National Uniform Billing Committee (NUBC) defines UB04 Condition Codes in its ‘UB-04 Data Specifications Manual 2007’ as codes used to identify conditions or events relating to this bill that may affect processing. The form locators (FL) 18 to 28 are listed as condition codes in the Centre for Medicare and Medicaid Manual System.
The fields in UB-04 are called “Form Locator” and from 18-28 form locators are further divided into situations identified by sub-codes referring the situation. The NUBC lists 99 situations with numeric codes start from 01-99. As an example, the code 01 denotes to the Military Service-Related condition explained as medical conditions incurred during military service.
Use Condition code D1
When changing total charges
Do not uses when adding a modifier because it makes a non-covered charge covered.
Use Condition code D9
Below are suggested remarks to include on the adjustment claim when use condition code D9.
Cost avoid resubmission – indicate reason for primary insurance denial
D9
Claim billed to Medicare as primary insurance and medicare denied as other insurance is primary
other insurance makes payment to provider
Cost avoid resubmission – Name and address of primary insurance
D7
Claim billed to Medicare secondary insurance
other insurance recoups payment
Reason for other insurance recoupment, i.e. WA file termed and date
D8
Assigned by Payer UB 04 Condition Codes
CC Codes
Description of CC
15
Clean claim delayed in CMS’ processing system.
16
Skilled Nursing Facility-SNF transition exemption . An exemption from the post-hospital requirement applies for this SNF stay or the qualifying stay dates are more than 30 days prior to the admission date.
60
Operating cost day outlier.
61
Operating cost outlier which is not reported by provider. Pricer indicates this bill is a cost outlier and MAC indicates the operating cost outlier portion paid in value code 17.
62
PIP bill not reported by providers. Bill was paid under PIP and recorded by system.
63
Bypass CWF edit for incarcerated beneficiaries. Services rendered to a prisoner or a patient in State or local custody (meets requirements of 42 CFR 411.4(b) for payment). Contractor use only.
64
Other than clean claim.
65
Non-PPS bill not reported by providers. MAC records this from system for non-PPS hospital bills.
EY
Lung reduction study demonstration claims, set demo code 30.
M0
All-inclusive rate for outpatient services.
M1
Roster billed influenza virus vaccine or pneumococcal pneumonia vaccine (PPV).
M3
SNF 3 day stay bypass for NG/Pioneer ACD waiver.
MA
Gastroenteritis (GI) bleed (acute comorbid).
MB
Pneumonia (acute comorbid).
MC
Pericarditis (acute comorbid).
MD
Myelodysplastic syndrome (chronic comorbid).
ME
Hereditary hemolytic and sickle cell anemia (chronic comorbid).
MF
Monoclonal gammopathy (chronic comorbid).
MG
Grandfathered Tribal Federally Qualified Health Centers.
MZ
IOCE error code bypass.
Beneficiary or Spouse Insurance and Identifiers
CC Codes
Description of CC
1
Military service related; coordinate with the Department of Veterans Affairs (VA).
2
Patient alleges the medical condition or injury causing this episode of care is due to the employment environment or events (e.g., workers’ compensation, black lung).
3
Patient is covered by an insurance not reflected here.
4
Bill is submitted for informational purposes only.
5
Lien has been filed. The provider has filed legal claim for recovery of funds potentially due to a patient as a result of legal action initiated by or on behalf of a patient.
7
Treatment of a non-terminal condition for a hospice patient. Report this code when the patient has elected hospice care, but the provider is not treating the patient for the terminal condition.
8
Beneficiary would not provide information concerning other insurance coverage. The MAC develops to determine proper payment.
9
Neither the patient nor the spouse is employed.
10
Patient and/or spouse is employed but no Employee Group Health Plan (EGHP) coverage exists.
11
Disabled beneficiary but no Large Group Health Plan (LGHP).
17
Patient is homeless.
18
Maiden name retained.
19
Child retains mother’s maiden name.
21
Billing for denial notice. Provider determined services are at a non-covered level or excluded, but it is requesting a denial notice from Medicare in order to bill Medicaid or other insurers.
22
Patient on Multiple Drug Regimen
23
Home Care Giver Available
24
Home IV Patient Also Receiving HHA Services
25
Patient Is a Non-U.S. Resident
26
Veteran’s Administration (VA) eligible patient chooses to receive services in a Medicare Certified Facility.
28
Patient’s and/or spouse’s EGHP is secondary to Medicare. In response to the Medicare Secondary Payer (MSP) questionnaire, the patient and/or spouse indicated that one or both are employed and that there is group health insurance from an EGHP or other employer-sponsored or provided health insurance that covers the patient but that either: the EGHP is a single employer plan and the employer has fewer than 20 full and part time employees; or the EGHP is a multiple employer plan that elects to pay secondary to Medicare for employees and spouses aged 65 and older for those participating employers who have fewer than 20 employees.
29
Disabled beneficiary and/or family member’s LGHP is secondary to Medicare. In response to the Medicare Secondary Payer (MSP) questionnaire, the patient and/or family member(s) indicated that one or more are employed and there is group health insurance from an LGHP or other employer-sponsored or provided health insurance that covers the patient but that either: the LGHP is a single employer plan and the employer has fewer than 100 full and part time employees; or the LGHP is a multiple employer plan and that all employers participating in the plan have fewer than 100 full and part-time employees.
31
Patient is a student (full time day).
32
Patient is a student (cooperative/work study program).
33
Patient is a student (full-time night).
34
Patient is student (part-time).
45
Ambiguous gender category.
46
Nonavailability statement on file.
48
Identifies claims submitted by a TRICARE-authorized psychiatric RTC for children and adolescents. This code is not required for Medicare billing. However, it is required for TRICARE billing, when applicable. Medicare will accept this condition code to comply with HIPAA transaction code set requirements.
52
Hospice beneficiary moves out of service area, including patients admitted to a hospital that does not have contractual arrangements with the hospice.
67
Beneficiary elects not to use Lifetime Reserve (LTR) days.
68
Beneficiary elects to use LTR days.
77
Provider accepts or is obligated/required due to contractual arrangement or law to accept payment by a primary payer as payment in full
78
Newly covered Medicare service for which an HMO doesn’t pay. For outpatient bills, condition code 04 should be omitted.
H0
Delayed filing, statement of intent submitted within the qualified period to specifically identify the existence of another third party liability situation.
End-Stage Renal Disease and Dialysis- ESRD Condition Codes
CC Codes
Description of CC
6
End Stage Renal Disease (ESRD) patient in the first 30 months of entitlement covered by employer group health insurance. Medicare may be a secondary insurer if the patient is also covered by an employer group health insurance during the patient’s first 30 months of ESRD entitlement.
59
Non-primary ESRD facility. Provider reports this code to indicate the ESRD beneficiary received non-scheduled or emergency dialysis services at a facility other than his/her primary ESRD dialysis facility.
70
Self-administered erythropoetin alpha (EPO). Code indicates the billing is for a home dialysis patient who self-administers EPO or darbopoetin alpha.
71
Full care in unit. The billing is for a patient who received staff-assisted dialysis services in a hospital or renal dialysis facility.
72
Self-Care in unit. The billing is for a patient who managed his/her own dialysis services without staff assistance in a hospital or renal dialysis facility.
73
Self-Care training. The bill is for special dialysis services where a patient and his/her helper (if necessary) were learning to perform dialysis.
74
Billing is for a patient who received dialysis services at home.
75
Billing is for a patient who received dialysis services at home using a dialysis machine that was purchased under the 100 percent payment program.
76
Back-up dialysis in-facility The bill is for a home dialysis patient who received back-up dialysis in a facility.
80
Patient receives dialysis services at home and the patient’s home is a nursing facility.
84
Dialysis for Acute Kidney Injury (AKI) on monthly basis
87
ESRD self care retraining
Hospitalization, Products and Services Condition Codes List
CC Codes
Description of CC
27
Patient referred to a sole community hospital for a diagnostic laboratory test. (Sole Community Hospitals only). The provider uses this code to indicate laboratory service is paid at 62 percent fee schedule rather than 60 percent fee schedule.
30
Non-research services provided to all patients, including managed care enrollees, enrolled in a Qualified Clinical Trial.
40
Same day transfer. The patient was transferred to another participating Medicare provider before midnight on the day of admission.
41
Claim is for partial outpatient hospitalization services which include a variety of psychiatric programs.
42
Continued care plan is not related to the patient’s inpatient admission condition or diagnosis.
43
Continued care not provided within post discharge window
44
Inpatient admission changed to outpatient. –Code used on outpatient claims only, when the physician ordered inpatient services, but upon internal utilization review performed before the claim was originally submitted, the hospital determined that the services did not meet its inpatient criteria. The change in patient status from inpatient to outpatient is made prior to discharge or release while the patient is still a patient of the hospital.
49
Product lifecycle replacement of a product earlier than the anticipated lifecycle due to an indication that the product is not functioning properly.
50
Product replacement for known recall by a Product Manufacturer or FDA.
51
Provider attestation of that services billed are unrelated outpatient non-diagnostic services which should not be bundled into the inpatient hospital claim.
53
The initial placement of a medical device provided as part of a clinical trial or a free sample.
69
Indirect Medical Education (IME)/Direct Graduate Medical Education (DGME)/Nursing and Allied Health (N&AH) payment only billing.
79
Comprehensive Outpatient Rehabilitation Facilities (CORF) services provided off-site. Physical therapy, occupational therapy, or speech pathology services were provided offsite.
98
Data associated with diagnosis-related grouper (DRG) 468 has been validated.
B4
Admission unrelated to discharge on same day
G0
Distinct medical visit. Multiple medical visits/evaluation and management visits occurred on the same day in the same revenue center and the visits were distinct and constituted independent visits. Not reported by CAHs.
List of Condition codes for SNF Services
CC Codes
Description of CC
20
Beneficiary requested billing. Provider determined services are part of a non-covered level of care or excluded, but beneficiary requests determination by payer. (Limited to home health and inpatient SNF claims.)
55
SNF bed is not available. Patient’s SNF admission was delayed more than 30 days after hospital discharge because a SNF bed was not available.
56
Medical appropriateness condition code. Patient’s SNF admission was delayed more than the 30 days after hospital discharge as patient’s condition made it inappropriate to begin active care within that period.
57
SNF readmission when patient previously received Medicare covered SNF care within 30 days of current SNF admission.
58
SNF patient terminated MA Plan enrollment. Providers report this code to waive 3-day qualifying stay requirement.
Rooms/Beds UB 04 Condition Codes List
CC Codes
Description of CC
36
General care patient in a special unit. – (Not used by Prospective Payment System (PPS) hospitals) The hospital temporarily placed the patient in a special care unit because no general care beds were available. Accommodation charges for this period are at the prevalent semi-private rate.
37
Ward accommodation at patient’s request – Not used by PPS Hospitals.
38
Semi-private room is not available. Not used by PPS Hospitals.
39
Private room medically necessary. Not used by PPS Hospitals.
Condition Codes for Special Programs
CC Codes
Description of CC
90
Service provided as part of an Expanded Access approval.
91
Service provided as part of an Emergency Use Authorization.
A0
This code identifies TRICARE claims submitted under the external partnership program.
A1
This code is to be used for services related to early and periodic screening diagnosis and treatment.
A2
Services provided under a program that receives special funding for the handicapped through title VII of the Social Security Act or TRICARE.
A3
Special federal funding.
A4
Family planning.
A5
Disability
A6
Pneumococcal pneumonia and influenza vaccines paid at 100%.
A9
Second opinion for surgery.
AJ
Payer responsible for co-payment.
AN
Preadmission screening not required.
B0
Medicare Coordinated Care Demonstration Program (MCCD).
B1
Beneficiary is ineligible for Full Demonstration Program.
W0
United Mine Workers of America demonstration indicator.
UB 04Condition Codes List for Transport Services
CC Codes
Description of CC
AK
Air ambulance required.
AL
Specialized treatment/bed unavailable.
AM
Non-emergency medically necessary stretcher transport required.
B2
Critical Access Hospital ambulance attestation that it meets criteria for exemption from ambulance fee schedule.
Pregnancy Related UB 04 Condition Codes
CC Codes
Description of CC
81
C-sections or inductions performed at less than 39 weeks gestation for medical necessity.
82
C-sections or inductions performed at less than 39 weeks gestation electively.
83
C-sections or inductions performed at 39 weeks gestation or greater.
AA
Abortion performed due to rape.
AB
Abortion performed due to incest.
AC
Abortion performed due to serious fetal genetic defect, deformity, abnormality0
AD
Abortion performed due to life endangering physical condition caused by, arising from or exacerbated by the pregnancy itself.
AE
Abortion performed due to physical health of mother that is not life endangering.
AF
Abortion performed due to emotional/psychological health of mother.
AG
Abortion performed due to social economic reasons.
AH
Elective abortion.
AI
Sterilization.
B3
Pregnancy indicator.
ClaimReopening Reason Condition Codes:
Condition Codes
Description
R1
This condition code is used when mathematical or computational mistakes happen
R2
R2 CC is used when a claim is submitted with an incorrect info provider number, referring to NPI, DOS, CPT code, etc.
R3
When misapplication of a fee schedule we used R3 CC.
R4
For Computer errors used R4 CC.
R5
R5 CC when duplicate claim denied and the party believes were incorrectly identified as duplicate.
R6
R6 CC for other clerical or typo errors and omissions which not specified in R1-R5.
R7
R7 CC is used when claim correction is required other than clerical errors within one year of the date of the initial determination.
R8
A claim reopening for good cause (1-4 years from the date of the initial determination) due to new and material proof that was not available or known at the time of the determination.
R9
A claim reopening for good cause (1-4 years from the date of initial determination) because the evidence that was considered in making the determination shows that an obvious error was made at the time of the determination initially.
Comorbid Reoccurrence Condition Codes:
CC Codes
Description
H3
Reoccurrence of GI bleed.
H4
Reoccurrence of Pneumonia
H5
Reoccurrence of pericarditis.
Disaster Related Condition Codes:
Condition Codes
Description
BP
Gulf Oil Spill of 2010
DR
Disaster Related
Public Health Reporting Condition Codes:
Condition Codes
Description
P1
P1 CC is used only when reporting public health data required by the state and should not be used for third-party billing purposes
P7
P7 code was created to indicate a direct inpatient admission (IP) from the emergency room for public health reporting purposes. This code is only used when reporting public health data required by the state.
C2 CC is used when automatic approval as billed based on a focused review
C3
C3 CC means partial approval
C4
C4 CC is used when Admission is denied.
C5
C5 CC is used when the post-payment review is applicable
C6
C6 CC was used when pre-admission/pre-procedure was authorized but QIO has not reviewed the services provided.
C7
C7 CC is used when Extended authorization is authorized but QIO has not reviewed the services provided
What are Medicare Condition Codes?
Medicare condition codes (UB04 Condition Codes) are a set of codes used in Medicare billing to provide additional information about the circumstances or conditions surrounding a specific claim. These codes are used to communicate essential details that may affect the payment or processing of the claim. Medicare condition codes are typically included on institutional claims, such as those submitted by hospitals, skilled nursing facilities, and other healthcare providers.
UB 04 condition codes are updated as per guidelines from the National Uniform Billing Committee (NUBC), also updated all information from the authorized source of information.
