General Question for the Week of February 22, 2016

General Compliance Question of the Week


Are there Medicare guidelines related to whether an outpatient can be admitted to the hospital?


Section 50.3.1 of chapter 1 in the Medicare Claims Processing Manual states the following. Per the hospital conditions of participation (CoP), patients are admitted to the hospital or critical access hospital as inpatients only on the recommendation of a physician or licensed practitioner permitted by the state to admit patients to a hospital. In some instances, a practitioner may order a beneficiary to be admitted as an inpatient, but upon reviewing the case, the hospital’s utilization review (UR) committee determines that an inpatient level of care is not medically necessary. 

The National Uniform Billing Committee (NUBC) developed condition code 44, which took effect on April 1, 2004, to report inpatient admissions that changed to outpatient. For use on outpatient claims only, when the physician ordered inpatient services, but upon internal UR performed before the claim was originally submitted, the hospital determined that the services did not meet its inpatient criteria.

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.