Warning from Medicare: Condition Code 44 should not be used as a substitution for inadequate utilization personnel staffing or the need for continuing education for physicians and hospital staff on admission protocols and processes. On the other hand, Condition Code 44 can serve as a reflection that the utilization process is being monitored and that when level of care determinations are found to be incorrect, they are changed and billed compliantly. The goal being this need should become an increasingly rare occurrence.
Questions persist about the proper use of Condition Code 44, making it truly an enigma for utilization professionals. Nonetheless, not much is said about another enigma: Condition Code W2. However, when these codes are used at your facility, they could reflect some deficiencies in your facility’s utilization review process, and could, therefore, result in loss of appropriate reimbursement for services your facility has provided.
The good news: During this RACmonitor webcast, Dr. John Zelem, a former surgeon, and physician advisor, will help you and your team understand the difference between Condition Code 44 and Condition Code W2, how and who can change the level of care order, plus how and when to utilize a physician advisor, the attending, and the UR committee to comply with the Conditions of Participation. Furthermore, he’ll explain how to improve existing processes to decrease incidences of Condition Code 44 and avoid the need for the utilization of Condition Code W2 at your facility to reduce the risk of audit and loss of appropriate reimbursement.
Why This is Relevant:
To maintain compliance, potentially reduce the risk of audit, and prevent a loss of reimbursement, it is essential to understand the proper usage of Condition Codes 44 and W2, and how to improve your facility’s existing utilization review process to decrease the need to use these billing codes at all.
Learning Objectives:
- Learn the role of the physician advisor in determining level of care, the attending in the downgrade, and the UR committee in the finalization of Condition Code 44 and Condition Code W2
- Learn about the timing requirements for use of Condition Code 44 and Condition Code W2
- Learn the differences in how Condition Code 44 and Condition Code W2 are billed
- Find out how to improve existing processes to decrease incidences of Condition Code 44 and avoid the need for utilization of Condition Code W2
- Find out who is and potentially will be tracking and monitoring the incidence of Condition Code 44
Who Should Attend:
Utilization review professionals; Case managers and case management professionals; physicians, physician advisors, revenue integrity professionals; finance; compliance and quality professionals.
John Zelem, MD, FACS
John Zelem, MD, is principal owner and chief executive officer of Streamline Solutions Consulting, Inc. providing technology-enabled, expert physician advisor services. A board-certified general surgeon with more than 26 years of clinical experience, Dr. Zelem managed quality assessment and improvement as a former executive medical director in the past. He developed expertise in compliance, contracts and regulations, utilization review, case management, client relations, physician advisor programs, and physician education. Dr. Zelem is a member of the RACmonitor editorial board.
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August 26, 2021 at 08:30AM
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Condition Code 44 vs. Condition Code W2: Understand When and How to Use Both - RACmonitor
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