List of UB 04 Condition Codes in Hospital Billing(2021)

National Uniform Billing Committee (NUBC) defines UB 04 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.

After table

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.

  • Not related to workers comp
  • Not related to auto
  • Not related to liability
  • Added KX modifier
  • Corrected value codes
  • Adding diagnosis code
  • Added modifier

Adjustment/Corrected Claim Condition Codes UB04

Medicare Condition Codes UB 04

CC CodesDescription of CC
D0Changes to service dates (When  only changing the admission date Use condition code D9.)
D1Use when changes to charges
D2Use when changes to revenue codes, HCPCs / HIPPS rate code
D3Use when second or subsequent interim PPS bill
D4Use when changes in diagnosis or procedure code
D5Use when cancel to correct Medicare Beneficiary ID number or provider ID
D6Use when cancel only to repay a duplicate or OIG overpayment
D7Use change to make Medicare the secondary payer
D8Use when change to make Medicare the primary payer
D9Use for any other change
E0Use when change in patient status

Condition Code Guidelines for D7, D8 and D9

IfAndRemarksUse CC
Claim billed to Medicare as primary insurance and  medicare denied as  other insurance is primaryCWF is updatedCost avoid resubmission – MSP file updated Medicare primaryD9
primary insurance deniedCost avoid resubmission – indicate reason for primary insurance denialD9
Claim billed to Medicare as primary insurance and  medicare denied as  other insurance is primaryother insurance makes payment to providerCost avoid resubmission – Name and address of primary insuranceD7
Claim billed to Medicare secondary insuranceother insurance recoups paymentReason for other insurance recoupment, i.e. WA file termed and dateD8

Assigned by Payer UB 04 Condition Codes

CC CodesDescription of CC
15Clean claim delayed in CMS’ processing system. 
16Skilled 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.
60Operating cost day outlier. 
61Operating 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.
62PIP bill not reported by providers. Bill was paid under PIP and recorded by system.
63Bypass 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.
64Other than clean claim.
65Non-PPS bill not reported by providers. MAC records this from system for non-PPS hospital bills.
EYLung reduction study demonstration claims, set demo code 30.
M0All-inclusive rate for outpatient services.
M1Roster billed influenza virus vaccine or pneumococcal pneumonia vaccine (PPV).
M3SNF 3 day stay bypass for NG/Pioneer ACD waiver.
MAGastroenteritis (GI) bleed (acute comorbid).
MBPneumonia (acute comorbid).
MCPericarditis (acute comorbid).
MDMyelodysplastic syndrome (chronic comorbid).
MEHereditary hemolytic and sickle cell anemia (chronic comorbid).
MFMonoclonal gammopathy (chronic comorbid).
MGGrandfathered Tribal Federally Qualified Health Centers.
MZIOCE error code bypass.

Beneficiary or Spouse Insurance and Identifiers

CC CodesDescription of CC
1Military service related; coordinate with the Department of Veterans Affairs (VA). 
2Patient 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).
3Patient is covered by an insurance not reflected here.
4Bill is submitted for informational purposes only.
5Lien 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.
7Treatment 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.
8Beneficiary would not provide information concerning other insurance coverage. The MAC develops to determine proper payment.
9Neither the patient nor the spouse is employed.
10Patient and/or spouse is employed but no Employee Group Health Plan (EGHP) coverage exists.
11Disabled beneficiary but no Large Group Health Plan (LGHP).
17Patient is homeless.
18Maiden name retained.
19Child retains mother’s maiden name.
21Billing 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.
22Patient on Multiple Drug Regimen
23Home Care Giver Available
24Home IV Patient Also Receiving HHA Services
25Patient Is a Non-U.S. Resident
26Veteran’s Administration (VA) eligible patient chooses to receive services in a Medicare Certified Facility.
28Patient’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.
29Disabled 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.
31Patient is a student (full time day).
32Patient is a student (cooperative/work study program).
33Patient is a student (full-time night).
34Patient is student (part-time).
45Ambiguous gender category.
46Nonavailability statement on file.
48Identifies 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.
52Hospice beneficiary moves out of service area, including patients admitted to a hospital that does not have contractual arrangements with the hospice.
67Beneficiary elects not to use Lifetime Reserve (LTR) days.
68Beneficiary elects to use LTR days.
77Provider accepts or is obligated/required due to contractual arrangement or law to accept payment by a primary payer as payment in full
78Newly covered Medicare service for which an HMO doesn’t pay. For outpatient bills, condition code 04 should be omitted.
H0Delayed 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 Condtion Codes

CC CodesDescription of CC
6End 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.
59Non-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.
70Self-administered erythropoetin alpha (EPO). Code indicates the billing is for a home dialysis patient who self-administers EPO or darbopoetin alpha.
71Full care in unit. The billing is for a patient who received staff-assisted dialysis services in a hospital or renal dialysis facility.
72Self-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.
73Self-Care training. The bill is for special dialysis services where a patient and his/her helper (if necessary) were learning to perform dialysis.
74Billing is for a patient who received dialysis services at home.
75Billing is for a patient who received dialysis services at home using a dialysis machine that was purchased under the 100 percent payment program.
76Back-up dialysis in-facility The bill is for a home dialysis patient who received back-up dialysis in a facility.
80Patient receives dialysis services at home and the patient’s home is a nursing facility.
84Dialysis for Acute Kidney Injury (AKI) on monthly basis
87ESRD self care retraining

Hospitalization, Products and Services Condition Codes List

CC CodesDescription of CC
27Patient 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.
30Non-research services provided to all patients, including managed care enrollees, enrolled in a Qualified Clinical Trial.
40Same day transfer. The patient was transferred to another participating Medicare provider before midnight on the day of admission.
41Claim is for partial outpatient hospitalization services which include a variety of psychiatric programs.
42Continued care plan is not related to the patient’s inpatient admission condition or diagnosis.
43Continued care not provided within post discharge window
44Inpatient 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.
49Product lifecycle replacement of a product earlier than the anticipated lifecycle due to an indication that the product is not functioning properly.
50Product replacement for known recall by a Product Manufacturer or FDA.
51Provider attestation of that services billed are unrelated outpatient non-diagnostic services which should not be bundled into the inpatient hospital claim.
53The initial placement of a medical device provided as part of a clinical trial or a free sample.
69Indirect Medical Education (IME)/Direct Graduate Medical Education (DGME)/Nursing and Allied Health (N&AH) payment only billing.
79Comprehensive Outpatient Rehabilitation Facilities (CORF) services provided off-site. Physical therapy, occupational therapy, or speech pathology services were provided offsite.
98Data associated with diagnosis-related grouper (DRG) 468 has been validated.
B4Admission unrelated to discharge on same day
G0Distinct 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 CodesDescription of CC
20Beneficiary 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.)
55SNF bed is not available. Patient’s SNF admission was delayed more than 30 days after hospital discharge because a SNF bed was not available.
56Medical 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.
57SNF readmission when patient previously received Medicare covered SNF care within 30 days of current SNF admission.
58SNF patient terminated MA Plan enrollment. Providers report this code to waive 3-day qualifying stay requirement.

Rooms/Beds UB 04 Condition Codes List

CC CodesDescription of CC
36General 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.
37Ward accommodation at patient’s request – Not used by PPS Hospitals.
38Semi-private room is not available. Not used by PPS Hospitals.
39Private room medically necessary. Not used by PPS Hospitals.

Condition Codes for Special Programs

CC CodesDescription of CC
90Service provided as part of an Expanded Access approval.
91Service provided as part of an Emergency Use Authorization.
A0This code identifies TRICARE claims submitted under the external partnership program.
A1This code is to be used for services related to early and periodic screening diagnosis and treatment.
A2Services provided under a program that receives special funding for the handicapped through title VII of the Social Security Act or TRICARE.
A3Special federal funding.
A4Family planning.
A6Pneumococcal pneumonia and influenza vaccines paid at 100%.
A9Second opinion for surgery.
AJPayer responsible for co-payment.
ANPreadmission screening not required.
B0Medicare Coordinated Care Demonstration Program (MCCD).
B1Beneficiary is ineligible for Full Demonstration Program.
W0United Mine Workers of America demonstration indicator.

UB 04 Condition Codes List for Transport Services

CC CodesDescription of CC
AKAir ambulance required.
ALSpecialized treatment/bed unavailable.
AMNon-emergency medically necessary stretcher transport required.
B2Critical Access Hospital ambulance attestation that it meets criteria for exemption from ambulance fee schedule.

Pregnancy Related UB 04 Condition Codes

CC CodesDescription of CC
81C-sections or inductions performed at less than 39 weeks gestation for medical necessity.
82C-sections or inductions performed at less than 39 weeks gestation electively.
83C-sections or inductions performed at 39 weeks gestation or greater.
AAAbortion performed due to rape.
ABAbortion performed due to incest.
ACAbortion performed due to serious fetal genetic defect, deformity, abnormality0
ADAbortion performed due to life endangering physical condition caused by, arising from or exacerbated by the pregnancy itself.
AEAbortion performed due to physical health of mother that is not life endangering.
AFAbortion performed due to emotional/psychological health of mother.
AGAbortion performed due to social economic reasons.
AHElective abortion.
B3Pregnancy indicator.

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.

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