Condition Codes

 

Adjustment/Cancel Claim Change

Use this table to determine which condition code is the most appropriate in coding an adjustment/cancel claim.

Code Description
D0 (zero) Use when the from and thru date of the claim is changed.
  • When you are only changing the admit date use condition code D9.
D1 If one of the above condition codes does not apply and there is a change to the COVERED charges this code should be used.
  • Use when adding a modifier to a line that would make the charges covered on the adjustment that were non-covered on the previous claim.
  • Use when the previous claim rejected for home health, hospice, HMO and other overlap reasons that have been updated.
D2 Use when there is a change to the revenue codes, HCPCS code, RUG code, or HIPPS code.
  • If only removing procedure codes or diagnosis codes, D9 would be more appropriate.
D3 Use for a second or subsequent interim claim by inpatient PPS hospitals only.
D4 Change in grouper input (ICD-9/ICD-10 Diagnosis codes and ICD-9/ICD-10 Procedure codes)
  • Only use if the provider is changing or adding an ICD-9/ICD-10 code.
  • If the provider is only deleting these codes, then the D9 with remarks would be more appropriate.
D5 Use when canceling a claim to correct the Medicare ID or provider number.
  • Condition code only applicable on a xx8 type of bill.
D6 Use when canceling a claim for reasons other than the Medicare ID or provider number. Use when canceling a claim to repay a payment.
  • Condition code only applicable to a xx8 type of bill.
D7 Use when the original claim shows Medicare on the primary payer line and now the adjustment claim shows Medicare on the secondary payer line.
  • Use D9 when adjusting primary payer to bill for conditional payment.
D8 Use when the original claim shows Medicare on the secondary payer line and now the adjustment claim shows Medicare on the primary payer line.
D9 Use for adjustments not described in any other condition codes. Remarks are required when using the D9 condition code to make a change.
  • Use in place of the D7 when adjusting the claim for conditional payment.
  • Use if adding a modifier to change liability and there is no change to the covered charge amount.
  • Use when adding or changing occurrence, occurrence span and/or value codes that do not affect the covered charges.
  • Use when changing the last 2 digits of the RUG code.
E0 (Zero) Use when the only change on the claim is a correction to the patient status code.

Assigned by Payer

Providers shall not submit these codes on their claims forms.

Code Description
15 Clean claim delayed in CMS' processing system. (Payer Only Code)
16 Skilled Nursing Facility (SNF) transition exemption (Payer Only Code). 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. (Payer code only.)
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/Spouse Insurance and Identifiers

ESRD and SNF-related insurance information is found under their respective categories.

Code Description
01 Military service related; coordinate with the Department of Veterans Affairs (VA). 
02 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).
03 Patient is covered by an insurance not reflected here.
04 Bill is submitted for informational purposes only.
05 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.
07 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.
08 Beneficiary would not provide information concerning other insurance coverage. The MAC develops to determine proper payment.
09 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.

Comorbid Reoccurrence

Code Description
H3 Reoccurrence of GI bleed.
H4 Reoccurrence of Pneumonia (CWF no longer tracks condition code H4 for dates of service on or after 01/01/2016).
H5 Reoccurrence of pericarditis.

Disaster

Code Description
BP Gulf oil spill of 2010
DR Disaster related

End Stage Renal Disease and Dialysis

Code Description
06 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

Code Description
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.

Public Health Reporting

Code Description
P1 This code should not be used for third party billing purposes. Use code P1 only when reporting public health data required by the state. This code indicates that a do not resuscitate order was written at the time of or within the first 24 hours of the patient's admission to the hospital and it is clearly documented in the patient's medical records. Do not report this code in an 837I encounter or claim.
P7 Use code P7 only when reporting public health data required by the state. This code was created
solely to indicate a direct inpatient admission from the emergency room for public health reporting
purposes. It is not intended to be used on claims sent to payers. Any public health entity that wants this code to be reported should issue its own instructions to hospitals.

QIO Approval

Code Description
C1 Approved as billed.
C2 Automatic approval as billed based on focused review.
C3 Partial approval.
C4 Admission denied.
C5 Post payment review applicable.
C6 Pre-admission/pre-procedure authorized but QIO has not reviewed service(s) provided.
C7 Extended authorization authorized but QIO has not reviewed service(s) provided.

Reopening Reason (TOB xxQ)

Code Description
R1 Mathematical or computational mistakes.
R2 Inaccurate data entry, for example miskeyed or transposed provider number, referring NPI, date of service, procedure code, etc.
R3 Misapplication of a fee schedule.
R4 Computer errors.
R5 Duplicate claim which the party believes were incorrectly identified as duplicate.
R6 Other clerical errors or minor errors and omissions not specified in R1-R5.
R7 Claim corrections other than clerical errors within one year of the date of initial determination.
R8 A reopening for good cause (one to four years from the date of the initial determination) due to new and material evidence that was not available or known at the time of the determination or decision and may result in a different conclusion.
R9 A reopening for good cause (one to four years from the date of initial determination) because the evidence that was considered in making the determination or decision clearly shows that an obvious error was made at the time of the determination or decision.

Reproductive

Code Description
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.

Rooms/Beds

Code Description
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.

SNF

Code Description
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.

Special Program

Code Description
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.

Transport

Code Description
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.
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