.

If the UR committee determines that the admission is not medically necessary, the committee must give written notification, no later than 2 days after the determination, to the hospital, the patient, and the practitioner responsible for the care of the patient.

When an inpatient admission is changed to outpatient status, the change must be documented in the medical record along with:

  • Orders and notes that indicate why the change was made
  • The care that was furnished
  • The participants in making the decision to change the status

Condition Code 44 Criteria Met

If all criteria for changing the status from inpatient to outpatient are met, bill the entire claim as though the inpatient admission never occurred as follows:

  • Report type of bill (TOB) 13X or 85X (critical access hospital)
  • Report condition code 44
  • Include all charges for services furnished per a physician's order

Condition Code 44 Criteria Not Met

If the determination that the inpatient admission did not meet admission criteria was not made until after the patient has been discharged, or other criteria for use of condition code 44 is not met, or if the admission is denied due to lack of medical necessity, Medicare may still make payment for certain Part B services under inpatient Part B benefits, TOB 12X.

Billing Acute Inpatient Non-covered Provider Liable Days

If all criteria for changing the status from inpatient to outpatient are not met, bill the entire stay as a provider liable non-covered claim as follows:

  • Report TOB 110
  • Report occurrence span code M1 (Do not include discharge date)
  • Total units equal total number of days billed
  • Non-covered units equal total days
  • Total charge equals rate X total units
  • Non-covered charges equal rate X number of non-covered days
  • Add a brief, clear and concise explanation for filing a no payment claim in Remarks

Once this claim finalizes, you may submit a Part B inpatient ancillary claim for covered ancillary services on TOB 12X.

Billing Acute Partial Inpatient Non-covered Provider Liable Days

When a portion of an inpatient acute care stay is non-covered, bill part of the claim as non-covered and part of the stay in which the patient received medically necessary services as covered, as follows:

  • Report TOB 11X
  • Report medically necessary services as covered
  • Report not medically necessary provider liable services as non-covered
  • Report occurrence span code M1 with the first provider liable day through the last provider liable day (Do not include the discharge date)
  • Total units equal total number of days billed
  • Covered units equal total days minus non-covered days
  • Total charge equals rate X total number of units
  • Non-covered charges equal rate X number of non-covered days
  • Add a brief, clear and concise explanation for filing a no payment claim in Remarks

Once this claim finalizes, you may submit a claim an inpatient Part B ancillary claim for covered Part B services furnished during the provider liable period on TOB 12X.

Sequential Billing

Claim must be billed in sequential order. Each claim must process before submitting the next claim in the sequence. Claims billed out of sequence will be returned to you for correction.

Bill the fully non-covered (110) or partially non-covered claim (11X) claim first.

Once the 110/11X claim processes, submit the Part B ancillary claim, 12X.

Once the 12X processes, submit the outpatient claim, 13X.

 

Reference

  • CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 50.3
    •