HFM: Utilization Review Hurting Results Fixing Inpatient Admissions

Dr. Ronald HirschJune 13, 2022

Nurse wearing mask folding her arms

Since 2004, the Centers for Medicare and Medicaid Services (CMS) has allowed hospitals to change the status of a patient who was improperly admitted as an inpatient to outpatient by following a process commonly known as Condition Code 44. Successful completion of this process allows the hospital to submit an outpatient claim and receive payment for almost all services.


The process is not simple; it does require a physician member of a utilization review (UR) committee to review the case, the attending must agree to the change and all parties must be notified in writing. Not only are there several steps, but it is also time-sensitive, as it must be completed prior to the patient’s discharge.


In 2013, CMS began to allow hospitals to complete a very similar process retrospectively after discharge where the hospital can get paid under Medicare Part B for eligible services when it is determined the patient should not have been admitted as an inpatient. This process is commonly called the self-denial/rebill process. While the self-denial/rebill process is similar to the Condition Code 44 process, there are significant differences that must be considered, especially by hospital financial services staff.


Read the full article here.

Author Bio: Dr. Ronald Hirsch is Vice President of the Regulations and Education Group at R1 RCM Inc. Dr. Hirsch was a general internist and HIV specialist and practiced at Signature Medical Associates, a multispecialty practice located in Elgin, IL. He was Medical Director of Case Management at Sherman Hospital in Elgin, IL from 2006 to 2012, where he was Chairman of the Medical Records Committee from 1995 to 2012, and also served on the Medical Executive Committee. Dr. Hirsch is certified in Health Care Quality and Management by the American Board of Quality Assurance and Utilization Review Physicians, certified in Revenue Integrity by the National Association of Healthcare Revenue Integrity, and on the Advisory Board of the American College of Physician Advisors. He is on the editorial board of RACmonitor.com. He is the co-author of The Hospital Guide to Contemporary Utilization Review, with the third edition published in 2021.