Value Codes

When reporting numeric values that do not represent dollars and cents, put whole numbers to the left of the dollar/cents delimiter and tenths to the right of the delimiter.

X
 
Code Description Addtional Description
01 Most common Semi-Private Rate - to provide for recording hospital's most common semi- private rate.  
02 Hospital has no semi-private rooms - using this code requires $0.00 amount.  
04 Inpatient Professional Component Charges Which Are Combined Billed - (Used only by some all- inclusive rate hospitals)  
05 Professional component included in charges and billed separately to carrier - (Applies to Part B bills only)  
06 Medicare Part A and Part B Blood Deductible for un-replaced deductible pints of blood supplied times the charge per pint. If all deductible pints have been replaced this code is not used  
07 Reserved for National Assignment  
08 Medicare Lifetime Reserve Amount in the First Calendar Year in Billing Period  
09 Medicare Coinsurance Amount in the First Calendar Year in Billing Period  
10 Medicare Lifetime Reserve Amount in the Second Calendar Year in Billing Period  
11 Medicare Coinsurance Amount in the Second Calendar Year in Billing Period  
12 Working Aged Beneficiary Spouse With an EGHP (Payer Code A)  
13 ESRD Beneficiary in Medicare Coordination Period

With an EGHP (Payer Code B).

Enter 6 zeros (0000.00) in the amt field if claiming conditional pay because EGHP has denied coverage
 
14 No-fault, including Auto/other liability insurance (Payer Code D). Enter 6 zeros (0000.00) in the amt field if claiming conditional pay because other insurer has denied coverage and there has been a substantial delay in payment  
15 Worker's compensation (WC) (Payer Code E). Enter 6 zeros (0000.00) in the amt field if claiming conditional pay because there has been a substantial delay in payment.  
16 PHS or other federal agency (Payer Code F). Enter 6 zeros (0000.00) in the amt field if claiming conditional pay because there has been a significant delay in payment  
NOTE: A six zero value entry for Value Codes 12- 16 indicates conditional Medicare payment requested (0000.00) (Payer Code C).12 13 14 15 16  
17 Operating Outlier Amount (Not reported by providers)  
18 Operating Disproportionate Share Amount (Not reported by providers)  
19 Operating Indirect medical education on Unibill (IME) (Not reported by providers)  
20 Payer Code (For internal use by third party payers only)  
23 - 24 Recurring Monthly Income

Medicaid Rate Code
Medicaid-eligibility requirements to be determined at state level.
25 Offset to Patient -Payment Amount Prescription drugs paid from for out of a long-term care facility resident/patient funds during the billing period.
26 Offset to Patient-Payment Amount Hearing and ear services paid for out of a long-term care facility resident/patient funds during the billing period.
27 Offset to Patient-Payment Amount Dental services paid for out of a long-term care facility resident/patient funds during the billing period.
28 Offset to Patient-Payment Amount Chiropractic services paid for out of a long-term care facility resident/patient funds during the billing period.
31 Patient liability amount for non-covered services FI approved the provider charging the beneficiary the amount shown for non-covered accommodations, diagnostic procedures, or treatments.
32 Multiple Patient Ambulance transport If more than one patient is transported in a single ambulance trip, report the total number of patients transported.
36 Reserved for National Assignment  
37 Pints of Blood Furnished Total number of pints of whole blood or units of packed red cells furnished, whether or not they were replaced.
38 Blood Deductible Pints Number of unreplaced deductible pints of blood supplied. If all deductible pints furnished have been replaced, no entry is made.
39 Pints of Blood Replaced Total number of pints of blood donated on patient's behalf
40 New Coverage Not Implemented by HMO (For inpatient service only) Inpatient charges for newly covered services not paid by the HMO. Must also report condition codes 04 and 78
41 Black Lung (Payer Code H) Portion of a higher priority BL payment made on behalf of a Medicare beneficiary that the provider is applying to Medicare charges on the bill. It enters six zeros (0000.00) in the amount field if it's billing conditionally for substantially delayed payment.
42 Veterans Affairs (VA) (Payer Code I) Portion of a higher priority VA payment made on behalf of a Medicare beneficiary that the provider is applying to Medicare charges on the bill
43 Disabled beneficiary under 65 with LGHP (Payer Code G) Portion of a higher priority LGHP payment made on behalf of a Medicare beneficiary that the provider is applying to Medicare charges on the bill. It enters six zeros (0000.00) in the amount field if it's billing conditionally for substantially delayed payment.
44 Amount provider agreed to accept from primary payer when amount is < charges but higher than payment received A Medicare secondary payment is due.
45 Accident hour  
46 Number of grace days following QIO/UR determination If C3 or C4 condition code is on the claim for QIO denial provider shows the number of days determined by the QIO to be covered while arrangements are made for the patient's post discharge. The field contains 1 numeric digit.
47 Any liability insurance (Payer Code L) Portion of a higher priority liability insurance payment made on behalf of a Medicare beneficiary that the provider is applying to Medicare charges on the bill. It enters six zeros (0000.00) in the amount field if it's billing conditionally for substantially delayed payment.
48 Latest Hemoglobin reading taken during this billing cycle Patients most recent hemoglobin reading taken before the start of the billing period effective 1/1/06. For patients just starting, use the most recent value prior to the onset of treatment. Whole numbers (i.e. two digits) are to be right justified to the left of the dollar/cents delimiter. Decimals (i.e. one digit) are to be reported to the right.
49 Hematocrit reading taken prior to the last administration of EPO during the billing cycle The most recent hematocrit reading taken before the start of this billing period. For patients just starting, use the most recent value prior to the onset of treatment. Whole numbers (i.e. two digits) are to be right justified to the left of the dollar/cents delimiter. Decimals (i.e. one digit) are to be reported to the right.
54 Newborn birth weight in grams Actual birth weight or weight at the time of admission for extramural birth
55 Eligibility Threshold for Charity Care Corresponding value amount the health care facility determines eligibility threshold for charity care
56 Skilled Nurse--Home visit hours (HHA only) Number of hours provided during billing period
57 Home Health Aide--Home visit hours (HHA only) Number of hours provided during the billing period
58 Arterial Blood Gas (PO2/PA2) Indicates arterial blood gas value at the beginning of each reporting period for oxygen therapy. This value or value 59 is required on the initial bill for oxygen therapy and on the fourth month's bill. The provider reports right justified in the cents area. Round to nearest whole percentage, i.e., report 56.5 as 57 to the right of the cents delimiter.
59 Oxygen Saturation(02 Sat/Oximetry) Indicates oxygen saturation at the beginning of each reporting period for oxygen therapy. This value or value 58 is required on the initial bill for oxygen therapy and on the fourth month's bill. The hospital reports right justified in the cents area. Round to nearest whole percentage, i.e., report 56.5 as 57 to the right of the cents delimiter.
NOTE: Codes 58 & 59 are not money amounts. They represent arterial blood gas or oxygen saturation levels.  
60 HHA Branch MSA The MSA in which the HHA branch is located
61 Location Where Service is Furnished (HHA and Hospice) MSA number (or rural state code) of the location where the home health/hospice service is delivered
62 HH Visits - Part A (Internal Payer Use Only)  
63 HH Visits - Part B (Internal Payer Use Only)  
64 HH Reimbursement - Part A (Internal Payer Only) Dollar amounts determined to be associated with HH visits in value code 62
65 HH Reimbursement - Part B (Internal Payer Only) Dollar amounts determined to be associated with HH visits in value code 63
66 Medicare spend down amount Dollar amount used to meet recipient's spend down liability
67 Peritoneal Dialysis Number of hours provided during billing period
68 Number of units of EPO administered and or supplied during the billing period Number of units of EPO administered and/or supplied relating or billing period
69 State Charity Care Percent Percentage of charity care eligibility for patient.
70 Interest Amount (For use by third party payers only)
71 Funding of ESRD Networks (For use by third party payers only)
72 Flat Rate Surgery Charge (For use by third party payers only) Standard charge for outpatient surgery
73-75 Payer Codes and Reserved for internal use only by third party payers.
76 Provider's interim rate (set internally) (For use by third party payers only)
77 Medicare new technology add-on payment Code indicates the amount of Medicare additional payment for new technology.
78-79 Payer Codes Reserved for internal use only by third party payers.
80 Covered Days Effective 03/01/07 Hardcopy UB04 Claims
81 Non-Covered Days Effective 03/01/07 Hardcopy UB04 Claims
82 Coinsurance Days Effective 03/01/07 Hardcopy UB04 Claims
83 Lifetime Reserve Days Effective 03/01/07 Hardcopy UB04 Claims
84-99 Reserved for National Assignment  
A0 Special Zip Code Reporting 5 digit zip code of location the beneficiary is initially placed on board the ambulance
A1 Deductible Payer A  
A2 Coinsurance Payer A  
A3 Estimated Responsibility Payer A  
A4 Covered Self-Administrable Drugs-Emergency The amount included in covered charges for SAD administered to the patient in an emergency situation e.g. insulin for diabetic coma. Must be used with Rev Code 0637
A5 Covered Self-Administrable Drugs-Not Self- Administrable in Form and Situation Furnished to Patient The amount included in covered charges for SAD administered to the patient because the drug wasn't self-administrable in the form and situation in which it was furnished to the patient. Must be used with Rev Code 0637
A6 Covered-Self-Administrable Drugs-Diagnostic Study and Other The amount included in covered charges for SAD administered to the patient because the drug was necessary for diagnostic study or other reason. Must be used with Rev Code 0637
A7 Co-payment Payer A  
A8 Patient Weight Code indicates weight of patient in kilograms. The weight of the patient should be measured after dialysis during the last dialysis session of the month. For newborns, use value code 54.
A9 Patient Height Code indicates the height of the patient in centimeters. The height should be measured during the last dialysis session of the month.
AA Regulatory Surcharges, Assessments, Allowances or Health Care Related Taxes Payer A  
AB Other Assessments or Allowances (e.g., Medical Education) Payer A  
AC-AZ Reserved for National Assignment  
B1 Deductible Payer B  
B2 Coinsurance Payer B  
B3 Estimated Responsibility Payer B  
B4-B6 Reserved for National Assignment  
B7 Co-payment Payer B  
B8-B9 Reserved for National Assignment  
BA Regulatory Surcharges, Assessments, Allowances or Health Care Related Taxes Payer B  
BB Other Assessments or Allowances (e.g., Medical Education) Payer B  
BC-C0 Reserved for National Assignment  
C1 Deductible Payer C  
C2 Coinsurance Payer C  
C3 Estimated Responsibility Payer C  
C4-C6 Reserved for National Assignment  
C7 Co-payment Payer C  
C8-C9 Reserved for National Assignment  
CA Regulatory Surcharges, Assessments, Allowances or Health Care Related Taxes Payer C  
CB Other Assessments or Allowances (e.g., Medical Education Payer C  
CC-CZ Reserved for National Assignment  
D0- D2 Reserved for National Assignment  
D3 Estimated Responsibility Patient  
D4 Clinical Trial Number 8-digit numeric
D5 Result of last Kt/V In-center hemodialysis - last reading during billing period; peritoneal/home dialysis - within 4 months of claim date of service. IF not Kt/V test performed use value of 9.99 with D5
DR Reserved by Disaster Related code  
DS-DZ Reserved for National Assignment  
E0 Reserved for National Assignment  
E1 Deductible Payer D  
E2 Coinsurance Payer D  
E3 Estimated Responsibility Payer D  
E4-E6 Reserved for National Assignment  
E7 Co-payment Payer D  
E8-E9 Reserved for National Assignment  
EA Regulatory Surcharges, Assessments, Allowances or HealthCare Related Taxes Payer D  
EB Other Assessments or Allowances (e.g., Medical Education) Payer D  
EC-EZ Reserved for National Assignment  
F0 Reserved for National Assignment  
F1 Deductible Payer E  
F2 Coinsurance Payer E  
F3 Estimated Responsibility Payer E  
F4-F6 Reserved for National Assignment  
F7 Co-payment Payer E  
F8-F9 Reserved for National Assignment  
FA Regulatory Surcharges, Assessments, Allowances or HealthCare Related Taxes Payer E  
FB Other Assessments or Allowances (e.g., Medical Education) Payer E  
FC Patient Prior Payments  
FD-FZ Reserved for National Assignment  
G0 Reserved for National Assignment  
G1 Deductible Payer F  
G2 Coinsurance Payer F  
G3 Estimated Responsibility Payer F  
G4- G6 Reserved for National Assignment  
G7 Co-payment Payer F  
G8 Facility where inpatient hospice service is delivered  
G9 Reserved for National Assignment  
GA Regulatory Surcharges, Assessments, Allowances or HealthCare Related Taxes Payer F  
GB Other Assessments or Allowances (e.g., Medical Education) Payer F  
GC-GZ Reserved for National Assignment  
H0- WZ Reserved for National Assignment  
X0-Y0 Reserved for National Assignment  
Y1 Part A Demonstration Payment Part A payment under demonstration instead of DRG payment
Y2 Part B Demonstration Payment Part B payment under demonstration
Y3 Part B Coinsurance (Demonstration Claims) Part B coinsurance payment under demonstration
Y4 Conventional Provider Payment Amount for Non-Demonstration Claims Amount Medicare would have reimbursed the provider if there had been no demonstration
Y5-ZZ Reserved for National Assignment  

 

Last Updated Wed, 26 Sep 2018 08:57:29 +0000