Condition code

The UB-04 has eleven condition code fields, form locators 18-28, filled in numerical order. CMS lists them as situational: a code goes on only when the condition or event it describes applies to the billing period. The National Uniform Billing Committee maintains the codes in its official data specifications manual, and Medicare contractors publish the ones Medicare uses¹. Professional claims have a smaller version. Item 10d of the CMS-1500 takes the subset of condition codes the NUCC approves when a payer asks for them, and workers’ compensation bills use them to mark a duplicate or an appeal².

Home health claims show how much work the codes do. On a Medicare home health claim, 47 marks a patient transferred from another agency, 54 marks a period with no skilled visits that a documented policy exception still allows the agency to bill, and DR marks billing under a disaster waiver of OASIS reporting. An adjustment carries one claim change reason code from the D0 to E0 range, such as D2 for a corrected HIPPS code, and a cancel carries D5 or D6 with a remark³.

Condition codes are not decoration. Medicare rejects an adjustment whose claim change reason code does not fit its type of bill⁴, and the same two characters can mean different things in different fields. On a home health claim, 61 is a condition code Medicare adds with an outlier payment, an occurrence code for a recent hospital discharge, and a value code for the area where care was given³. Check which field a code belongs in before you enter it.