What is a Condition Code in Medical Billing

The CMS-1450 form of the UB-04 form plays an important role in filing claims. Designed to promote uniform billing across medical institutes, the UB-04 contains 81 fields called Form Locators (FL). Each form locator demands a specific set of information that is essential to file claims. The information related to the field locators varies from payer to payer—what one payer needs may not be required by the other payer. While billing the payers, the medical biller makes sure to fill the required form locators. However, there are form locators that require extra attention as they demand to fulfill certain conditions. This is where the term Condition Code comes in. Condition codes refer to specific form locators in the UB-04 form that demand to describe the conditions applicable to the billing period. It is important to note that condition codes are situational. These codes should be entered in an alphanumeric sequence.

Definition of Condition Codes

National Uniform Billing Committee (NUBC) in its Official UB-04Data Specifications Manual 2007 defines condition codes as codes used to identify conditions or events relating to this bill that may affect processing. The form locators (FL) 18 to 28 are listed as condition codes in the CMS Manual System: Medicare Claims Processing Pub. 100-04 Chapter 25 Update (https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2922CP.pdf).

The field attributes of condition codes as described in NUBC’s manual are “11 fields, 1 line, 2 positions, alphanumeric, and all positions fully coded.”

Understanding the Conditions/Situations Mentioned by NUBC

The form locators from 18-28 are further divided into situations identified by sub-codes referring and/or explaining the situation. The NUBC’s 2007 manual lists 99 situations with numeric codes ranging from 01-99. For example, the sub-code 01 refers to the Military Service-Related situation explained as medical conditions incurred during military service. The sub-code 09 refers to Patient is Homeless explained as the patient is homeless. The sub-code 80 refers to Home Dialysis-Nursing Facility home dialysis furnished in an SNF or nursing facility. The last numeric sub-codes from 81-99 are reserved for assignment by NUBC.

In addition to the numeric sub-codes, condition codes also have alphanumeric sub-codes referring/or explaining situations that are largely associated with medical programs and associated with procedures. These alphanumeric codes are named—A0, A1, A2 […] AA, AB, AC, […] AZ, B0, B1, B2 […] W0 […] and ZZ. The sub-code A0 refers to TRICARE External Partnership Program identifying TRICARE claims submitted under the External partnership Program. Similarly, the sub-codes AA, P1, and W0 refer to Abortion Performed due to Rape, Do Not Resuscitate Order (DNR), and United Mine Workers of America (UMWA) Demonstration Indicator respectively.

It is advisable to read NUBC’s Official UB-04Data Specifications Manual 2007 (or the latest edition) for a deep understanding of the situations assigned to conditions codes.

Using the Condition Codes

While filling the UB-04 the provider must fill the codes in sequence. For example, if you wish to explain situations referred to in sub-codes 04 and 69 then you must put them under the form locators FL18 and FL19 in sequence. So, the format will be—FL18-04 and FL19-69 explaining situations Information only Bill and IME/DGME/N&AH Payment Only.