The UB-04 Claim Form

1. PART TWO The UB-04 Claim Form Chapter 9 Condition Codes

2. LEARNING OUTCOMES After completing this chapter, you will be able to define the key terms and: Discuss the codes that are used in FLs 18-28 of the UB-04 to report special conditions about a claim that may affect its processing and payment. Become familiar with the major categories of condition codes. Explain various billing situations that arise when particular condition codes are used. Recognize the condition codes that must be coordinated with data supplied in other fields of the UB-04.

3. LEARNING OUTCOMES (cont.) Discuss the use of FL 29 to report the state in which an accident occurred in a claim with services related to an auto accident.

4. KEY TERMS • condition code • focused medical review • outlier • 72-hour rule • working aged person

5. FLs 18-28 CONDITION CODES • Some claims are straightforward and payers easily understand what benefits are due. Other claims are more complex and may contain information that seems contradictory, incomplete, or illogical to a payer. If this happens, the claim can be held up or denied. • A condition code is a two-digit numeric or alphanumeric code that identifies a special condition or unique circumstance about a claim. They cover a wide range of circumstances and range from 01 to 99 and A0 to ZZ. • Condition Code Groupings: • insurance • patient condition codes • room codes • TRICARE, product replacement, and skilled nursing facility codes • other special codes

6. FLs 18-28 CONDITION CODES (cont.) • Guidelines • If applicable, completion of these fields is required for Medicare and all other payers • Eleven condition codes may be listed on a single claim (FLs 18-28) • Codes should be listed in ascending order, starting with numbers and followed by letters • If more than eleven codes are necessary, FL 81 (Code-Code field) can be used for the overflow

7. CONDITION CODE GROUPS • Insurance Codes 01 – 16 • Patient Condition Codes 17 – 35 • Room Codes 36 – 45 • TRICARE, Product Replacement, and SNF Information Codes 46 – 57 • Other Special Codes • Other Special Codes 58 – 69 • Renal Dialysis Setting Codes 70 – 76 • Miscellaneous Codes 77 – 99 • Special Programs A0 – BZ • QIO Approval Indicator Services C0 – CZ • Claim Change Reasons D0 – ZZ

8. FL 29 ACCIDENT STATE • FL 29 is used to report the state in which an automobile accident occurred on a claim for related medical services • Guidelines • Not used for Medicare; other payers require it • Field contains two positions for the two-character state abbreviation • FL 30 UNLABELED FIELD

9. Example • Neither patient nor spouse is employed [09] • Maiden name retained [18] • Patient on multiple drug regimen [22] • Private room medically necessary [39] • Beneficiary elects to use LTR days [68]

10. Example • Patient and/or spouse is employed but no EGHP coverage exists [10] • Patient on multiple drug regimen [22] • General care patient in special unit [36] • Product replacement for known recall of a product [50] • Beneficiary elects not to use Lifetime Reserve Days (LRD) [67] • Second opinion surgery [A9] • Preadmission screening not required [AN] • Extended authorization [C7]

11. CHAPTER REVIEW • In what order would the condition codes for the following be listed: • semiprivate room not available • extended authorization • condition is employment related • [02, 38, C7] • What type of condition is indicated by codes that begin with the letter D? • [claim changes] • How many claim change condition codes may be reported on one claim? • [one]

12. TERMINOLOGY QUIZ • A patient or his or her spouse who is over age 65 and who is eligible for group health insurance through employment or the employment of the spouse: • [working aged person] • Only source of inpatient services in a given geographic area: • [sole community hospital] • A case that incurs unusually high costs for its DRG classification: • [outlier]