What is a condition code in medical billing?

What is a condition code in medical billing?

As per National Uniform Billing Committee (NUBC), condition codes help identify conditions or  events related to the bill. These are specific form locators in the UB-04 form to describe the  conditions or events for the applicable billing period. The condition codes are situational and  always entered in an alphanumeric sequence.

It is important to note that the provider must fill the codes in sequence in the UB-04 form. For  instance, in the conditions or events for sub-codes 04 and 69, the form locators FL18 and FL19 are  used in the sequence. The format will be FL18-04 and FL19-69.

Medicare Condition Codes 

Adjustment/Cancel Claim Change 

  • D9- used when only changing the admit date D0- used when changing the from and thru date of  the claim.
  • D7- used when the original claim shows Medicare on the primary payer and the adjustment claim  shows Medicare on the secondary payer.
  • D9- used condition code when adjusting primary payer to the bill.
  • D8- used when the original claim shows Medicare on the secondary payer and the adjustment claim  shows Medicare on the primary payer line.
  • D2- change in revenue codes, HCPCS codes, HIPPS codes, or RUG codes. Use D9 for removing  procedure & diagnosis codes.
  • D3- used when subsequent or second interim claims by inpatient PPS hospitals.
  • D4- for changing or adding diagnosis & procedure codes ICD-/ICD-10. For deleting the  codes, D9 would be appropriate.
  • D5- canceling claims to correct the Medicare ID or provider number. Condition code is only  applicable in an xx8 type of bill.
  • D6- canceling claims to repay a payment. Condition code is only applicable in an xx8 type of bill.
  • D1- if none of the above conditions codes apply and there is a change to the COVERED charges.  Adding a modifier would make the charges covered on the adjustment claim. Use when the previous  claim gets rejected due to hospice, HMO, home health, and other overlap reasons.
  • E0- Use when correction to the patient status code needs the changes.

The below-mentioned condition codes the provider should not use on the claim forms.

  • 15 clean claims delayed
  • 16 SNF transition exemption
  • 60 Operating cost day outlier
  • 61 Operating cost outlier not reported by the provider
  • 62 PIP bills paid and recorded by the system
  • 63 Bypass CWF for prisoners or patients in State or local custody
  • 64 Other than the clean claim
  • 65 Non-PPS bills
  • MO inclusive rates for outpatients
  • M1 PPV or roster billed influenza virus vaccine
  • M3 SNF 3 day stay bypass
  • MA Gastroenteritis bleed
  • MB Pneumonia
  • MC Pericarditis
  • MD Myelodysplastic syndrome
  • ME Hereditary hemolytic and sickle cell anemia
  • MF Monoclonal gammopathy
  • MG Grandfathered Tribal Federally Qualified Health Centers
  • MZ IOCE error code bypass

According to NUBC's 2007 manual list, the numeric code 01 code refers to the Military Service Related Situation, 09 code refers to the patient as homeless. Condition code 80 refers to the Home  Dialysis-Nursing facility. The subcodes starting from 81-99 get reserved by NUBC.

In addition to numeric codes, the alphanumeric condition codes help with medical programs and  procedures.

A0 refers to TRICARE External Partnership Program, AA refers to Abortion Program due to Rape,  PI refers to Do not Resuscitate (DNR), and W0 refers to United Mine Workers of America  (UMWA) Demonstration Indicator.

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